Respiratory distress in the patient with a tracheostomy (update)

This is an update of a previous version of this post. I am reposting to coincide with the release of a new textbook that I am pretty excited about. The textbook is the Resuscitation Crisis Manual. It provides very succinct action scripts for the major emergencies that we see. It is exactly the textbook that I always wanted in residency, but didn’t exist. The absence of this kind of resource was exactly the reason that I started First10EM. (Perhaps, in the future, Scott can just keep me up to date on his projects. If I had just waited a couple years, I could have had the textbook without feeling like I had to write it by myself.) I wrote the “Tracheostomy Emergencies” chapter of the book – hence the decision to repost this topic. (I guess I should note that I don’t get anything for writing that chapter, so I don’t have any financial conflicts of interest – just intellectual biases.)

If you want to hear more about the book, check out this EMCrit podcast.

Case

A 45 year old man, well known to your department because of a prior anoxic brain injury and multiple complications including a permanent tracheostomy, is brought in by ambulance from home in respiratory distress. You know from prior conversations with the family that the patient is to receive full, aggressive medical management. He is using every accessory muscle that you can see, his respiratory rate is 55, and his oxygen saturation is 87% on room air…

My approach

Call for help. You will want RT present. You may also want ENT and someone who can operate a fiberoptic scope (if that isn’t you).

Ensure all your difficult airway equipment is out and ready.^1,2

Apply oxygen to both the patient’s face and the tracheostomy site. (If there has been a laryngectomy, there will be no connection between the upper airway and the trachea, but if you are not sure, put oxygen on the face.) The priority is oxygenation and not necessarily definitively securing the airway.¹

Assess for breathing (air movement) by looking, listening, and feeling at both the mouth and the tracheostomy. Waveform capnography should be applied if available.^1,2

Aside from your normal differential diagnosis of respiratory distress, the tracheostomy adds three important considerations: tube obstruction, tube displacement, and equipment problems.

Key question: Is the tracheostomy patent and appropriately placed?

• Detach any external device, such as a humidifier or speaking valve
• Remove the inner cannula. (This step will immediately resolve any respiratory distress resulting from an obstructed inner cannula.)
• Attempt to pass a suction catheter.
  If it passes, you have a patent airway. Suction, and consider partial obstruction. Ventilate via
  the tracheostomy if required. Continue with your standard dyspnea work-up
• If the suction catheter does not pass, assume the tube is either displaced or obstruced. Deflate the cuff (if present) and immediately remove the tube.¹
• Alternate option: If immediately available, and the patient is stable (not hypoxic), you can inspect the tracheostomy with a fiberoptic scope to rule out obstruction and displacement.

Key question: Is there a patent upper airway?

In patients with normal upper airway anatomy, you are going attempt to ventilate or intubate orally. In patients with a laryngectomy, or with large tumors that occlude the airway, skip those steps. 

Attempt to ventilate using standard upper airway techniques, such as oral and nasal airways, bag-valve-mask, or LMAs. To do this, you will have to occlude the stoma by placing a hand over top of it and applying gentle pressure. An immediate intubation attempt is also reasonable. (Skip if laryngectomy.)¹

If unsuccessful, attempt to ventilate via the stoma. You can apply a small pediatric facemask or a size 2 LMA over the stoma and attempt to BVM ventilate. To prevent air leak, have an assistant close the patient’s mouth and nose.^3,4,5

If unsuccessful, attempt to intubate the stoma. I would insert a bougie first, feel for hold-up, and then advance a small (6.0) cuffed ETT over top. You may also use a replacement trach (generally, a smaller size than the one removed).^2,6,7

Algorithms from the UK National Tracheostomy Safety Project

Notes

The management of tracheostomy emergencies is guided by limited evidence. We mostly rely on reviews of prior complications and expert opinion. The most comprehensive management guidelines currently available are probably those produced by the UK National Tracheostomy Safety Project, in conjunction with key groups such as the Difficult Airway Society.¹

For every patient with a laryngectomy (no remaining connection between the upper airway and the trachea), there are 20-30 patients with tracheostomies (the connection remains).

The initial approach to a deteriorating patient with a tracheostomy is similar to the approach to the intubated patient, so it is reasonable to start with the DOPES mnemonic.

However, if the patient isn’t on a vent, stacked breaths and pneumothorax are less likely to be a problem.

In general, do not replace a tracheostomy that is less than 7 days old. Call ENT.^6,8 (However, if the patient is dying, you aren’t going to wait for the surgeon. In emergency medicine, we often have to break these kinds of rules. I would use a bougie through the stoma first, both because of its smaller size, and the potential to ‘confirm’ that you are in the airway. I would then advance a small sized tube over top.)

Other FOAMed Resources

National Tracheostomy Safety Project

Tracheostomy emergencies on EMCrit

Tracheostomy in the Critical Care Airway Mangement (CCAM) course handbook

The Technologically Dependent Child on PEM Playbook

Respiratory Distress in a Tracheostomy Patient on LITFL

LMA to stoma ventilation on RESUS.ME

Trouble with Trachs – Recannulating the Stenosed Trach Site on Taming the SRU

Tracheostomy emergencies at Intensive

References

1. McGrath BA et al. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012;67:1025-41. PMID: 22731935
2. Mitchell RB, Hussey HM, Setzen G. Clinical consensus statement: tracheostomy care. Otolaryngology–head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 148(1):6-20. 2013. PMID: 22990518
3. Padley A. Yet another use for the laryngeal mask airway–ventilation of a patient with a tracheostomy stoma. Anaesthesia and intensive care. 29(1):78. 2001. PMID: 11261918
4. Kannan S, Birch JP. Controlled ventilation through a tracheostomy stoma. Anaesthesia and intensive care. 29(5):557. 2001. PMID: 11669450
5. Ball DR, Paton L, Jefferson P, Caldwell D. Tracheostomy ventilation using a laryngeal mask as a ‘bridge to extubation’. Anaesthesia. 2010;65:(12)1232-3. PMID: 21182613
6. Morris LL, Whitmer A, McIntosh E. Tracheostomy care and complications in the intensive care unit. Crit Care Nurse. 2013;33:(5)18-30. PMID: 24085825
7. Behar S, Cooper J. Best Practices In The Emergency Department Management Of Children With Special Needs. Pediatric emergency medicine practice. 12(6):1-25; quiz 26. 2015. PMID: 26118120
8. Lewis RJ. Tracheostomies. Indications, timing, and complications. Clinics in chest medicine. 13(1):137-49. 1992. PMID: 1582143

Other reading

Townsley RB, Baring DE, Clark LJ. Emergency department care of a patient after a total laryngectomy. Eur J Emerg Med. 2014;21:(3)164-9. PMID: 23426202

Patel MR, Cannon TY, Shores CG. Chapter 242. Complications of Airway Devices. In: Tintinalli J et al. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381728

Greenwood JC and Winters ME. Tracheostomy Care. In: Roberts JR, ed. Roberts and Hedges’ clinical procedures in emergency medicine, 6e. Philadelphia,PA: Elsevier; 2014.

O’Connor MF, Glick DB. Airway Management. In: Hall JB, Schmidt GA, Kress JP.eds. Principles of Critical Care, 4e. New York, NY: McGraw-Hill; 2015. http://accessmedicine.mhmedical.com/content.aspx?bookid=1340&Sectionid=80032102