Trachy Emergencies!

By Kane Guthrie

Objectives

• A brief look at tracheostomy emergencies.• Indications for tracheostomy.• The different types of tracheostomy tubes. • Approach to the trachy emergency.• Case studies.

The Trachy!

Tracheotomy:‘is a surgical incision into the trachea for the

purpose of establishing an airway”

Tracheostomy‘is the stoma (opening) that results from the

tracheotomy”

The Tube’s

• Tracheostomy tubes are devices that aid passage of air into the lungs for effective

respirations.

Trachy Emergencies

Most common emergencies you will face:– Obstruction– Displacement

• More Pt being D/C home with long term Trachies!

= ED nurses need to know what to do when things go wrong!!

Anatomy

Indications!

• To maintain the airway• To protect the airway• For bronchial toilet• For weaning from IPPV

Cautions & Contraindications

• Difficult anatomy• Moderate coagulopathy• Proximity to site of recent surgery or trauma• Localised infection• Severe gas exchange problems

Patients generally requiring an emergency trachy don’t have the luxury of having these conditions corrected before hand!

Patient Benefits!

• Less risk of long-term airway damage.• Patient comfort – no tube in mouth!• Some can eat & talk!• Tube more secure some patients can mobilise.

The Types!

Surgical:

Percutaneous:

Surgical

• Normally done electively (ICU,OT) • Can be done @ bedside (emergently)• 3-5cm incision 1 cm below cricoid• Done under general or local anaesthetic.Procedure– Dissection down to the trachea, surgical incision is

made in “T” shape, between 2nd & 3 rd tracheal rings.

Percutaneous

• Done in emergency circumstance where theater is not an option.

Procedure:– No surgical incision required- opening is made via

percutaneous “stab” into trachea.

Emergency

• Emergency circumstance requiring extreme measure to secure the airway

• Cricothroidotomy

• Procedure:– Percutaneous stab into trachea to provide an

opening and allow ventilation.– Scalpel-bougie, Scalpel –finger, Ball point pen!

The TypesCuffed:

Uncuffed:

The Types

1. Cuffed and uncuffed2. Fenestrated and unfenestrated3. Those with inner cannulas and those without

Cuffed Vs Uncuffed

• Used initially• Reduces aspiration,

foreign matter in airway.

• Prevents air escape in MV.

• Cuff pressure 15-25mmHg.

• Use in emergencies!

• Used long term• Pt needs reasonable

bulbar function to clear own secretions

Fenestrated

Fenestrated:• Has pre-cut opening in posterior aspect of

tube.• Facilitates air entry through the tube and

allows speech.• Has 2 tube’s one that allows suctioning, eating

& during sleep, the other allows talking.

Inner cannula

• Have an inner tube that allows removal if becomes obstructed to allow removal & cleaning

• Reduce potentially life threatening complications.

• Increases the WOB.

The Size’s

www.resusroom.com

Immediate Complications

• Bleeding• Pneumothorax or pneumomedistinum• Injury to adjacent structures• Post obstructive APO

Early Complications

• Bleeding RT - HT or coughing• Mucous Plugging• Tracheitis• Cellulitis• Displacement of tube- false passage• SubQ emphysema• Atelectasis

Late Complications

• Swallowing problems• Tracheal stenosis• Tracheo-inominate artery fistula• Tracheoesophageal fistula • Granuloma formation

When to Suction?

• Course breath sounds (crackles)• Noisy Breathing• ∧or ∨ resp rate• ∨ Sp02• Copious secretions• Pt attempting but unable to cough or clear

secretions• Distressed or agitation

Factors that can Contribute to Emergencies!

• Overproduction of sputum• Coughing• Irritation of the trachea• Undue movement of the tube• Multiple suctioning attempts• Dry, hardened secretions –sputum plug• Cuff integrity compromised• Vomitus or aspiration of stomach contents

The Approach

• Is the tracheostomy tube displaced or obstructed?

• Is the tube cuffed or uncuffed?• How old is the tract?• What is the size of the tube?• Why was the tube placed?

Case 1

• 28 male P1 ambulance• Known Quad with long term trachy.• P/C: ?Blocked trachy• 0/A: Cyanosed lips, not moving air. • V/S: Spo2 70%, HR 145, GCS 8

What do you do?

Blocked Trachy

• Apply O2 to mouth and trachy• Try Suctioning – remove inner cannula. • Partial occlusion use saline Nebs,

humidification, suctioning.• If fail try BVM – push down occlusion into

lungs. • Change trachy tube or re-intubate!

The Blocked Trachy

Case 2

• 74 male known throat ca• Long term trachy - fenestrated• P/C Trachy fallen out• O/A: Mild resp distress, unable to talk/• V/S: RR 22, Spo2 90%, Bp 138/84,

• What do you do?

The Dislodged Trachy

• Completely dislodged vs. false passage!• Most prevalent in newly created trachy!• Occurs with forceful coughing and poorly

secured trachy.

The Dislodged Trachy

• Replace with same size or smaller.• May need trachy dilators and bougie to assist.• Trachy set not available use small ETT. • Check correct placement – pass suction

catheter, Etco2, clinical improvement, auscultation, CXR.

• R/F to ENT.

Take Home Points

• Trachy emergencies generally uncommon!• Have an approach!• Know how to suction!• Provide O2 to trachy and to mouth if

distressed!• Always change to cuffed tube in emergencies!• Same size or smaller or just use an ETT!

Questions?

References:

• www.resusroom.com/• SCGH- Tracheostomy Education package.• Hess, D. (2005). Tracheostomy Tubes and Related

Appliances. Respiratory Care. 50(4), 497-510.• De Leyn, P. et.al. (2007). Tracheotomy: clinical review

and guidelines. European journal of Cardio-thoracic surgery. 412-421.

• Jordan, S. & Gay, S. (2002).Tracheostomy Emergencies. American Journal of Nursing. 102(3), 59-63.