Lessons from ICU-IS-SIM 001
Author: Chris Nickson
Peer Reviewers: Jo Simpson
Human beings have a natural inclination to attach a bag-valve apparatus and start bagging any patient with an endotracheal tube who is experiencing respiratory compromise. Most of the time this is useful, as it excludes the ventilator as a problem and isolates the problem as being an issue with the tube or patient.
However, if the type of endotracheal tube the patient has is a tracheostomy tube, rather than an oral or nasal endotracheal tube, this ‘reflex’ can lead to catastrophe.
Like any endotracheal tube, tracheostomy tubes can become blocked or displaced (remember “DOPES“). However if they are displaced, such that the tube communicates with the subcutaneous pretracheal tissues rather than the tracheal lumen, positive pressure ventilation can lead to dramatic subcutaneous emphysema. This can make securing an airway – either orally or via front of neck access – very difficult and may impair further attempts at oxygenation and ventilation.
Hence, the key initial steps in management of a tracheostomy patient with respiratory distress, before providing bag-valve ventilation, are:
- remove the inner cannula (if present)
- ensure tube patency and position
- in an emergency, this is best done by checking that a suction catheter passes freely
- if the patient is breathing spontaneously, tube position can be confirmed using ETCO2
- in non-emergency situations, bronchoscopy and chest x-ray can also help confirm tube position
While doing this, the patient can be oxygenated via a face mask over the mouth and nose – but ensure the tracheostomy tube cuff (if present) is deflated! Otherwise, the oxygen has no chance of entering the lungs if the tracheostomy tube is actually still in the trachea.
Remember, only provide positive pressure ventilation after confirming tracheostomy tube patency and position.
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‘Lessons from ICU-IS-SIM’ is our way of disseminating the lessons we learn, and continually relearn, from the simulation programme at The Alfred ICU as we try to ensure better care for our patients.