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
