Here’s what you need to know when you have an airway emergency.
One of the most important parts of coming across an airway emergency is first assessing the problem. Compare the situation in front of you with the normal state. Experience and time with caring for tracheostomy tubes will be the best teacher. Dyspnea would be signaled by an abnormally high respiratory rate, abnormal breathing pattern, low saturation, or appearance of panic.
Checking the following items will help to assess the source of an issue.
Excessive secretions or dried secretions are the primary cause of an obstructed tracheostomy. Assess the sputum consistency and amount produced by the patient. To rule out this problem the following may help to confirm the presence or absence of this problem.
- Assessment: Visible secretions coming from the tracheostomy. Noises from the tracheostomy are the quickest assessment of this situation. Auscultation may reveal rhonchi or coarse breath sounds in the presence of secretions.
- If a patient is using a mechanical ventilator an increased Peak Inspiratory Pressure (PIP) may be observed.
- Passing a suction catheter should relieve this situation. If it does not attempt suctioning again.
- Bagging/Lavage/Suction sequence may be used. (Note: It may not be your institution’s policy to use a saline lavage. Follow local policy and procedures)
- Remove the inner cannula and replace with a new inner cannula.
- Finally, it may be necessary to completely change the tracheostomy tube. Prepare equipment and personnel to safely complete this procedure.
A tracheostomy tube that is not in the proper position (one that is pulled out and causing a large leak) will not perform as it should. If the tracheostomy tube needs to be reinserted the cuff must be deflated before advancing the tube back into position.
Displacement of the tube also includes a tube that may appear in correct position but is not because it has been inserting into a false channel instead of the trachea. Placement of the tracheostomy tube into a false channel is difficult to notice as patients are often able to talk. To rule out this problem the following may help to confirm the presence or absence of this problem.
- First listen to confirm bilateral breath sounds. Diminished or absent breath sounds are a good indication that something is not normal.
- If a patient is using a mechanical ventilator a high Peak Inspiratory Pressure (PIP) may be observed or the alarm may be activated . This is because the false channel leads only to the tissues surrounding the trachea and not the lungs.
- If you aren’t able to pass the catheter and hit resistance there is a good chance that the tracheostomy is in a false channel. Passing a suction catheter should remove any retained secretions and should clear the high PIP situation.
- Between suction attempts observe that the saturations improve on 100% FiO2. If they do not this may be another clue that the tracheostomy tube is in an incorrect position.
Correct tracheostomy tube position should not be assumed based on flange position. Again using assessment skills to assess lung sounds, end tidal CO2, returned tidal volume from a ventilator are more accurate measures.
If both of the conditions above are satisfactory look towards the equipment and possible failure or sub-optimal performance. The equipment for tracheostomy is quite durable however it may occur that the equipment is the source of the problem. Replace any non-functioning equipment promptly.
Application of Emergency Resuscitation Equipment to Tracheostomy Tube
Applying a resuscitation bag is essentially the same as attaching the resuscitation bag to an endotracheal tube. The difference is typically we expect the endotracheal tube to have a fully inflated cuff. All the air delivered from the resuscitation bag flows to the lungs and then out via the exhalation valve.
Do a quick check to see that the tracheostomy tube cuff is inflated.
If the patient is using an uncuffed tracheostomy tube remove the cuffless tracheostomy tube and replace it with a cuffed tracheostomy tube.
In either case (with a cuffed or uncuffed tracheostomy tube) resuscitation breaths may leak from around the tracheostomy tube. If you aren’t able to provide an adequate tidal volume do not waste time to fully remove the tracheostomy tube and completely occlude the stoma with a piece of gauze.