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Tracheostomy

Emergencies

Jacqueline Pflaum-Carlson, MD

Henry Ford Hospital Detroit

Disclosures

• None

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Objectives

• Differentiate between standard tracheostomy and post laryngectomy tracheostomy

• Review standard tracheostomy parts

• Know when to call for help

• Identify and stabilize life threatening emergencies typical for ER docs

TracheostomyLaryngectomy

Images complements of Mayo Clinic and MSKCC

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Typical Tracheostomy Set Up

Cuffed Trach Uncuffed trach

Fenestrated Cuffed Trach Fenestrated uncuffed trach

Obturator

Pilot balloon

Outer cannula

Cuff

Inner Cannula

Fenestration

https://www.hopkinsmedicine.org/tracheostomy/about/types.html

Our Focus

• Vent dependent patients with cuffed

tracheostomies

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Tracheostomy Complications

• Early:

• Obstruction

• Displacement

• Malfunction

• Bleeding

• Late:

• Tracheoinnominate artery fistula

• Tracheoesophageal fistula

• Infection

Case #1

• 75 y/o male s/p trach and PEG coming from LTAC for acute

respiratory distress. LTAC facility states patient has had

increased secretions since his arrival and today he was

noted to be hypoxic, tachypneic and diaphoretic.

HR 130 BP: 140/100 RR 28 SpO2 86% on 100% FiO2 8

PEEP

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CXR

What do you want to know?

• Is the trach functional?

• Why was the trach placed?

– Is there an upper airway obstruction that can complicate oral

intubation or oxygenation if necessary.

• Why was the trach placed?

– <7 days the stoma is unlikely to have matured and you’re at high

risk of creation of a false passage if trach needs replacement

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Case #1

• 75 y/o male s/p trach and PEG 4 days ago at OSH following

a large MCA stroke leaving him hemiplegic and non-

communicative.

• Is the trach functional?

Is the tube obstructed?

Remove inner cannula and attempt

to pass suction catheter.

Is the patient breathing?

Assess for pulse

Start ACLS

Apply high flow to both the

face and tracheostomy

site

Emergency Oxygenation Pathway

Standard oral airway maneuvers with covered

stoma

(BVM, Oral/Nasal airway adjuncts, LMA)

Stoma Ventilation:

Face mask to stoma (pediatric sized)

LMA to stoma

Attempt oral intubation (prepare for difficult)

Attempt stoma intubation with small cuffed ETT

Deflate cuff and attempt

oral ventilation.

Consider Removing the Tracheostomy

No

Yes

No

Is the patient improving?

Continue assessment for

underlying cause

Approach to the

Hypoxic Patient

with Tracheostomy

No improvement

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Case #1

• RT arrives to bedside, inner cannula is removed and suction

applied

• Patients vitals improve, saturation improves to 95%

Tracheostomy Obstruction

• Mucus plugging, blood clot, foreign body

– Clinical presentation: respiratory distress, ventilatoryfailure

– Diagnosis: difficulty suctioning

– Management: remove inner cannula and pass suction catheter to attempt to clear obstruction, if unable to clear, may need to remove trach completely

• If > 7 days, remove and replace with new trach using obturator

• If <7 days, surgeon should be involved. May need to endotracheally intubate

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Is the tube obstructed?

Remove inner cannula and attempt

to pass suction catheter.

Is the patient breathing?

Assess for pulse

Start ACLS

Apply high flow to both the

face and tracheostomy

site

Emergency Oxygenation Pathway

Standard oral airway maneuvers with covered

stoma

(BVM, Oral/Nasal airway adjuncts, LMA)

Stoma Ventilation:

Face mask to stoma (pediatric sized)

LMA to stoma

Attempt oral intubation (prepare for difficult)

Attempt stoma intubation with small cuffed ETT

No

Yes

No

Is the patient improving?

Continue assessment for

underlying cause

Approach to the

Hypoxic Patient

with Tracheostomy

No improvement

Deflate cuff and attempt

oral ventilation.

Consider Removing the Tracheostomy

Images curtesy of National Tracheostomy Safety Project

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• Oral intubation should only be

attempted if upper airway is patent

– Notify emergent or urgent airway team (if

available)

– Have adjuncts at bedside: fiberoptic

scope, glidescope, LMA, Bougie

• Stoma intubation can be facilitated

using a bougie

– Be cognizant of ETT distance

– Should be followed by bronchoscopic

airway assessment

Image: Iddrisu Baba, Yabasin & Adam, Abass & Wilfred, Sam-Awortwi & Ibrahim, Mohammed & Reith, Andreas & Jacob Bagviel, Yangyuoru & Du Nguyen, Phu & Kampo, Sylvanus & Ziem, Juventus.

