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