Tracheostomy and Emergencies

Question 1

What are the indications of tracheostomy?

Answer 1

1. Maintain airway in upper airway obstruction with laryngeal involvement
   1A. NPC with laryngectomy
   1B. OHS which failed CPAP with severe recurrent type 2 RF
2. Airway access for suctioning retained secretions (rare)
3. Aspiration mitigation in glottic dysfunction
4. Long term ventilation (limits damage of prolonged intubation)
5. Neuromuscular junction disease unable to maintain airway

Question 2

When is the optimal time to perform tracheostomy?

Answer 2

10-14 days of intubation

Multiple RCTs failed to demonstrate benefit earlier than said timing

Question 3

What are the complications of tracheostomy

Answer 3

A. Intraoperative
B. Post-operative
C. Late

Question 4

What is the most lethal complication of tracheostomy perioperative period?

Answer 4

Accidental decannulation of tracheostomy tube prior to tract maturation
(maturation takes up to 10 days)

High risk of creation of false tissue tract while attempting to reinsert tracheostomy tube causing mediastinal emphysema
- Can attempt with tracheal dilator
- If fail, for endotracheal intubation (and temporary sealing of tract while awaiting repeat surgery)

Question 5

Can patients with tracheostomy speak?

Answer 5

Yes, intelligible whispers, if:

1. Tracheostomy tube cuff is deflated to allow small cuff leak
2. One-way speaking valve is placed (needs downsizing of tracheostomy tube)

Question 6

Can patients with tracheostomy eat?

Answer 6

Only if they can tolerate uncuff trachy

1. Inflated cuff causes posterior trachea to obstruct oesophagus, limiting swallowing and increasing aspiration risk
2. Tracheostomy prevents elevation of larynx

Question 7

Intracuff pressure

Answer 7

Maintained at 20-25mmHg
- Less common injuries with low pressure, high volume cuffs
- Intracuff pressures vary with barometric pressure! (recheck during flight)

1. Mucosal capillary perfusion pressure at 25mmHg
   -> excess cuff pressure cause mucosal ischaemia and tracheal stenosis
2. Underinflated < 18mmHg has risk of aspiration and nosocomial pneumonia

Question 8

What are the causes of post-tracheostomy airway haemorrhage?

Answer 8

< 48 hours - incisional wound

> 48 hours - tracheoarterial fistula
- Initial mild to moderate bleeding turning massive haemorrhage
- Requires emergency sternotomy for ligation of innominate artery

Question 9

When do you suspect tracheo-oesophageal fistula?

Answer 9

1. Cough and SOB 2 months following tracheostomy removal
2. Recurrent aspiration and nosocomial pneumonia

Pathogenesis: pressure necrosis by tube cuff or tube tip in <1% patients

Evaluation: tracheoscopy or bronchoscopy

Question 10

Aspiration post-tracheostomy removal

Answer 10

1. Scarring at stoma site interfere with rostrocaudal excursion of larynx during swallowing (necessary for glottic closure)
2. Vocal cord adduction weakness from prolonged diversion of ventilation away from glottis

Question 11

Upper airway obstruction post-decannulation

Answer 11

May develop immediately, or months to years

Delayed upper airway obstruction due to progressive slowly, gradual narrowing of airway
1. Subglottic or tracheal stenosis
2. Tracheomalacia

Symptoms
- Exercise induced dyspnoea (wrongly ascribed to poor lung condition)
- Stridor or dyspnoea at rest
- Sudden stridor in acute illness

Question 12

Types of tracheostomies and components

Answer 12

A. Cuffed or uncuffed
- Cuffed: for mechanical ventilation or respiratory emergencies
- Uncuffed: spontaneous breathing

B. Fenestrated or non-fenestrated
- Fenestrated: for phonation but suboptimal for ventilation
- Non-fenestrated: for mechanical ventilation
- Speaking valve: 1 way valve capped at end of trachy for phonation, opens on inhalation and closes on exhalation
(MUST BE UNCUFFED ELSE PATIENT SUFFOCATES TO DEATH)

C. Single lumen or double lumen
- Single: no inner cannula (paeds), nrrds to change wholely when obstructed
- Double: inner cannula for cleaning

Question 13

Tracheostomy Emergency - Desaturation

Answer 13

1. Call for help - airway team, ENT
2. Look, feel and listen to mouth and tracheostomy
   2A. Adjunct capnography

> If no breathing commence CPR!

3. High flow oxygen to BOTH face and tracheostomy site
4. Remove speaking valve and inner cannula - check for mucous plugging
5. Can suction catheter pass through?
   - Yes - partial obstruction: suction, ABCD
6. Complete obstruction - remove tracheostomy tube
   5A.**Check: is the upper airway patent or post-laryngectomy? **
   5B. Put on high flow oxygen to BOTH face and tracheostomy stoma
7. Airway management
   Patent airway
   - Oral adjunct
   - Intubation via oral or trachy stoma

Laryngectomy
Tracheostomy stoma intubation
(DO NOT ATTEMPT ORAL INTUBATION AS IT IS FUTILE)

Question 14

Tracheostomy Emergency - Dislodged Tracheostomy

Answer 14

1. Ask: When was the tracheostomy performed?
   - Less than 1 month: friable, not well formed tract
   - More than 1 month: well formed tract
2. High flow oxygen BOTH face and trachy stoma
3. Partial or complete dislodgement?
   - Partial: railroad with NGT. If unsuccessful to treat for emergency, call airway and ENT, prepare for intubation. Check if s/p laryngectomy
   - Complete: see below

3A. More than 1 month - attempt to insert NEW tracheostomy tube

3B. Less than 1 month
- Call airway and ENT team
- Tracheal dilator
- Careful consideration for reinsertion
(High risk of false tract and mediastinal emphysema)

4. Intubation
   - Check whether laryngectomy performed
   - Post laryngectomy - Trachy stoma intubation
   - No laryngectomy - oral intubation with covering of trachy stoma