Tracheostomy Replacement

• Tracheostomy stoma’s take approximately 7 days to mature

– Attempts to replace and manipulate prior to 7 days can result in a false passage

• Placement without obturator can result in false passage due to sharp edge of inner cannula

• Resistance during replacement should be respected

• Post replacement visualization with bronchoscopy

• If unable to replace trach, intubation should be attempted either orally or with ETT via the stoma

IMAGE: Sodhi, K. (2019). Anticipated Difficult Tracheostomy: Should CT Scan Be a Pre-

Requisite. [online] Imedpub.com. Available at: http://www.imedpub.com/articles/anticipated-

difficult-tracheostomy-should-ct-scan-be-a-prerequisite.php?aid=21666 [Accessed 19 Mar.

2019].

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Tracheostomy Replacement

• Accidental dislodgement

• Trach fracture

• Balloon malfunction

• Air leak with stoma enlargement

• Unsurpassable obstruction

https://aneskey.com/quality-of-life-and-complications-after-percutaneous-tracheostomy/

Case #2• 38 year old obese female presents from home complaining of

bleeding from her trach site. She is vent dependent due to

hypercapnic respiratory failure. This morning she woke up in a “pool

of blood” and noted blood to be seeping from around the trach site, it

stopped just prior to coming to the ED. She denies any vent alarms,

she denies chest pain or shortness of breath but does report

lightheadedness.

• HR 105 BP 140/95 RR 12 Sat 100% on PEEP 5, FiO2 21% Vt 420

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What do you want to know?

• How old is the trach?

– 3 weeks

• Where was it placed and was there any difficulty?

– Your facility in the OR, surgeon said she was his most difficult

trach in ten years

• Is she on any blood thinners?

– No

• Is the trach functional?

What do you want to do next?

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Bleeding from Tracheostomy

• Post Tracheostomy bleeding

approx. 6%

• First 48-72 hours

– Superficial venous bleeding from

manipulation or aggressive suctioning

• Generally not “major” but can cause problems

if clots form in airway

– Management: Packing, xerofoam, gel

foam, silver nitrate, epi injections

• After 72 hours high risk for

tracheoinnominate artery fistula

Manfro G., Dias F.L., de Farias T.P. (2018) Tracheostomy Complications. In: de Farias T. (eds)

Tracheostomy. Springer, Cham

Tracheoinnominate Artery

Fistula

• Connection between the innominate

(brachiocephalic) artery and the trachea.

• <1% risk of forming, with up to 86%

mortality

• Risk Factors:

– High cuff pressures

– Low trach placement

– Repetitive head movements (seizures, tics) resulting

in repeated friction/movement.

• Many patients with massive hemorrhage

from TIF have history of sentinel bleed

http://qims.amegroups.com/article/viewFile/1817/2553/7243

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Tracheoinnominate Artery

Fistula

• Diagnosis:

– OR with rigid bronch and direct visualization

– Role for CTA?

• Management: apply pressure

– Hyperinflate cuff up to 50 mL or direct

compression with finger

– Emergent consultation with ENT +/-

cardiothoracic surgery

– Reversal of coagulopathy and resuscitation

with blood products.

Case #3

• 65 y/o m with h/o TBI, chronic ventilation who is being sent

to the ED from SNF for abdominal distention and increasing

ventilator requirements with frequent suctioning of thin

yellow secretions.

HR: 90 BP 110/80 RR 12 SpO2: 90% on 80% FiO2, PEEP 8,

Vt 450

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Case #3

• CXR hypoventilatory lungs with dilated esophagus and large

gastric bubble.

• ABG reveals mild respiratory acidosis.

• Bedside suction performed and thin, bilious secretions are

obtained.

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Tracheoesophageal Fistula

• Most commonly a result of prolonged mechanical ventilation.

• Risk Factors: high cuff pressures, prolonged time of intubation, steroid use, IDDM, poor nutritional status, old age.

• Presentation: air leaks despite hyperinflated cuff, abdominal distension, recurrent pneumonia

• Diagnosis: CT may identify, esophagram, bronchoscopy as gold standard.

• ED Management:

• Adjust ventilator to optimize gas exchange

• Hold feeds and decompress abdomen via LIS

• Treat aspiration pneumonia

• Consider surgical consult

Infection

• Stoma Infection

• Ventilator Associated pneumonia

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Summary

• Tracheostomy emergencies are airway emergencies follow ACLS protocols

• Oral intubation is an option in patients with patent upper airways

• You can intubate a stoma

• In massive tracheostomy bleeding, consider tracheoinnominate fistula and call for help

Thank you

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