Tracheostomy Emergency 001
Author: Chris Nickson
Reviewers: Andrew Udy, Chris Hebel
You asked to urgently attend a patient who is in respiratory distress.
The patient is a 26 year-old man who is undergoing rehabilitation following an isolated traumatic brain injury. While he was in ICU a percutaneous tracheostomy was performed for airway protection and to assist sputum clearance. 8 weeks later, he is in rehabilitation and still has a tracheostomy tube in situ.
Q1. What will you do as part of your immediate assessment?
As with any potential medical emergency you should assess ABCs and call for help early
- look, listen and feel for breathing at the mouth and tracheostomy
- perform CPR if indicated
A useful approach in an intubated patient is to assess ‘MASH’:
- Movement of the chest during ventilation — is it absent, or is movement only on one side? Is the chest hyper-expanded?
- Arterial saturation (pulse oximetry (SpO2), and/or arterial blood gas if available)
- Skin colour of the patient (is he turning blue or pinking up?) — the SpO2 monitor may lag behind the true oxygen saturation of the patient or may read incorrectly
- Haemodynamic stability
Consider the possible causes of respiratory problems in an intubated patient — think ‘DOPE’:
- displaced tube
- obstructed tube
- patient factors (e.g. pneumonia, pneumothorax, pulmonary embolus)
- equipment problems (e.g. ventilator if present)
While you are performing your assessment you note the following:
- the patient appears distressed
- marked accessory muscle use
- chest is not moving
- SpO2 90% on 15 L/min oxygen via tracheostomy hood
Q2. In an emergency, how can you tell if the airway is patent in a tracheostomy patient?
Patency of the tracheostomy tube can be assessed rapidly at the bedside by passing a suction catheter down the tracheostomy tube.
If the suction catheter passes freely, then the tube is patent. If it doesn’t, then suctioning may clear the obstruction (e.g. sputum). If the suction catheter passes, but with increased resistance, there may be partial obstruction.
Common causes of obstruction are:
- sputum plugging
- malposition (e.g. tip of the tracheostomy tube is abutting the tracheal wall)
- tube displacement (e.g. creation of a false tract on attempted reinsertion of a tracheostomy tube that has fallen out)
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.
Q3. What should you always do before assessing airway patency as described in Q2?
Remove the inner cannula!… as well as any plugs or speaking valves if present.
Most tracheostomy patients with have a double lumen tube. This means there is ‘a tube within the tube’. If secretions, blood or a sputum plug has obstructed the inner cannula the problem is immediately solved on removal. This is an easy way to fix life-threatening airway obstruction.
Always do this first.
The inner cannula can usually be easily removed.
- Depending on the type of tracheostomy tube there may be a ‘pull tag’, others may have a ‘twist to unlock’ mechanism.
- Sometimes the inner cannula is difficult to see as it may be transparent or the same colour as the outer cannula.
- The nurse at the bedside will usually remove the inner cannula before calling for assistance, however this should be confirmed, never assumed.
Note that all patients at the Caulfield Acquired Brain Injury (ABI) unit and The Alfred ICU should, with few exceptions, have a double lumen tracheostomy tube.
You check to see if an inner cannula is present. You pull the tab and remove the inner cannula. The patient begins to breathe normally and the SpO2 monitor increases to 100%. You examine the inner cannula and find a sputum plug obstructing the tip.
Q4. What should you do next?
Give yourself a pat on the back and then:
- Complete your assessment ensuring there is no other cause of respiratory distress. Further investigation (e.g. a chest radiograph) may be required if a pneumonia is suspected, for instance.
- Ensure a replacement inner cannula is inserted into the tracheostomy tube. The inner cannula is an important safety measure protecting against sputum plugging of tracheostomy tubes. In addition, Some inner cannulae need to be replaced to connect to breathing circuits.
- Review the tracheostomy care record and confirm that appropriate routine trachesotmy care is being performed.
- Notify the consultant. The external ICU Consultant at The Alfred ICU should be notified of potential emergencies affecting tracheostomy patients at Caulfield ABI unit.
- 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.