Basic management of tracheostomy emergencies

1. Basic management of tracheostomy emergencies Dr Harry Chan & Jackie Hylton October 30th 2012

2. Tracheostomy care in perspective 5000 tracheostomies performed / yr 600 incidents reported to NPSA ~ 70% incidents patients came to harm

3. Contents of talk • Recognition of a tracheostomy problem 2) Basic approach to managing the tracheostomy emergency

5. What are the commonest tracheostomy emergencies? Blockage and obstruction Accidental displacement

6. How do you recognise a tracheostomy problem? General colour, distress, effort Obstruction ‘see-saw’ respiration Displacement tube appears out surgical emphysema noisy breathing from mouth vocalisation when cuff up

8. O2, help, assess patency oxygenation

9. You are asked urgently to see a patient who has been stepped down from the High Dependency Unit yesterday. You are told that he is not a laryngectomy patient He appears breathless, sweaty and has an obstructed breathing pattern……… What would you do?

10. 7 steps • Oxygen • Help • Look, listen and feel • Remove possible obstructing parts • Insert suction catheter • Deflate tracheostomy cuff • Remove tracheostomy tube

11. OXYGEN 1 To the tracheostomy…………….

12. And to the face……..if there is a possible patent upper airway

13. HELP 2 ENT ICU Anaesthesia

14. LOOK, LISTEN & FEEL 3

15. In the ideal world…………….. A Water’s circuit A capnograph trace

16. REMOVE ANY OBSTRUCTING PARTS 4 Speaking valves Humidification devices Any inner cannula

17. REMOVE SPEAKING VALVES

18. REMOVE HUMIDIFICATION DEVICES

19. REMOVE ANY INNER CANNULA

20. 5 INSERT A SUCTION CATHETER

21. The patient is still deteriorating and becomes more hypoxic What now?

22. 6 DEFLATE THE TRACHEOSTOMY CUFF If present, deflate cuff

23. The patient still deteriorates and is severely hypoxic now What next?

24. REMOVE THE TRACHEOSTOMY TUBE 7

25. 7 steps • Oxygen • Help • Look, listen and feel • Remove possible obstructing parts • Insert suction catheter • Deflate tracheostomy cuff • Remove tracheostomy tube

26. The patient stops breathing What are your options for oxygenating and ventilating the patient now?

27. Basic emergency oxygenation Cover stoma with a swab

28. Stomal ventilation

29. What is the airway expert likely to do ?

30. Airway expert emergency oxygenation options Oral intubation Railroading an Aintree catheter over a fibreoptic scope

31. You arrive at a cardiac arrest on the ward to a patient who has had a laryngectomy in the past….. He is not breathing What would you do now?

32. What’s different about the laryngectomy patient?

33. Pre - laryngectomy Post - laryngectomy

34. The laryngectomy patient • In many ways, more straight forward – there is only one potential airway… You cannot bag mask ventilate or intubate via the normal oral route You can still go through the 7 steps, just avoid the upper airway!

35. Summary Tracheostomy emergencies usually relate to obstruction or displacement of tubes Initial management includes 1)O2 2)help 3) assessment of breathing 4) removing possible obstructions 5) using a suction catheter to test patency 6) Deflating any cuff 7) Removing the tracheostomy tube if required Management of the laryngectomy patient is limited to the neck

36. www.tracheostomy.org.uk