Tracheostomy Emergency 002
Author: Chris Nickson
Reviewers: Andrew Udy, Chris Hebel
A 38 year-old man with a history of severe traumatic brain injury is undergoing rehabiliation. He has trachestomy tube in situ. A percutaneous tracheostomy was performed 2 months ago, when he was in ICU for airway protection and to assist sputum clearance.
Today he started coughing up sputum and became unsettled. After a coughing fit he pulled at his trachestomy tube, then pushed it back in. Over the past few minutes there has been a small amount of bleeding around the trachostomy site and the patient has developed marked respiratory distress.
The staff at the bedside have removed the inner cannula from the tracheostomy tube and administered 15 L/min O2 via a tracheostomy hood. Unfortunately, his SpO2 is falling and his chest is not moving normally despite significant respiratory effort.
You asked to urgently assess him.
Q1. What will you do immediately?
As always, assess ABCs and call for help early
- look, listen and feel for breathing at the mouth and tracheostomy
- perform CPR if indicated
The airway is the priority!
- This patient has signs of complete airway obstruction: hypoxia with absent or paradoxical chest movement despite increased respiratory effort.
High flow oxygen should be administered to the mouth/ nose and to the stoma site.
- If the tracheostomy tube is cuffed, you will need to deflate the cuff to oxygenate via the nose/ mouth.
The next step is to remove the inner cannula (and plug or speaking valve if present)
- usually, as in this case, the bedside nurse performs this step before calling for help — always confirm that this has occurred, do not assume!
Next it is important to check if tracheostomy tube is patent or displaced. This is done by passing a suction catheter through the tracheostomy tube and suctioning.
- If the suction catheter cannot be passed then the tube is either blocked or displaced. Note that even if able to pass then the tube could still have a partial blockage or be partially displaced, though there is typically increased resistance.
- If capnography (carbon dioxide / CO2 monitoring) is available, the position and patency of the tracheostomy tube can be confirmed by colour change (purple to yellow) on a colorimetric device or by the presence of an end-tidal CO2 (ETCO2) waveform.
You discover that a suction catheter does not pass through the tracheostomy tube. The patient is still in respiratory distress, is hypoxic and his chest is not moving normally.
Q2. Should you attempt positive pressure ventilation with bag-valve apparatus next?
Only attempt postive pressure ventilation once the position of the tracheostomy tube within the trachea has been confirmed (e.g. able to pass suction catheter freely through the tracheostomy tube).
Given the clinical information provided the patient may have created a false tract by traumatically replacing the tracheostomy tube in the stoma. A malpositioned tube can directly obstruct the trachea, or indirectly due to local swelling and bleeding. If the tracheostomy tube is positioned in the subcutaneous tissue, rather than in the trachea, positive pressure ventilation will result in subcutaneous emphysema that may worsen airway obstruction and make intubation difficult.
Q3. What should you do next?
Remove the tracheostomy tube!
- Inability to pass a suction catheter means that the tracheostomy tube is either blocked or displaced, and should be removed.
- This can be a difficult act for doctors to commit to perform. The bottom line is that if it is not working, take it out. Failure to act in this situation can result in severe hypoxic injury or death.
Oxygenation and ventilation via the oral route is usually effective
- Always check patients’ histories to ensure that they have not had a laryngectomy, bilateral vocal cord palsies or some other reason why this may be difficult or impossible
- Remember to cover the tracheostomy site during oxygenation and ventilation via the oral route (e.g. apply gauze and gentle pressure)
- The airway can be optimised using head tilt and chin lift, or jaw thrust. Use airway adjuncts as required.
If the oral airway management is unsuccessful, attempt oxygenation and ventilation via the stoma
- options include the use of a paediatric mask or a laryngeal mask airway (LMA) held over the stoma site
If the patient’s respiratory distress and oxygenation doses not improve with these measures, a definitive airway (e.g. oral endotracheal intubation) is usually indicated.
You remove the tracheostomy tube and oxygenate the patient via a face mask. His hypoxia resolves and his respiratory distress settles. You then notify the appropriate consultants and document the events, your assessment and the ongoing management plan.
References and links
- Hess DR. Tracheostomy tubes and related appliances. Respir Care. 2005 Apr;50(4):497-510. Review. PubMed PMID: 15807912.[Free Full Text]
- LITFL CCC — Respiratory distress in a tracheostomy patient
- LITFL CCC — Tracheostomy tubes
- UK National Tracheostomy Safety Project at www.tracheostomy.org.uk (see the emergency flowcharts)
All case-based scenarios on INTENSIVE are fictional. They may include realistic non-identifiable clinical data and are derived from learning points taken from clinical practice. Clinical details are not those of any particular person; they are created to add educational value to the scenarios.