My simple basic guide for dealing with the tracheostomy patient in the emergency department.

1. Trachy Emergencies!
By Kane Guthrie

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

3. 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”

4. The Tube’s
• Tracheostomy tubes are devices that aid
passage of air into the lungs for effective
respirations.

5. 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!!

6. Anatomy

7. Indications!
• To maintain the airway
• To protect the airway
• For bronchial toilet
• For weaning from IPPV

8. 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!

9. 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.

10. The Types!
Surgical:
Percutaneous:

11. 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.

12. Percutaneous
• Done in emergency circumstance where
theater is not an option.
Procedure:
– No surgical incision required- opening is made via
percutaneous “stab” into trachea.

13. 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!

14. The Types
Cuffed:
Uncuffed:

15. The Types
1. Cuffed and uncuffed
2. Fenestrated and unfenestrated
3. Those with inner cannulas and those without

16. Cuffed Vs Uncuffed
• Used initially • Used long term
• Reduces aspiration, • Pt needs reasonable
foreign matter in bulbar function to clear
airway. own secretions
• Prevents air escape in
MV.
• Cuff pressure 15-
25mmHg.
• Use in emergencies!

17. 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.

18. Inner cannula
• Have an inner tube that allows removal if
becomes obstructed to allow removal &
cleaning
• Reduce potentially life threatening
complications.
• Increases the WOB.

19. The Size’s
www.resusroom.com

20. Immediate Complications
• Bleeding
• Pneumothorax or pneumomedistinum
• Injury to adjacent structures
• Post obstructive APO

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

22. Late Complications
• Swallowing problems
• Tracheal stenosis
• Tracheo-inominate artery fistula
• Tracheoesophageal fistula
• Granuloma formation

23. 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

24. 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

25. 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?

26. 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?

27. 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!

28. The Blocked Trachy

29. 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?

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

31. 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.

33. 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!

34. Questions?

35. 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.