tags:: #on/simulation | #note/sharing # Tracheostomy Emergencies in Anesthesiology: ## What is a tracheostomy? Either an open surgical or percutaneous tracheotomy (may be the preferred term actually) creating an opening to the trachea through the front of the neck, performed below the cricothyroid membrane in the 2nd or 3rd tracheal rings. The length from the stoma to the carina is 4-7 cm in most patients. ### When teaching tracheostomy emergencies, what are the [[essential questions]]? - How do I prepare all patients for the OR? What do I need to know about their airway? *topic essential* - When should we use checklists? *overarching essential* - How do I create a safe airway plan for all patients? *topical essential* - How do I maximize the team during a crisis? *overarching essential* ### Fenestrated vs Non-fenestrated: Tracheostomy tubes can be fenestrated or non-fenestrated. They consist of an outer cannula, an inner cannula, and an obturator for placement. Image below is fenestrated. Outer cannula with balloon, inner cannula with fenestration and cap, inner cannula without fenestration, obturator, tracheal tie. ![[iu 1.jpeg]] See the source: [Tube Types.pdf](https://www.dropbox.com/s/r6sw8y4qzk001wf/Tube%20types.pdf?dl=0) for detailed description of the different types of tubes and their components. For initial placement, a non-fenestrated tube is used. This may be exchanged for a fenestrated tube in order to bridge to weaning and to allow speaking. The first tube exchange should take place in the hospital with experienced clinicians present. A speaking valve is a 1-way valve allowing air to enter the trachea from within the tube, but does not allow air to leave the tracheostomy through the tube. This type of Passy-Muir Valve *cannot be used with a cuffed tube, as it would not allow exhalation should the cuff be inflated.* ### Cuffed vs Uncuffed: Cuffed tubes must be used for positive pressure ventilation. Uncuffed tubes may be used for long-term in non-PPV patients (non-vented), but in the setting of an emergency must be exchanged for a cuffed tube in order to produce a seal. ### Tube Ties "Tracheostomy tube ties should be used to prevent accidental decannulation. A patient may be turned in bed after making sure the tracheostomy tube is secure. The panel recognized that ties may not be suitable and the tracheostomy sutured, for example, in a patient who recently underwent local or free flap surgery, to avoid neck pressure from the ties. A patient should not be discharged from the hospital with a tracheostomy tube sutured in place. Sutures are usually removed at the first tube change, which should occur prior to discharge." (Mitchell et al., 2013) p.12 ## Why have a tracheostomy? The most common reason is for long-term ventilation, to promote weaning from the vent, and to allow. Some patients will have tracheostomy performed after laryngectomy or other complex head/neck surgery, others for acute or chronic upper airway obstruction. ## Surgical considerations for patients with tracheostomy: An appropriate airway management plan should take into account the indication of the tracheostomy, the maturity status of the stoma, the type and size of tracheostomy tube, the expected patient positioning, and presence of patient’s concurrent health conditions. ## Pre-anesthesia Checklist ![[CleanShot 2022-02-22 at 17.45.04.jpg]]A Preanesthesia checklist for tracheostomized patients (Rosero et al., 2021) ### Laryngectomy? During a laryngectomy, the proximal tracheal end is diverted anteriorly to the skin to form a permanent stoma and there is no upper airway. Of note, the laryngectomy stoma can look similar to the stoma created in a tracheotomy; however, mask ventilation and oral tracheal intubation will not be possible. (Rosero et al., 2021) Recommendations are for tracheostomy (esp laryngectomy) patients to have an **emergency airway plan poster** at the top of the bed because it is difficult for even experts to work through the challenges of managing patients with a tracheostomy during an emergency. ### Fresh stoma (< 7 days?) ### Cuffed tube, other features of device? ### Prone? ### Will the patient have paralysis? PPV? ### Other special considerations? - Laser surgery (needs laser resistant ETT etc) - Uncuffed tube cannot provide PPV even during moderate sedation ![[Management tracheostomy to OR.jpg]] ### T-tubes are a problem - They do not have the 15 mm adaptor to connect to a circuit or BVM - There is no easy way to seal proximally - Shown is the approach to use a Supraglottic Device to seal proximally ![[CleanShot 2022-02-22 at 17.53.12.jpg]] (Rosero et al., 2021) ---- ## Emergent Life-Threatening Complications ### Decannulation - **50% of airway-related deaths** - Early dislodged should be replaced with the same or smaller size and observed - 90% of catastrophic complications occur within 7 days of placement (Bontempo & Manning, 2019) In the setting of a decannulation event, you need to know how old the tracheostomy is (< or > 7 days), and if the patient is post-laryngectomy. If they are post-laryngectomy, they cannot be intubated from above and may require immediate re-surgical access by way of [[Emergency Front of Neck Access]]. A fresh tracheostomy is less likely to be successfully managed be replacement of the tube through the stoma, since the tract is not yet mature the risk of false passage is higher. Some recommendations are for a bronchoscopic replacement if you need to do an exchange within the first week. ### Obstruction #### Mucus Plug Mucus plugs form and need to be suctioned out. Patients may be ventilated on humidified air to reduce the likelihood of mucus plugging. The inner cannula cannot be fenestrated if suction is going to be attempted. If a fenestrated tracheostomy needs to be suctions, replace the inner cannula with a non-fenestrated cannula first. Fenestrated cannulas typically can be capped - so one may be able to tell the difference that way. #### Granulation Tissue Standard fenestrated tracheostomy tubes may not be properly positioned in the patient’s airway.  The fenestrations may come in contact with the tracheal wall.  This can increase the risk of  granulation tissue and result in airway compromise.  Granulation tissue formation has even been reported to have grown through the fenestrations, obliterating the tracheal lumen, requiring emergent intervention to restore airway patency. ### Occlusion on the wall of the trachea Problems can occur when the distal trach tube end abuts the tracheal wall. This can occlude the tube. ### Insertion into false tract Do **NOT** vigorously bag in an emergency. This will worsen the situation if there is a displacement. This can result in significant subcutaneous emphysema, making the situation worse if someone needs to re-establish the tract. ### Bleeding Bleeding can be from an innominate fistula. It can present with a sentinal bleed. All bleeding needs to be investigated by way of a bronchoscopy. Immediately, massive bleeding can be occluded by over-inflation of the cuff or by manual pressure. ## Management of decannulation: ### in NON-LARYNGECTOMY patients: - Call for help - BVM while occluding the stoma manually - place supraglottic device and occlude the stoma - attempt ETT placement one size smaller from above, placing the cuff distal to the stoma to make a seal - attempt jet ventilation at sternal notch ### in LARYNGECTOMY patients, especially if trach < 7 days old: - Call for help - attempt to replace the tracheostomy with fiberoptic or bougie - attempt to place an ETT same size - attempt to place and ETT size smaller (only insert 4-7 cm) - attempt to BVM stoma with pediatric mask - attempt jet ventilation at sternal notch ![[CleanShot 2022-02-22 at 18.18.03.jpg]] (Rosero et al., 2021) --- ## Management of Obstruction: ### Proposed checklist: - Remove external devices - reposition head, extend neck - Avoid vigorous bagging - Assess patency by passing a suction catheter beyond the tip of the tube - Do NOT use a bougie or tube changer - remove inner cannula - confirm patency of inner cannula and replace if necessary - deflate cuff - remove tracheostomy tube - attempt to place an ETT same size - attempt to place and ETT size smaller (only insert 4-7 cm) --- ## References: Benjamin, J., Roy, K., Paul, G., Kumar, S., Charles, E., Miller, E., Narsi-Prasla, H., Mahan, J. 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