tracheostomy emergencies

Tracheostomy Tracheostomy Emergencies and Emergencies and

ManagementManagement

Charles S. Williams RRT, AE-CCharles S. Williams RRT, AE-C

Learner objectivesLearner objectives

Recognize a tracheostomy patient Recognize a tracheostomy patient needing emergency intervention.needing emergency intervention.

Identify common causes of Identify common causes of tracheostomy emergencies.tracheostomy emergencies.

Describe ways to establish an Describe ways to establish an emergent airway.emergent airway.

Review various tips for suctioning a Review various tips for suctioning a patient with a tracheostomy tubepatient with a tracheostomy tube..

Signs of Tracheostomy Tube Signs of Tracheostomy Tube ProblemsProblems

Signs of Tracheostomy Tube Signs of Tracheostomy Tube ProblemsProblems

Patient showing signs of respiratory Patient showing signs of respiratory distressdistress

Increased work of breathing/retractionsIncreased work of breathing/retractions Decreased breath sounds/chest riseDecreased breath sounds/chest rise Altered mental statusAltered mental status Changes in vital signsChanges in vital signs CyanosisCyanosis Ventilator high pressure alarmsVentilator high pressure alarms

Common Causes of Common Causes of Tracheostomy ProblemsTracheostomy Problems

The most common causes of The most common causes of respiratory distress for a respiratory distress for a

patient with a tracheostomy patient with a tracheostomy tube in place are, tube in place are, tubetube

blockage from secretionsblockage from secretions and and tube dislodgementtube dislodgement..

DD - - Dislodged/ DisplacedDislodged/ Displaced

OO - - ObstructionObstruction

PP - - PneumothoraxPneumothorax

EE - - Equipment FailureEquipment Failure

Common Causes of Common Causes of Tracheostomy Tube Tracheostomy Tube

ProblemsProblems

DD – Dislodged – Dislodged

Improper airway positioningImproper airway positioning Trach ties or Dale straps too loose.Trach ties or Dale straps too loose. Vigorous coughing or sudden Vigorous coughing or sudden

movements.movements. Sudden weight changes (i.e. a Sudden weight changes (i.e. a

connected Ambu bag).connected Ambu bag).

Trach tubes may become dislodged from:

OO – Obstruction – Obstruction

Improper positioning of the patient.Improper positioning of the patient. SecretionsSecretions BleedingBleeding Foreign objectsForeign objects Edema in the trachea (rare)Edema in the trachea (rare)

Trach tubes may become obstructed from:

FirstFirst: Attempt to pass suction catheter: Attempt to pass suction catheter

TipTip - Measure catheter against obturator - Measure catheter against obturator

Managing Trach Tube Managing Trach Tube ProblemsProblems


If catheter If catheter cannotcannot pass pass to measured depth…to measured depth…

If catheter If catheter is able is able to pass to pass to measured depth…to measured depth…

……obstruction is obstruction is withinwithin the trach tubethe trach tube

……obstruction is obstruction is belowbelow the trach tube. the trach tube. Tube is most likely Tube is most likely dislodged/displaced.dislodged/displaced.


… …clean or replace the clean or replace the inner cannula.inner cannula.

……instill normal saline, instill normal saline, attempt suctioning and bag attempt suctioning and bag ventilation.ventilation.

•Prepare to change the trach Prepare to change the trach tubetube

If obstruction is If obstruction is withinwithin the trach tube…the trach tube…

If obstruction is If obstruction is belowbelow the trach tube….the trach tube….

Changing a Trach TubeChanging a Trach Tube

Trach Tube, obturator, syringe and ties Trach Tube, obturator, syringe and ties (ready to go)(ready to go)

Proper positioning of the patient Proper positioning of the patient (neck (neck hyperextended, supine).hyperextended, supine).

Towel/shoulder rollTowel/shoulder roll Suction equipmentSuction equipment Manual resuscitator bag and masksManual resuscitator bag and masks

Water soluble lubricantWater soluble lubricant Normal saline/sterile waterNormal saline/sterile water


1.1. Gather equipmentGather equipment

2.2. Position patient flat and midlinePosition patient flat and midline

3.3. Hyperextend neck (towel roll)Hyperextend neck (towel roll)

4.4. Lubricate new tubeLubricate new tube

5.5. Deflate old cuff w/ syringe (Do not Deflate old cuff w/ syringe (Do not cut)cut)

6.6. Undo old ties, remove tubeUndo old ties, remove tube

7.7. Put in new trach, remove obturatorPut in new trach, remove obturator

8.8. Attempt to ventilateAttempt to ventilate

9.9. Secure new trach tubeSecure new trach tube


Always have at Always have at least two people!least two people!

If you meet any If you meet any resistance: resistance: STOP!STOP!

