15.3 Tracheostomy Troubleshooting Flashcards
You have been called urgently to attend a ventilated patient on the ICU who has become acutely agitated,
hypertensive and profoundly hypoxic.
A percutaneous tracheostomy was performed 18 hours ago and is being weaned from ventilatory support.
a) List possible causes for this patient’s acute hypoxia. (25%)
Patient problems:
Pneumothorax.
Haemothorax.
Pneumomediastinum.
Haemomediastinum.
Surgical emphysema.
Atelectasis, inadequate ventilation due to
overly rapid weaning.
Aspiration.
___________________
Equipment problems:
Tracheostomy tube blocked with secretions or blood.
Cuff puncture or deflation or herniation over
end of tube.
Dislodged tube.
Ventilator circuit blockage or disconnection.
Inappropriate ventilator settings
Inappropriately low fraction of inspired oxygen.
b) What clinical features support an airway problem? (40%)
> > Acute desaturation.
> > Obvious incorrect placement of tracheostomy.
> > Paradoxical chest movement.
> > Increased work of breathing and tachypnoea.
> > Absence or abnormal morphology
of capnography trace.
> > Hypertension.
> > Surgical emphysema.
> > Neck swelling.
> > In an awake patient,
severe agitation and restlessness.
c) How would you manage an airway problem in this patient? (35%)
> > Fast bleep for senior help/resuscitation team according to local protocols,
and call for difficult airway trolley.
> > 100% oxygen via Mapleson C
to tracheostomy and over mouth.*
> > Stop nasogastric feed.
> > Assess:
• Chest and Mapleson C bag movement.
• Capnography waveform.
• For obvious tube dislodgement, secretions, blood, neck swelling, surgical emphysema.
> > In the absence of breathing or a normal capnography trace:
• Attempt two ventilated breaths.
• If unsuccessful, remove inner tube
(if present) and pass suction
tube through tracheostomy
to clear any blood
or secretions causing blockage
(inner tube may need reinserting
to reconnect to circuit).
• If unsuccessful, deflate cuff and
observe whether the patient now
able to breathe around tracheostomy.
Consider reinflating if condition
improves (cuff may have herniated over end of tube).
> > If no improvement,
remove tracheostomy
(occlude stoma with gauze
and occlusive dressing),
start 2 person face mask oxygenation with
oropharyngeal airway,
either spontaneous or
manually assisted ventilation.
> > If successful and oxygen saturations improving:
• Continue whilst checking notes for
previous ease of laryngoscopy,
indication for percutaneous tracheostomy etc.
(although laryngoscopy
grade may have worsened).
• Ensure emergency drugs,
difficult airway trolley and senior help have
arrived before attempting oral intubation.
> > If unsuccessful try:
• SAD.
• Oral intubation (uncut tube to be advanced beyond stoma).
• Intubation of stoma (size 6.0 COETT),
although the tract will not have
developed yet, and so mask
ventilation via this route unlikely to be an
option either.
> > Once airway managed appropriately,
move on to assess and manage
cardiorespiratory stability.
