• Can be inserted 2 ways: surgically or percutaneously
• Surgical tracheostomy – Performed by a specialist surgeon in the operating theatre.
  • Performed under direct vision by dissection of overlying structures.
• Percutaneous tracheostomy – Insertion is often performed by an intensivist within the ICU using a Seldinger guide-wire technique.
  • Benefits of percutaneous insertion (vs surgical) include lower rates of local infection, reduced bleeding and reduced need for transportation of patients.
  • Due to this, it is often considered the standard of care in those that can have it performed safely.

These can be divided into immediate, delayed and long-term.

• Size
  • Range from 4mm to 10mm diameter in adults (paediatric sizes can be smaller).
• Length
  • Most are of a standard length.
  • Some can be longer for use in obese patients.
  • Adjustable length tracheostomy tubes are also available (aka adjustable flange tracheostomies).
• Inner and outer tubes
  • Most (esp. in hospital) tracheostomies have an inner and outer cannula/tube.
  • This is a safety mechanism – Allows for removal of the inner tube in the event of obstruction of the tube (blood clots, tenacious secretions).
  • It is important to know what type of tube a patient with a tracheostomy has. Some tubes can connect to the ventilator via the outer tube and some only via the inner tube. In those who connect via the inner tube, it is important to have a spare tube nearby in the event of blockage as without this, is is not possible to ventilate the patient.
• Flange
  • Flat plastic plate attached to the outer tube that lies flush against the patient’s neck and allows the tube to be secured in position.
• Cuffs
  • Most tracheostomy tubes are cuffed, allowing for positive pressure ventilation to be delivered and protects the airway against aspiration.
  • Can be uncuffed if the patient has a patent upper airway and is requiring minimal ventilator support.
• Fenestrations
  • Hole on the upper curve of the outer tube – allows enhanced flow through the vocal cords to facilitate speech.
• Tracheostomy cap
  • Used to occlude the tracheostomy tube during respiration prior to decannulation (weaning) – with cuff down.
• Pilot Cuff
  • Serves an an indicator of amount of air in the cuff.
• Laryngectomy Tubes
  • A specialized tube used specifically in Laryngectomy patients.
  • Usually uncuffed.

• Similar principles apply to patients who are ventilated via an endotracheal tube.
• As most patients are in the weaning phase from ventilation, spontaneous modes of ventilation are more common than mandatory modes.

• Speech

There are several different skills that allow speech.

1. Pushing air out around the cuff of the tube.
2. Speaking valves.

One-way valve on the end of tube which open on inspiration and closes on expiration. This forces air past the vocal cord to allow speech.

It is extremely important that the tracheostomy cuff is fully deflated.

3. Voice Prosthesis devices

Often used in laryngectomy patients.

Surgically placed trachea-oesophageal fistula with a valve inserted.

The valve allows phonation by directing gas from the lungs and trachea (via patient occlusion of the stoma) through the valve and out through the oesophagus and pharynx.

• Swallowing

Often a problem in tracheostomy patients – Especially those with new large bore stomas.

Inflated cuff tube causes a mechanical obstruction to swallowing.

• Chronic lack of air-flow through the pharynx results in a loss of sensation and inability to coordinate the swallowing muscles.
• In the weaning phase of removing a tracheostomy – cuff deflation periods allow air flow and better sensation to allow for better swallowing.

• Past medical Hx and why the tracheostomy was placed.
• Is this a tracheostomy or laryngectomy patient?
  • Ideally – The patient should have a sign above their bed indicating whether they are a tracheostomy or laryngectomy patient.

• Start with vital signs, end of the bed observation and in particular, respiratory rate and work of breathing.

• What type of tube is it?
• Is it a single (without inner cannula) or dual (with inner cannula)? It may be possible to remove the inner cannula.
  • Look at the opening of the cannula.
  • Remove a speaking valve or any caps (if patient is currently weaning).
  • Look for a locking mechanism with an arrow on it which indicates that an inner tube is present. If not obvious, look at the cannula to see if you can see an inner cannula inside.
• Does the patient have a patent upper airway? Ask the nurse and review the notes.
• Signs of bleeding around the stoma.

All of the above steps are safe for a junior doctor to perform as part of initial management and trouble shooting.

• Tenacious secretions
• Blood clots
• Sputum plugs

• If the patient has a patent upper airway (i.e. not a laryngectomy patient), attempt to give oxygen as via as many ways as possible. This can include via the tracheostomy tube and orally.
• If in doubt whether this is a laryngectomy of tracheotomy patient, deliver oxygen via both areas.
• If the patient is really struggling – need to give oxygen via the tracheostomy. This can be achieved by attaching a bag/valve mask to the tracheostomy.
  • Note: It is important the the tracheostomy tube is not displaced. If the tube has been displaced into the subcutaneous tissues, oxygenation via the tube will lead to subcutaneous emphysema which may worsen the situation.
  • Must establish the tube is patent prior to delivery of oxygen.

• There are many guidelines – A useful stepwise approach is available at org.uk (Algorithms for Tracheostomy and laryngectomy patients attached at end of this document).
• Basic steps to follow:
  • Look, listen and feel for airflow through the tracheostomy tube.
  • If the patient is not breathing – Call an arrest.
• Look for End-tidal CO2 (may be available depending on the ward) as an indicator of ventilation.
• If there is a speaking valve cap of filter – remove this.
• Look for an inner cannula, if present, remove this.
• All tracheostomy patients should have a suction catheter at the end of their bed – These are generally soft with a side-port that needs to be covered to give suction (see image below).
• Deflate the cuff – make sure the cuff has not herniated around the bottom of the tube which can occur.
• At this point, if there is still no airflow and the patient is deteriorating, it is time to pull the tube out.
• This part of the algorithm is the most confronting – However, if you have followed the algorithm to this point, then the next step is to remove the tracheostomy.

• In most cases, the tracheostomy will not be sutured in position – If it is, use a stitch cutter to remove these.
• Ties around back of neck (usually Velcro) which need to be untied.
• Deflate the cuff and then pull the tracheostomy out.

• Treating team consultant/advanced trainee/registrar
• Tracheostomy team if available
• If the above are not available – someone with advanced airway skills – ENT, ICU, Anaesthetics, Rapid Response Teams

• Get to know the Tracheostomy emergency algorithm (see attached schematic below).
• Contact the tracheostomy team at your hospital to discuss equipment used and troubleshooting.
• Review equipment used in your wards and on different patients.
• Be familiar with emergency equipment that will be required in an emergency.
• Have a low threshold for escalation.

• Hyzy R, Mathur P, Finlay G. Overview of tracheostomy, Up to Date. 2016: 13 October
• Nickson C. Tracheostomy tubes. Life in the Fast Lane. 2014: 11 June
• Nickson C. Percutaneous tracheostomy. Life in the Fast Lane. 2015: 15 April
• Various authors. Tracheostomy and laryngectomy emergency management guidelines. National tracheostomy safety project. 2016
• RNSH ICU – Tracheostomy Team
• The Handbook – Critical Care Airway Management Critical Care Airway
• The First10EM – The bleeding tracheostomy
• Agency for Clinical Innovation. Care of Adult Patients in Acute Care Facilities with a Tracheostomy, Clinical Practice Guideline, 2013