Tracheostomy

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

1. Epidemiology
   1. Incidence: 110,000 per year in United States
2. Indications
   1. Neuromuscular disorder
   2. Extensive Head or neck procedure
   3. Laryngectomy
   4. 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
3. Complications
   1. Complications occur in 40-50% of patients (catastrophic events in 1%)
   2. Original indication for Tracheostomy impacts complication management
      1. Laryngectomy results in the Tracheostomy stoma being the only airway (no acccess via mouth or nose)
      2. Distorted anatomy, major Laryngeal Trauma, major resections decrease the likelihood of access from pharynx
   3. Foreign Body Aspiration
      1. Consider especially if Developmental Delay
   4. Obstruction
      1. See Tracheostomy Tube Replacement below
      2. Presents with Hypoxia, respiratory distress and inability to suction secretions through tube
      3. Causes
         1. 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)
         2. Granulation tissue
            1. Suspected if resistance and bleeding occur on attempted suctioning
         3. False tract
            1. Consider if tube recently changed
         4. Consider non-Tracheostomy causes of Hypoxia (Pneumonia, Pneumothorax, Pulmonary Embolism)
            1. See Hypoxia
      4. Approach
         1. Remove external devices (e.g. speaking valve, humidifier)
         2. Remove inner cannula
            1. Retain the inner cannula and clear of any obstruction
         3. Suction Tracheostomy (clears most obstructions)
            1. Suction catheter should pass through any mucus obstruction
            2. Attempt Positive Pressure Ventilation (PPV) via Tracheostomy tube again
            3. If suction catheter does not pass, move to deflating cuff as below
            4. Consider attaching EtCO2 monitor to check for tube patency
         4. Deflate cuff to allow for air leakage around obstructed tube (if still obstructed)
            1. Attempt bag-valve mask (BVM) ventilation from above (mouth and nose) after cuff deflated
            2. Exception: Do not ventilate mouth and nose if laryngectomy has been performed
               1. Only airway after laryngectomy is via stoma
         5. Replace Tracheostomy tube with Endotracheal Tube if still obstructed
            1. See Tracheostomy replacement as described below
            2. Immature tract (<7 days) requires replacement under direct visualization (fiberoptic scope)
            3. Pass Endotracheal Tube beyond level of suspected obstruction
   5. Tracheostomy Accidental Decannulation or Displacement
      1. Within first 7 days of placement
         1. High risk for adverse outcome (e.g. creation of false passage)
            1. Mature stoma has not yet formed, and tracheocutaneous tract is narrow
         2. Perform under direct visualation (e.g. fiberoptic scope)
            1. Risk of false passage
      2. More than 7 days after Tracheostomy placement
         1. See Tracheostomy replacement as below
   6. Tube cuff rupture
      1. See Tracheostomy Tube Replacement below
      2. Risk of aspiration, air leak and tube displacement
   7. 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
      6. Serious complications
         1. Mediastinitis
         2. Necrotizing Fasciitis
   8. Bleeding
      1. Otolaryngology or pulmonology Consultation for likely bronchoscopy to identify bleeding source
         1. Alternatives include CT Angiogram, local surgical exploration
      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
         2. Innominate artery erosion often presents with sentinel bleed that transiently pauses
      3. Causes
         1. Tracheostomy surgery complication (first 48 hours after placement)
         2. Innominate artery erosion (>3 weeks after placement, see below)
         3. Mucous membrane dryness
         4. Granuloma adjacent to Tracheostomy entry site
         5. Tracheitis
         6. Repeated suctioning
         7. Excessive coughing
      4. Initial stabilization while awaiting emergent otolaryngology intervention
         1. Replace a uncuffed Tracheostomy tube with a cuffed Tracheostomy tube
         2. Consider Endotracheal Intubation from above (if no prior laryngectomy)
            1. Tracheostomy tube may be removed after Endotracheal Tube has been removed
         3. Hyperinflate Tracheostomy cuff until balloon is rigid and offering tamponade pressure
         4. Refractory bleeding may be treated with manual pressure
            1. Apply finger within stoma
            2. Apply anterior pressure to the innominate artery
   9. Innominate Artery Erosion or Tracheoinnominate Fistula (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. Typically occurs between 3 days and 6 weeks from Tracheostomy placement or revision
      4. Herald bleeding may precede Massive Hemorrhage
         1. Consult proceduralist who placed the Tracheostomy
      5. 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
      6. Definitive Management
         1. Vascular Surgery
         2. Intervention Radiology
         3. Otolaryngology
   10. Tracheoesophageal fistula
       1. Findings
          1. Persistent tracheal air leak
          2. Cough with Swallowing
          3. Aspiration Pneumonia
       2. Diagnosis
          1. Upper endoscopy
          2. Esophagram
   11. Other Complications after Tracheostomy Removal (Decannulation)
       1. Tracheal stenosis
          1. Typically within 2 months of decannulation
       2. Tracheocutaneous fistula
          1. Persistent stoma track >3-6 months after decannulation
4. Procedures: Tracheostomy replacement
   1. Contraindications (Relative)
      1. Incomplete stoma tract maturation (<2-7 days from initial insertion)
         1. See complications above
         2. Should be performed under direct visualization (fiberoptic scope)
         3. Risk of creating false passage
   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. Apply 100% Oxygen to the patient's face and Tracheostomy site for preoxygenation
         1. Apply PPV via a pediatric Bag Valve Mask or LMA over the stoma (with mouth and nose closed) OR
         2. Apply PPV via mouth and nose with stoma occluded, if there has not been laryngectomy
      2. Patient should cough or have tube suctioned before replacement
      3. Deflate the Tracheostomy tube cuff (if present)
      4. 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 replace 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
5. Resources
   1. EMedicine
      1. http://emedicine.medscape.com/article/865068-overview#showall
6. References
   1. Claudius and Behar in Herbert (2013) EM:Rap 13(10): 7-9
   2. Shoenberger and Swaminathan in Swadron (2022) EM:Rap 22(3): 1-2
   3. Engle and Ponce (2021) Crit Dec Emerg Med 35(9): 11
   4. Swadron (2019) Pulmonology 2, CCME Board Review, accessed 6/18/2019
   5. Warrington (2019) Crit Dec Emerg Med 33(9): 12
   6. Weingart and Swaminathan in Swadron (2022) EM:Rap 22(8):2-4