Tracheostomy Emergencies

Tracheostomy Emergencies and Management

Charles S. Williams RRT, AE-C

Learner objectives  Recognize

a tracheostomy patient needing emergency intervention.  Identify common causes of tracheostomy emergencies.  Describe ways to establish an emergent airway.  Review various tips for suctioning a patient with a tracheostomy tube.

Signs of Tracheostomy Tube Problems

Signs of Tracheostomy Tube Problems 

Patient showing signs of respiratory distress



Increased work of breathing/retractions



Decreased breath sounds/chest rise



Altered mental status



Changes in vital signs



Cyanosis



Ventilator high pressure alarms

Common Causes of Tracheostomy Problems The most common causes of respiratory distress for a patient with a tracheostomy tube in place are, tube blockage from secretions and tube dislodgement.

Common Causes of Tracheostomy Tube Problems D

-

Dislodged/ Displaced

O

-

Obstruction

P

-

Pneumothorax

E

-

Equipment Failure

D – Dislodged Trach tubes may become dislodged from:  Improper

airway positioning  Trach ties or Dale straps too loose.  Vigorous coughing or sudden movements.  Sudden weight changes (i.e. a connected Ambu bag).

O – Obstruction Trach tubes may become obstructed from:  Improper

positioning of the patient.  Secretions  Bleeding  Foreign objects  Edema in the trachea (rare)

Managing Trach Tube Problems First: Attempt to pass suction catheter

Tip - Measure catheter against obturator

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

If catheter is able to pass to measured depth…

…obstruction is within the trach tube

…obstruction is below the trach tube.  Tube is most likely dislodged/displaced.

Managing Trach Tube Problems If obstruction is within the trach tube…

If obstruction is below the trach tube….

…clean or replace the inner cannula.

…instill normal saline, attempt suctioning and bag ventilation. •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) Lubricate new tube Deflate old cuff w/ syringe (Do not cut) Undo old ties, remove tube Put in new trach, remove obturator Attempt to ventilate Secure new trach tube

4. 5. 6. 7. 8. 9.

Changing a Trach Tube 

Always have at least two people!



If you meet any resistance: ST OP!

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

oximetry

skin color, vitals signs, pulse

Inserting a Trach Tube The “guidewire” technique:

 May use a nasogastric tube or suction catheter

Inserting a Trach Tube The “Fingertip” technique:

 Tracheostomy tube in place

 Trach tube removed  Thyroid gland isthmus causing obstruction  Skin opening and tracheal window not aligned

Inserting a Trach Tube The “Fingertip” technique:

 Neck extended  Gloved forefinger inserted into stoma, below thyroid ishtmus

 Tracheostomy tube inserted as finger is removed

Managing Trach Tube Problems If attempts at re-inserting a new tube are unsuccessful:

or

 Apply an occlusive

dressing to the stoma  Begin BVM ventilation

 Begin BVM to stoma

ventilation (pediatric mask?)  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

against trach tube  Do not cut ET tube

Confirm placement 1. 2.

Breath sounds End-tidal CO2

 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

Every patient with a tracheostomy tube should have the following equipment at bedside:    

Spare trach tubes (same size and one smaller) Obturator placed in a clear, plastic bag at HOB Manual resuscitator bag, masks Suction equipment

Suctioning Tips  “Safe

suction” measurement

 Fenestrated  Ballard

Trach Tube

in-line suction

Sources 

EMS Management of Tracheostomy Emergencies



Tracheosomy Care for All Ages: Maryland Institute For Emergency Medical Services



Dislodged Tracheostomy, Paradorn Pattanong M.D.

Questions?

Thank You!