Tracheostomies

Tracheostomies

Jan 31, 2017 0
critical care,education,intensive care,onthepods

James talks to Dr Jon Gatward about tracheostomies.

Summary Writer:  Sam Orton

Editor: Jon Gatward

Interviewee: Jon Gatward

About Dr Jon Gatward

Jon is a dual-trained Anaesthetist/Intensivist from the UK but now works full time as an Intensive Care Specialist at Royal North Shore Hospital in Sydney. He has special interests in medical education, simulation and airway management. He runs the in-situ simulation program at Royal North Shore ICU, where he is also the education coordinator.

Jon heads up the RNSH tracheostomy team, a group of inter-professional clinicians who care for patients with tracheostomy and laryngectomy.  He also runs an airway course (the Critical Care Airway Management Course) in Sydney twice a year. He is also interested in patient safety and quality, and a member of the Intensive Care Services Network Best Practice Working Group at the NSW Agency for Clinical Innovation. He is loving being a new Dad to baby Thomas.

Tracheostomies

With Dr Jon Gatward, Staff Specialist Intensivist, Royal North Shore Hospital

Overview

A tracheostomy is a tube inserted in the neck between the level of the larynx and the sternum. There is a varied population that require a tracheostomy. These include patients with respiratory disease, neurological disease and post-surgical.

Some may have a patent upper airway (above the tracheostomy site), while others, such as post laryngectomy patients may not. Deterioration of a patient with a tracheostomy, particularly, with increased work of breathing and tachypnoea is a medical emergency. In addition to calling for help, there are many simple steps that junior doctors and other medical staff can perform to stabilise the patient and begin troubleshooting.

Tracheostomy basics

What are the indications for insertion of a tracheostomy?

These fall into 3 broad categories:

  • Prolonged mechanical ventilation

Most common. Prevents damage to the larynx and upper airway from long term endotracheal intubation and ventilation. A tracheostomy is also preferable in that it provides a stable airway for clinicians, is more tolerable for the patient and allows for reduced sedation levels and earlier rehabilitation

  • Upper airway obstruction

Tumour, surgery, foreign body, infection (i.e. abscess)

  • Airway secretions

Tracheostomy insertion allows for easier pulmonary toilet and suction of secretions

  • Reduced levels of sedation and improved patient comfort
  • Avoidance of laryngeal injury
  • Improved communication
  • Better oral care
  • Improved ventilation
  • 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.

 

Immediate (peri-procedure) Intermediate (can occur at any time) Long-term
  • Bleeding
  • Hypoxia
  • Loss of airway
  • Pneumothorax/subcut emphysema
  • Tube dislodgement
  •  Tube obstruction
  • Tracheomalacia
  • Tracheostenosis
  • Tracheo-oesophageal fistula
  • Tracheo-Inominate fistula
  • Stoma infection
  • Swallow dysfunction

 

 

 

  • 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.
Image 1 (left): Features of a dual cannula tracheostomy tube
Source: Trachs.com
  • 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.

  1. 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.

Case 1

You are a junior doctor working on an after-hours shift covering the acute spinal unit. You are asked to review a 25-year-old spinal patient with a tracheostomy who has developed difficulty breathing.

This is an emergency. If the patient looks very distressed or peri-arrest, then a code blue/arrest call should be called as increased help and advanced airway skills may be needed.

  • Related to the underlying reason for the need for the tracheostomy tube:
    • Neurological conditions.
    • Respiratory conditions.
  • Related to the tracheostomy tube:
    • Blocked by secretions/blood.
    • Tube misplacement – Particularly concerning is when the tracheostomy tube is dislodged into the subcutaneous tissues.
  • 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.
Example of a dual cannula tracheostomy tubeand inner cannulae
Source: Trachs.com
laryngectomy tube
Source: Trachs.com

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.
Suction catheter, note the flexible, soft tube and valve port at the distal end which needs to be covered to create suction. These should be available at the bedside
  • 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.

Case 2

You are the after-hours junior doctor covering the Head and Neck surgical ward. A nurse calls you to review a patient who is bleeding. The nursing staff are not sure if it is from within or around the tracheostomy tube.

  • Call for help – If this is a small amount of blood, it may be sufficient to call for help from a senior member of the team. However, if there is respiratory distress or any signs of deterioration – Call an arrest.
  • Personal Protective Equipment.
  • Try to clear the airway – once again use the suction catheter to try and remove any blood causing an obstruction and allow better visualisation.
  • If it appears the blood is coming from around the site – apply firm pressure and homeostatic dressings to get control of the bleeding.
  • If the blood is coming up the tube – this is a more serious problem.
  • Place pressure over the sternal notch.
  • Maximally inflate the cuff of the tube (if the patient has an uncuffed tube, which are often found in laryngectomy patients, this may not be possible).
  • Using a maximally inflated cuff works by applying pressure which can tamponade and bleeding vessels.
  • If the patient is still deteriorating despite the above measures – the placement of an endotracheal tube (from someone with advanced airway skills) may be able to reach distal to the bleeding site and provide oxygenation to the lungs with the endotracheal tube cuff providing some airway protection.

Case 3

You are the junior doctor on an after-hours shift and a nurse calls you over to review a patient whose tracheostomy may have fallen out.

Remember, that most tracheostomy patients have two airways – Upper and tracheostomy airways.

  • Call for help.
  • Ask for help to occlude the tracheostomy stoma so that any ventilation applied to the upper airway goes to the lungs.
  • Normal airway assessment – including simple airways manoeuvres, oxygenation.
  • If the patient is unable to be ventilated and oxygenated via the upper airway, consideration of tracheostomy re-instrumentation may be considered.
  • This is not advocated if a patent upper airway is present.
  • If the patient has a laryngectomy then there is not an upper airway, insertion of a new tracheostomy tube will need to be considered by senior staff.
  • 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.
Emergency Laryngectomy guidelines UK
Source: Tracheostomy.org.uk

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Tags: #airway obstruction,#airway secretions,#ICU,#intensivecare,#laryngectomy,#mechanicalventilation,#postop,#respiratory medicine,#SMACC,#surgery,#tachypnoea,#The Global Tracheostomy Collaborative,#trachea,#tracheostomy,#tracheotomy,#upperairway

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