Trachy Emergencies

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 2 nd & 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 Cuffed and uncuffed Fenestrated and unfenestrated Those with inner cannulas and those without

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

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 C omplications 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.

32. 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!

33. Questions?

34. 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.