Imagine you’re in resus, juggling your many sepsis patients, when a patient is rushed into the room. All you hear is “trach problem.” Before you jump to the AMAC > ENT pathway, think about this simple outline. There are 3 main trach emergencies and 3 major things you need to know. Read below for an approach to tracheostomy emergencies.
3 Important Questions:
- WHEN was the trach placed. This changes management if the trach is dislodged.
- <7 days, don’t touch the trach **CALL ENT** the stoma tract is not mature
- >7 days old, stoma tract should be formed, you can replace the trach if needed
- WHAT size/type Sinai stocks Shiley, Elmhurst stocks Portex, they do the same thing but ideally, for an exchange, use the same type and size if possible
- WHY the trach was placed. Basically you want to know did the patient have a laryngectomy or a tracheostomy. This also changes management. Tracheostomy is more common with a plethora of indications. Laryngectomy however is usually reserved for patients with laryngeal disease, those airway structures are completely removed and there is no longer a connection between nose/mouth and the trachea/lungs.
3 Main Emergent Complications and Approach:
- Most common complication, typically secondary to secretions
- Remove inner cannula
- Suction trach
- If unable to pass suction through trach after multiple attempts, remove and replace if safe. Ventilate via oropharynx if airway patent.
- Extremely difficult to replace if tract has not formed – usually takes 1 week for tract to heal
- <7 days = BVM and orotracheal intubation, do not attempt to replace trach, ENT needs to evaluate the trach
- >1 week w mature tract = possible to attempt to replace trach with obturator
- Most feared complication is tracheoinnominate fistula – innominate artery erodes into the trachea
- Incidence is 0.7% with mortality rate approaching 100%
- Causes – pressure necrosis from cuffs with too high of pressures, improper placement of cannula tip, radiation therapy, steroids, hyperextension of head
- Most commonly 3-4 weeks after surgery
- MGMT – oxygenate, cuff overinflation (attempt to tamponade bleeding) translaryngeal intubation, direct compression, ENT/SURGERY, possible IR
Here are detailed algorithms for trach management:
Here is the anatomy of the tracheostomy tube! Know your tools:
Listen to this podcast: EMCrit Trach Emergency
Read this article on consensus guidelines: Guidelines Tracheostomy and Laryngectomy Airways
Check out these Sources:
- McGrath, B. A., et al. “Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies.” Anaesthesia 67.9 (2012): 1025-1041.
- Morris, Linda L., Andrea Whitmer, and Erik McIntosh. “Tracheostomy care and complications in the intensive care unit.” Critical care nurse 33.5 (2013): 18-30.
- http://tracheostomy.org.uk/ – Great site with information about emergent trach care.