Laryngectomy & Tracheostomy Emergency Management & Patient Perspective

Laryngectomy & TracheostomyEmergency Management&Patient Perspective Amy Kerr, SLT Mr Taran Tatla, ENT Consultant Wednesday 17th July 2013

Altered Airway • Huge impact on people’s lives • Discoordinated care can result in dangerous, potentially fatal situations • Practices variable • Awareness & knowledge can be lacking • Catastrophic events • Opportunity to do better

Artificial Airway Incidents • Majority due to airway loss: • Displaced trache • Tube occlusion (partial or complete) • Airway obstruction / stenosis • Potential factors: • Lack of staff education • Confusion with anatomy • Lack of equipment / resources

What is the purpose of an Artificial Airway? • Provide adequate ventilation and oxygenation • Maintain a patent airway • Eliminate airway obstruction • Reduce the potential for aspiration • Provide access for secretion clearance

Normal anatomy

Tracheostomy

Laryngectomy

Total Laryngectomy • Removal of larynx • Separation of trachea from oesophagus • Permanent stoma

Contributing factors to an emergency • Over production of sputum • Coughing • Irritation of trachea • Undue movement of the tracheostomy tube • Multiple suctioning attempts • Dry, hardened secretions • Sputum plug blocking airway or tracheostomy tube • Cuff integrity compromised • Aspiration of stomach contents • Dysphagia

National Patient Safety Agency • Approached by the National Association of Laryngectomy Clubs – due to concerns re: emergency care • 171 surveys returned

National Patient Safety • 26/171 patients required ambulance assistance and felt that staff didn’t have the right equipment available. • 30/171 patients required emergency treatment in hospital and felt that the hospital staff did not know how to manage their specific needs. • The main concerns for both were lack of: • Tracheostomy masks for delivering oxygen • Suction units for clearing stoma • Tracheal forceps to remove plugs • A patient wrote of his experience in A+E with chest pains. “The nurse was going to give oxygen. I told the nurse I was a neck breather and she then said put the mask on him and we’ll force the air down”

Emergency Management • Ventilation • Suctioning • Aspiration • Loss of airway • Cardiopulmonary resuscitation

Ventilating Tracheostomy vs Laryngectomy patients • Via the stoma* / tracheostomy ^ • Trache patients – inflate cuff to form seal • Laryngectomy – insert a trache/endotracheal tube into stoma and inflate cuff • *never via the mouth for a laryngectomy • ^must not forget standard oral airway manoeuvres in an emergency with an obstructed tracheostomy

Suctioning • Tracheostomy: • ensure non-fenestrated inner cannula and suction via the tracheostomy • Laryngectomy : • suction via the stoma, no need to place tracheostomy tube.

Aspiration – Tracheostomy • Reduce risk by changing to a cuffed tube and inflating cuff, change to a non-fenestrated inner cannula • NB: inflating cuff will help reduce aspiration of secretions but not completely eliminate • Request SLT assessment • If chronic consider use of medication to reduce secretions

Aspiration - Laryngectomy • If no Surgical Voice Restoration (SVR), very low risk unless recent Head & Neck Surgery

Total Laryngectomy - SVR • If patient has SVR then ensure; • The voice prosthesis is in place – if dislodged and you are able to see the tract – place catheter • Is the voice prosthesis leaking? If it is leaking continue NBM and request SLT assessment

Loss of airway • Tracheostomy: • Suction – if unable to pass catheter remove inner cannula – remove secretions • If still unable to pass catheter patient may require a trache change • Consider positioning of trache, type of trache • Remember standard oral airway manoeuvres

Loss of Airway • Laryngectomy: • Place tracheostomy / endotracheal tube via stoma • Laryngectomy tube (monitor stoma size) • Suction as required • Humidification: • Regular nebulisers • Humidified oxygen • Ensure adequate hydration to thin & loosen secretions • Speaking valves (e.g. Passy-Muir) NOT for use with laryngectomy patients!

Cardiopulmonary Resuscitation • Tracheostomy: • Inflate cuff (if tube not blocked or displaced) • Bag ventilate via tracheostomy tube connector (catheter mount) • If the tracheostomy tube is removed due to blockage/ displacement & unable to be replaced: • If the upper airway is patent, cover the stoma (swabs/ hand) and ventilate via the upper airway (e.g. Bag-valve-mask) • If the upper airway is not patent, ventilate via a paediatric mask or laryngeal mask airway (LMA) applied to the stoma • Compression to breath ratio 30:2

Cardiopulmonary Resuscitation • Laryngectomy: • Bag via stoma using a paediatric mask or LMA • Insert a trache / endotracheal tube and inflate cuff to form seal • Compression to breath ratio 30:2

UK National Tracheostomy Safety ProjectNTSPwww.tracheostomy.org.uk

Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012 Jun 26. doi: 10.1111/j.1365-2044.2012.07217, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd."

Laryngectomy & Tracheostomy Emergency Management & Patient Perspective