Tracheostomy

Aka: Tracheostomy, Tracheostomy Obstruction, Tracheostomy Malfunction, Tracheostomy Hemorrhage, Tracheostomy Tube Replacement, Tracheostomy Tube Cannula Replacement

1. Indications
   1. Neuromuscular disorder
   2. Extensive Head or neck procedure
   3. Upper airway obstruction
      1. Congenital craniofacial anomaly (e.g. laryngeal hyperplasia)
      2. Foreign body
      3. Supraglottic mass or infection
      4. Bilateral Vocal Cord Paralysis
      5. Neck Trauma with secondary injury to the Larynx, trachea, Thyroid cartilage or other airway adjacent structures
      6. Severe facial Trauma
      7. Severe, refractory Sleep Apnea
      8. Airway burns
2. Complications
   1. Foreign Body Aspiration
      1. Consider especially if Developmental Delay
   2. Obstruction
      1. See Tracheostomy Tube Replacement below
      2. Presents with Hypoxia, respiratory distress and inability to suction secretions through tube
      3. Mucous plugging
         1. Instill saline and attempt aspiration
         2. Tracheostomy replacement if in place >6 weeks or unable to unplug with other measures (see below)
      4. Granulation tissue
         1. Suspected if resistance and bleeding occur on attempted suctioning
      5. False tract
         1. Consider if tube recently changed
   3. Tube cuff rupture
      1. See Tracheostomy Tube Replacement below
      2. Risk of aspiration, air leak and tube displacement
   4. Tracheitis (often accompanied by Pneumonia)
      1. Presents as increased secretion volume or change in color or odor (with or without fever)
      2. Obtain culture of discharge
      3. Obtain Chest XRay
      4. Initial empiric antibiotic selection may be assisted by prior Tracheostomy culture results
      5. Admission indications
         1. Pneumonia with Hypoxia
         2. Frequent suctioning required
         3. Neuromuscular disorder
   5. Bleeding
      1. Otolaryngology or pulmonology Consultation for likely bronchoscopy to identify bleeding source
      2. Any significant bleeding, even if stopped, requires careful evaluation
         1. Initial bleeding event may transiently stop, but herald masssive bleeding when clot is displaced
      3. Causes
         1. Mucous membrane dryness
         2. Granuloma adjacent to Tracheostomy entry site
         3. Tracheitis
         4. Repeated suctioning
         5. Excessive coughing
         6. Innominate artery erosion (see below)
   6. Innominate artery erosion (rare, but catastrophic)
      1. Emergency condition requiring immediate otolaryngology or thoracic surgery management
      2. More common with metal Tracheostomy tubes or recently placed or upsized Tracheostomy tubes
      3. Temporizing measures
         1. Cuff balloon hyperinflation to tamponade the innominate artery
         2. Attempt to lever the Tracheostomy tube against the region of the innominate artery
         3. Intubate patient from above or replace Tracheostomy tube with Endotracheal Tube (over an Elastic Bougie)
            1. Place finger along ET Tube and attempt to compress the innominate artery against the Sternum
3. Procedures: Tracheostomy replacement
   1. Contraindications (Relative)
      1. Incomplete stoma tract maturation (<2-7 days from initial insertion)
   2. Indications
      1. Displaced or obstructed Tracheostomy tube
      2. Tracheostomy tube cuff rupture
   3. Procedure risks
      1. Failed tube replacement (risk of death with no definitive airway)
      2. Stoma tract tissue damage (including false tract or destruction of immature tract)
      3. Bleeding (including life-threatening bleeding from the Innominate artery)
         1. Minimal post-procedure minor bleeding from tissue is common
   4. Assemble assistance
      1. Involve respiratory therapy
      2. Involve Anesthesia (and otolaryngology if available)
   5. Prepare two Tracheostomy tubes and an Endotracheal Tube
      1. Measure the internal and external diameters of the tube being replaced
      2. Tracheostomy tube (Shiley or Bivona) similar in size to that being replaced
      3. Tracheostomy tube (Shiley or Binova) a size smaller than that being replaced
      4. Endotracheal Tube similar to the smaller callibre tacheostomy tube (or 6-0 for an adult)
      5. Use cuffed tubes if Mechanical Ventilation is expected
   6. Lubricate the tubes
      1. Apply saline-based lubricant (avoid petroleum-based lubricant due to aspiration risk)
   7. Prepare the patient airway
      1. Patient should cough or have tube suctioned before replacement
      2. Deflate the Tracheostomy tube cuff (if present)
      3. Remove the Tracheostomy inner cannula
         1. In cases of inner cannula obstruction, the inner cannula alone may be replaced
   8. Exchange the tube (high risk)
      1. Avoid prolonged exchange procedure
         1. Patient is without definitive airway until new Tracheostomy is positioned correctly
      2. Use seldinger technique
         1. Pass soft red Rubber catheter, guidewire or Elastic Bougie into old Tracheostomy to maintain passage
      3. Remove the old Tracheostomy over the catheter or bougie
      4. New Tracheostomy tube is inserted over catheter (without the inner cannula or obturator)
         1. Avoid creating false passage on replacement (especially if <7 days after insertion)
         2. Once the Tracheostomy is in place, remove the catheter, guidewire or bougie
         3. The inner cannula or obturator is inserted inside the Tracheostomy
         4. Inflate the Tracheostomy tube cuff
      5. Consider placing the small Endotracheal Tube if unable to replay the Tracheostomy tube
         1. Consider placement over a wire or Elastic Bougie (see above)
         2. May also hold airway open with nasal speculum, hemostat or suction catheter
   9. Alternatives
      1. Endotracheal Tube (6.0 or 6.5 mm) may be used temporarily in place of a Tracheostomy tube
      2. Obstructed inner cannula may be replaced alone, without replacing the outer device
4. Resources
   1. EMedicine
      1. http://emedicine.medscape.com/article/865068-overview#showall
5. References
   1. Claudius and Behar in Majoewsky (2013) EM:Rap 13(10): 7-9
   2. Swadron (2019) Pulmonology 2, CCME Board Review, accessed 6/18/2019
   3. Warrington (2019) Crit Dec Emerg Med 33(9): 12