Tracheostomy Emergencies

Management
 objectives

 Mx of Respiratory distress in pt w tracheostomy

 Mx of bleeding in pt w tracheostomy.

 Important tips about tracheostomy care

Respiratory distress
 DDX of Respiratory distress

1. Accident decanulation

2. Dislodged/ Displaced

3. Obstruction

4. Pneumothorax

5. Equipment Failure
 D – Dislodged
Trach tubes may become dislodged when:
 ventilator tubing attached to the
tracheostomy
 Ventilated patient is turned, or moved
from their bed to a trolley.
 Restless or agitated patients may pull it
 too loose Trach ties.
 O – Obstruction

Trach tubes may become obstructed from:

 Improper positioning of the patient.

 Secretions
 Bleeding
 Foreign objects
 Edema in the trachea (rare)
 Respiratory distress Mx
First: Attempt to pass suction catheter

Tip - Measure catheter against obturator

Managing Trach Tube Problems
If catheter cannot pass to If catheter is able to pass
measured depth… to measured depth…

…obstruction is within the …obstruction is below the

trach tube trach tube.
 Tube is most likely
dislodged/displaced.
 Managing Trach Tube Problems
If obstruction is within the If obstruction is below the
trach tube… trach tube….

…instill normal saline, attempt

…clean or replace the inner suctioning and bag ventilation.
cannula.
•Prepare to change the trach tube
 Changing a Trach Tube
 Trach Tube, obturator, syringe and ties (ready to go)

 Proper positioning of the patient (neck hyperextended, supine).

 Towel/shoulder roll
 Suction equipment
 Manual resuscitator bag and masks
 Water soluble lubricant
 Normal saline/sterile water
 Changing a Trach Tube

1. Gather equipment
2. Position patient flat and midline
3. Hyperextend neck (towel roll)
4. Lubricate new tube
5. Deflate old cuff w/ syringe (Do not cut)
6. Undo old ties, remove tube
7. Put in new trach, remove obturator
8. Attempt to ventilate
9. Secure new trach tube
 Changing a Trach Tube
 Always have at least
two people!

 If you meet any

resistance: STOP!
 Possible Complications When
Inserting a Trach Tube
 Creation of a false lumen or passage

 Subcutaneous air

 Pneumothorax or Pneumomediastinum

 Bleeding
Confirming Placement of Trach
or ET Tube
 No resistance encountered while inserting
tube
 Equal chest rise
 Bilateral breath sounds
 End-tidal CO2 detection
 Improved skin color, vitals signs, pulse
oximetry
 Managing Trach Tube Problems

If attempts at re-inserting a new tube are unsuccessful:

or

 Apply an occlusive  Begin BVM to stoma

dressing to the stoma ventilation (pediatric mask?)
 Begin BVM ventilation  Must for Laryngectomy
patients!
If other interventions are unsuccessful, then consider:

 Endotracheal tube into stoma

or
Oral intubation (if appropriate), while
maintaining occlusive dressing over stoma.
 Inserting an ET Tube

 Measure ET tube Confirm placement

against trach tube 1.
2.
Breath sounds
End-tidal CO2

 Do not cut ET tube  Secure ET tube

 P – Pneumothorax

Pneumothorax can develop from:

 High Peak Inspiratory Pressures

 High Positive End-Expiratory Pressures (PEEP)
 Vigorous bagging with Ambu
 Underlying disease (COPD)
 Trauma
 Signs and Symptoms of a
Pneumothorax
 Shortness of breath/
respiratory distress
 Diminished or absent breath
sounds
 Tracheal deviation
 Sub-Q emphysema
 Cyanosis
 Signs and Symptoms of a
Pneumothorax
 Patient needs immediate
needle decompression!
(2nd intercostal space) ACLS

 Do not wait for X-ray

confirmation!
 E – Equipment

Equipment problems can result from:

 Ventilator/power failure
 Vent circuit problems (disconnected,
obstructed)
 Trach supplies and equipment missing

Troubleshoot all equipment and maintain necessary supplies

bleeding from or around a
tracheostomy
 DDX of bleeding from or
around a tracheostomy
First 24 hr- days Post Op:
1- inadequate surgical hemostasis
2- preexisting coagulopathy

several days - months post Op:

– should be considered to be a tracheal-innominate
artery fistula (TIF) until proven otherwise
– granulation tissue formation
– Coagulopathy
– tumor invasion
– pulmonary artery rupture
Innomiate artery = brachiocephalic artery
 tracheal-innominate artery
fistula (TIF)
 Incidence 0.3-0.7 %
 Mortality rate 85-90%
 Over 75% of TIF’s occur in the first 3 wk
after tracheostomy
 often heralded by a self-limited “sentinel
bleed” in the hrs - day prior to the
exsanguinating hemorrhage from either
the tracheostomy tube itself or around the
tracheostomy site
 Causes of TIF
 low placed tracheostomy (4th tracheal ring
or below)
 abnormally high innominate artery
 high pressure tracheostomy cuffs (as
opposed to the current utilized low
pressure cuffs)
 Mx oF TIF in the floor

Over inflation of the tracheostomy tube Ballon Oral re-intubation with manual
Success rate is 80% compression of the fistula by finger
against the sternum
Mx of TIF
 Physiological Changes caused by
Tracheostomy

Loss of upper air way functions include:

 Warming of air
 Humidification of air
 Filtering of air, including dust particles and micro-
organisms
 Communication/vocalising
 Swallowing, nutrition & hydration
 Smell
 Decrease the dead space by 50%=150 ml
 Difference in dead space between endotracheal tube and
tracheostomy 20 ml
 Tracheostomy tube Size
 the outer diameter of the tracheostomy
tube should be: ⅔ - ¾ of the tracheal
diameter.

 As a general rule outer diameter:

adult females: 10mm
adult males: 11mm
Tips for suctioning
 Suctioning tips
Suction catheter size (Fg) =
(Size of tracheostomy tube – 2) *2

 The lowest possible vacuum pressure should be

used - ≤ 100-120 mmHg (minimise atelectasis)

 Duration: not more than 10 sc

 Installation of saline to ‘aid’ suctioning is not

recommended