Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain the situation and reassure them as much as possible.
   To ensure the patient is kept informed and reassured. E
2. 2.Show
   Cleanse hands using an alcohol‐based handrub and apply personal protective equipment.
   To minimize the risk of infection (NHS England and NHSI [179], C).

Procedure

1. 3.Show
   Assess whether the patient is breathing. If not, call the resuscitation team and commence cardiopulmonary resuscitation (CPR).
   A patient who is not breathing requires immediate CPR (RCUK [232], C).
2. 4.Show
   If the patient is breathing, apply high‐flow oxygen therapy (reservoir mask at 15 L/min to both the face and the stoma or tube).
   To reduce the risk of hypoxia (O'Driscoll et al. [209], C).
3. 5.Show
   Call for expert help.
   To get additional and expert help early (NTSP [206], C).
4. 6.Show
   Assess the patency of the tracheostomy tube, if present. If there is not a tracheostomy tube in place, proceed to step 8.
   To determine whether there is any air flow in or out of the tracheostomy tube (NTSP [206], C).
5. 7.Show
   Remove the decannulation cap, speaking valve, or heat and moisture exchanger (if present).
   To remove any potential source of obstruction (Morris et al. [167], C).
6. 8.Show
   Remove the inner tube (if present).
   To determine whether an occluded inner tube is the source of the obstruction (Cosgrove and Carrie [52], C).
7. 9.Show
   Pass a suction catheter down the tracheostomy tube or stoma and apply suction.
   To determine the patency of the tube and remove a sputum plug if present (NTSP [206], C).
8. 10.Show
   If the suction catheter can be passed, the tube is patent. Repeat suction if a sputum plug is the likely cause.
   To remove any secretions that may be obstructing the airway (NTSP [206], C).
9. 11.Show
   If the suction catheter cannot be passed, deflate the cuff (if present) and reassess the patient.
   Deflating the cuff will allow air to flow past the cuff in the event of a completely obstructed tracheostomy tube (NTSP [206], C). This will also help to assess whether it is the tube that is causing the problem. E
10. 12.Show
    Ventilate the patient using either a bag valve mask or a Mapleson C system (water circuit). These can either be applied directly onto the patient's face using an anaesthetic mask or attached directly onto the tracheostomy tube.
    To ventilate the patient while the cause is being investigated or treated. By attempting to ‘bag’ or ventilate via the tracheostomy tube, its patency can simultaneously be assessed (ICS [116], C; NTSP [206], C).
11. 13.Show
    If the patient stabilizes or improves, continue to ventilate and oxygenate until expert help arrives and the tracheostomy tube can be assessed.
    To prevent hypoxia (NTSP [206], C; O'Driscoll et al. [209], C).
12. 14.Show
    If the patient continues to deteriorate, the tracheostomy tube needs to be removed.
    It is safer to remove the tracheostomy tube and ventilate the patient by other means if there is no ventilation via the altered airway (NTSP [206], C).
13. 15.Show
    Prepare to remove the tracheostomy tube by removing any external sutures and tube tapes.
    To allow removal of the tube (NTSP [206], C).
14. 16.Show
    Quickly remove the tube and cover the stoma with gauze and an occlusive dressing, or with a gloved hand.
    To allow effective ventilation of the upper airways. E
15. 17.Show
    Continue to ventilate using any of the methods described in step 12.
    To prevent hypoxia (ICS [116], C; NTSP [206], C).
16. 18.Show
    Prepare to either intubate the patient orally or recannulate the stoma using an endotracheal tube or a size smaller tracheostomy tube.
    To secure an appropriate airway in the patient (Mitchell et al. [161], C).
17. 19.Show
    Use a fibreoptic scope and perform a guided insertion if able.
    To minimize the risk of causing a false passage, especially if the patient's airway is known to be difficult (NTSP [206], C).
18. 20.Show
    Once the airway has been inserted, inflate the cuff and secure the endotracheal tube or tracheostomy tube in place with tapes or ties.
    To secure the airway. E
19. 21.Show
    Continue to ventilate using a bag valve mask or water circuit until the patient is able to ventilate spontaneously and stabilizes. Administer supplemental oxygen as required.
    To ensure the patient is being ventilated and oxygenated (NTSP [206], C).
20. 22.Show
    Check the patient's observations/NEWS and document. Aim for oxygen saturations of 94–98% (or 88–92% if the patient is at risk of hypercapnic respiratory failure).
    To ensure the patient is not being over‐ or under‐oxygenated (O'Driscoll et al. [209], C).
21. 23.Show
    Consider performing an arterial blood gas and chest X‐ray.
    To ensure the post‐event patient assessment is thorough. E
22. 24.Show
    Assess how the patient is ventilating and oxygenating and determine whether they require further respiratory support in a high‐dependency or intensive care unit.
    To ensure the patient is being cared for in the most appropriate clinical area. E

Post‐procedure

1. 25.Show
   Monitor the patient's respiratory status and observations/NEWS frequently until they are stable. Escalate any concerns or deterioration in condition/NEWS immediately.
   To identify any concerns or clinical deterioration early, and ensure timely escalation to senior staff if required (RCP [230], C).