Possible Complications Possible Complications When Inserting a Trach When Inserting a Trach

TubeTube Creation of a false lumen or passageCreation of a false lumen or passage

Subcutaneous airSubcutaneous air

Pneumothorax or Pneumothorax or

PneumomediastinumPneumomediastinum

BleedingBleeding

Confirming Placement of Confirming Placement of Trach or ET TubeTrach or ET Tube

No resistance encountered while No resistance encountered while inserting tubeinserting tube

Equal chest riseEqual chest rise

Bilateral breath soundsBilateral breath sounds End-tidal CO2 detectionEnd-tidal CO2 detection Improved skin color, vitals signs, Improved skin color, vitals signs,

pulse oximetrypulse oximetry

The “guidewire” technique:The “guidewire” technique:

Inserting a Trach TubeInserting a Trach Tube

May use a nasogastric tube or suction catheterMay use a nasogastric tube or suction catheter

The “Fingertip” technique:The “Fingertip” technique:


Tracheostomy tube in Tracheostomy tube in placeplace

Trach tube removedTrach tube removed Thyroid gland isthmus causing Thyroid gland isthmus causing obstructionobstruction Skin opening and tracheal window Skin opening and tracheal window not alignednot aligned

The “Fingertip” technique:The “Fingertip” technique:


Tracheostomy tube inserted as Tracheostomy tube inserted as finger is removedfinger is removed

Neck extendedNeck extended Gloved forefinger inserted into Gloved forefinger inserted into stoma, below thyroid ishtmusstoma, below thyroid ishtmus


If attempts at re-inserting a new tube are If attempts at re-inserting a new tube are unsuccessful:unsuccessful:

Apply an occlusive Apply an occlusive dressing to the stomadressing to the stoma Begin BVM Begin BVM ventilationventilation

Begin BVM to stoma Begin BVM to stoma ventilation ventilation (pediatric mask?)(pediatric mask?)

Must for Must for Laryngectomy Laryngectomy patients! patients!

or

Endotracheal tube into stomaEndotracheal tube into stoma

If other interventions are unsuccessful, then If other interventions are unsuccessful, then consider:consider:

Oral intubation (if appropriate), while Oral intubation (if appropriate), while maintaining occlusive dressing over maintaining occlusive dressing over

stoma.stoma.

or

Inserting an ET TubeInserting an ET Tube

Measure ET tube Measure ET tube against trach tubeagainst trach tube Do not cut ET tubeDo not cut ET tube

Confirm Confirm placementplacement

1.1. Breath soundsBreath sounds2.2. End-tidal CO2End-tidal CO2

Secure ET tubeSecure ET tube

PP – Pneumothorax – Pneumothorax

High Peak Inspiratory PressuresHigh Peak Inspiratory Pressures High Positive End-Expiratory Pressures High Positive End-Expiratory Pressures

(PEEP)(PEEP) Vigorous bagging with AmbuVigorous bagging with Ambu Underlying disease (COPD)Underlying disease (COPD) TraumaTrauma

Pneumothorax can develop from:Pneumothorax can develop from:

Signs and Symptoms of a Signs and Symptoms of a PneumothoraxPneumothorax

Shortness of breath/ Shortness of breath/ respiratory distressrespiratory distress

Diminished or absent Diminished or absent breath soundsbreath sounds

Tracheal deviationTracheal deviation Sub-Q emphysemaSub-Q emphysema CyanosisCyanosis

Signs and Symptoms of a Signs and Symptoms of a PneumothoraxPneumothorax

Patient needs immediate Patient needs immediate needle decompression! needle decompression! (2(2ndnd intercostal space) ACLS intercostal space) ACLS

Do not wait for X-ray Do not wait for X-ray confirmation!confirmation!

EE – Equipment – Equipment

Ventilator/power failureVentilator/power failure Vent circuit problems (disconnected, Vent circuit problems (disconnected,

obstructed)obstructed) Trach supplies and equipment missingTrach supplies and equipment missing

Troubleshoot all equipment and maintain necessary Troubleshoot all equipment and maintain necessary suppliessupplies

Equipment problems can result from:

Spare trach tubes (same size and one smaller)Spare trach tubes (same size and one smaller) Obturator placed in a clear, plastic bag at HOBObturator placed in a clear, plastic bag at HOB Manual resuscitator bag, masksManual resuscitator bag, masks Suction equipment Suction equipment

Every patient with a tracheostomy tube should Every patient with a tracheostomy tube should have the following equipment at bedside:have the following equipment at bedside:

““Safe suction” measurementSafe suction” measurement

Fenestrated Trach TubeFenestrated Trach Tube

Ballard in-line suctionBallard in-line suction

Suctioning TipsSuctioning Tips

EMS Management of Tracheostomy EmergenciesEMS Management of Tracheostomy Emergencies

Tracheosomy Care for All Ages: Maryland Institute For Tracheosomy Care for All Ages: Maryland Institute For

Emergency Medical ServicesEmergency Medical Services

Dislodged Tracheostomy, Paradorn Pattanong M.D. Dislodged Tracheostomy, Paradorn Pattanong M.D.

SourcesSources

Questions?Questions?

Thank You!Thank You!

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