James talks to Dr Jon Gatward about tracheostomies.
Summary Writer: Sam Orton
Editor: Jon Gatward
Interviewee: 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.
With Dr Jon Gatward, Staff Specialist Intensivist, Royal North Shore Hospital
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.
What are the indications for insertion of a tracheostomy?
These fall into 3 broad categories:
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
Tumour, surgery, foreign body, infection (i.e. abscess)
Tracheostomy insertion allows for easier pulmonary toilet and suction of secretions
These can be divided into immediate, delayed and long-term.
|Immediate (peri-procedure)||Intermediate (can occur at any time)||Long-term|
There are several different skills that allow speech.
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.
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.
Often a problem in tracheostomy patients – Especially those with new large bore stomas.
Inflated cuff tube causes a mechanical obstruction to swallowing.
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.
All of the above steps are safe for a junior doctor to perform as part of initial management and trouble shooting.
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.
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.
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