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Tracheostomy: emergency care and recannulation

Evidence‐based approaches

Rationale

Patients with an altered airway (or who have recently been decannulated) who present with signs of airway, breathing or circulatory problems should be escalated immediately and assessed by an experienced and appropriate practitioner.

Indications

The following indications would give cause for concern and necessitate immediate management (ICS [116], NTSP [206]):

a dislodged tracheostomy
overt signs of respiratory distress (pale, sweaty, clammy, cyanosed, increased work of breathing, tachypnoea, using accessory muscles)
silent breathing, or grunting, snoring or stridor
reduced or falling oxygen saturations
restlessness, agitation or confusion
tachycardia or hypotension
blood‐stained secretions (haemoptysis).

Contraindications

There are no contraindications to managing a patient who has airway compromise and subsequent breathing problems.

Principles of care

A patient's airway may become compromised for a variety of reasons. The compromise may be secondary to an underlying condition or disease, such as cancer of the head and neck. It may be that the patient already has an altered airway that has occluded due to tenacious secretions, and requires suctioning or change of the inner cannula. It may be that the tracheostomy tube has become partially or completely dislodged, or the patient may have failed decannulation due to an underlying problem such as tracheomalacia and require recannulation. All of the above require immediate management and escalation to an expert practitioner versed in airway management. Algorithms produced by the NTSP ([206]) can be used to guide practitioners in the emergency management of altered airways (see Figure 12.35).

Anticipated patient outcomes

The patient will have a patent airway and be able to ventilate and oxygenate, preventing further deterioration or cardiopulmonary arrest.

Pre‐procedural considerations

All staff should remain calm and reassure the patient as required. Staff should work together but with clear leadership, communicating what actions need to be taken and when. There should be no delay in escalating the situation to the relevant teams, and staff should be encouraged to call the resuscitation team if the patient is deteriorating or expert help is delayed. The resuscitation and advanced airway trolley should be brought to the patient's bedside along with a fibreoptic scope in order to deal with the emergency (NTSP [206]).

Procedure guideline 12.14

Tracheostomy: emergency management

Table 12.15 Prevention and resolution (Procedure guideline 12.14)

Problem	Cause	Prevention	Action
Profuse tracheal secretions	Local reaction to tracheostomy tube or infection (as below)	Ensure vigilant care of the tracheostomy or stoma. Keep the patient well hydrated. Ensure good infection control practice and take standard precautions at all times when carrying out any aspect of care for a patient with an altered airway.	Suction frequently and ensure secretions are kept thin and loose. Check inner tube frequently and change if required. Consider use of saline or mucolytic nebulizers if secretions are tenacious. Ensure vigilant care of the surrounding skin to keep it as clean and dry as possible. Use a foam dressing and change it frequently. Send a sputum sample to microbiology to ensure it is not infected. Give antimicrobials if indicated and prescribed.
Lumen of tracheostomy tube occluded	Tenacious or dried sputum or blood occluding tube	Provide humidification via an HME or warmed and humidified oxygen therapy. Check and change inner tubes frequently. Suction the patient as required. Encourage the patient to report if they notice any change or difficulty with their breathing.	Call for help from the resucitation team. Apply high‐flow oxygen over the nose and mouth and over the tracheostomy tube. Remove the speaking valve or HME immediately. Remove the inner tube. Suction the patient. Deflate the cuff (if applicable). Remove the tracheostomy if the above interventions have failed and the patient is deteriorating. Ventilate and oxygenate the patient using a bag valve mask or water circuit until a new altered airway has been inserted.
Tracheostomy tube accidentally dislodged	Tracheostomy tapes not adequately secured Tracheostomy tube not secured by staff during procedures or moving and handling of the patient	Ensure the tracheostomy tapes are secure at all times with a maximum of one or two finger spaces between the skin and tapes. Always hold the tracheostomy tube while turning, moving or mobilizing the patient. Educate the patient and staff about safe mobilization and manual handling of patients with an altered airway. The person who holds and secures the tube should lead the manoeuvre and give clear commands regarding when it is safe to move.	Call for expert help or the resucitation team, depending on how newly formed the tracheostomy tube is and the condition of the patient. Oxygenate the patient via the nose and mouth and via the stoma. Prepare a new tracheostomy tube and promptly insert it. If there are any concerns regarding the risk of forming a false passage, the tube should be checked by an appropriate clinician using a fibreoptic scope.
Unable to insert a clean tracheostomy tube during tube change or after accidental dislodgment	Unpredicted shape or angle of stoma	Emergency equipment with spare tubes, lubricant, tracheostomy dilators etc. should always be readily available at the patient's bedside, in the tracheostomy box. Ensure the resuscitation trolley, the advanced airway trolley and the fibreoptic scope are readily available. Ensure an appropriately trained practitioner changes the tube and a second competent practitioner assists. Discuss the plan of action for the team to take if recannulation is not possible. Ensure all members are aware of their role and actions to be taken.	Remain calm and summon expert help or call the resucitation team. Apply high‐flow oxygen over the patient's stoma site and the nose and mouth. Lubricate the tube well and attempt to reinsert it at various angles. If unsuccessful, attempt to insert a smaller‐size tracheostomy tube. If this is impossible, keep the tracheostomy tract open using tracheal dilators or put traction on the stay sutures if present. Do so until expert help arrives. Monitor the patient and observations continuously. If the patient's condition deteriorates, begin ventilation using a bag valve mask over the patient's nose and mouth while occluding the stoma with a dressing or gloved hand. Once the tube has been successfully inserted, it may be necessary for an expert to look via a fibreoptic scope and check no false passage was created during the procedure and the tube is cannulating the trachea.
Tracheal bleeding	Trauma to the trachea during tube change or from suctioning, bleeding from a tumour, erosion into a blood vessel, or uncorrected coagulopathies	Ensure vigilant care of the tracheostomy or stoma. Avoid frequent and multiple suctions if not indicated. Correct any coagulopathies.	Minimal bleeding should be monitored and reported to the multidisciplinary team. The tracheostomy cuff should be inflated to protect the airway if there is perfuse bleeding, and the patient escalated immediately. Perform suction as required.
Infection	Upper airway defences are bypassed in patients with a tracheostomy, predisposing patients to a higher risk of lower respiratory tract infection	Ensure good infection control practice and take standard precautions at all times when carrying out any aspect of care for patients with an altered airway.	Obtain a sputum sample or swab the stoma site and send the sample to microbiology. Give empirical antibiotics as per local microbiology guidelines.

HME, heat and moisture exchanger.