Tracheostomy Emergencies with Trachy Tracey

*gurgle* *snore* *slaver* Tracheostomy Emergencies with Trachy Tracey 2017 Learning objectives • Describe the difference in anatomy tracheotomy and a laryngectomy between a • Understand why we use tracheostomies in critical care • Describe what a tracheostomy ‘red flag’ is, and describe an appropriate response when faced with one. • List what equipment you need in your bedspace and demonstrate how to use it effectively in an emergency • Demonstrate the assessment and management of a patient with a blocked/displaced tracheostomy. • Types of airway devices used during anaesthesia • How often major complications leading to serious harm occur in association with airway management, in ICU and ER settings • Nature of these events and learning acquired to reduce frequency and consequences NAP4 Findings • 20%(36/184) of all airway incidents occurred in ICU • 70% of reported events and 60% of deaths involved complications with tracheostomies. • Displaced tracheostomy were the greatest cause of major morbidity and mortality in ICU. This concurs with a previous study in 2004 which found that 60% of airway incidents involved tracheostomies becoming blocked or displaced ( McGrath and Thomas 2004) Findings • Obese patients at increase risk of such events and adverse outcome • Failure to use capnography in ventilated patients contributed to >70% of ICU related deaths • Tracheostomy guidelines were not readily available for trainees and nurses. A survey in the northwest of England showed that only 2 out of 16 units has tracheostomy guidelines readily available ( Bates 2010) Tracheostomy related problems 5th highest primary airway problem highlighted Tracheostomy related problems accounted for the 5th highest incidence of all primary airway problems !! Interpretation of results • Many of the events and deaths reported to NAP4 were potentially avoidable. • Obese patients at increase risk of such events and adverse outcome. • Movement and transfer of patients are high risk procedures resulting in an increase in adverse airway events. Recommendations • Algorithms (strategies) must be available for all staff for the management of accidental decannulation and /or a blocked tracheostomy tube with a step-wise approach to management of a compromised airway. • All staff involved in the care of patients with tracheostomies should receive training in maintaining the airway and in safe movement of patients. Including training re capnography interpretation. • There must be clear lines of communication for escalation of airway events to advanced airway skilled personnel. Tracheostomy or laryngectomy ? Tracheostomy, is a semipermanent or permanent opening to the trachea Laryngectomy is the surgical removal of the larynx, usually completely and permanently. The remnants of the trachea are stitched to the anterior neck. There is no connection from the nose or mouth to the lungs!! It can be very hard to tell the difference on visual inspection What type of tracheostomy does my patient have? ‘Mouth breather’ ‘Neck breather’ Position between the 2nd and 3rd Tracheal cartilage This patient has had а TRACHEOSTOМY Sllrgical / Pet'1:111181eous: --·--·--·--·-·--·--·--·--·--·----·- ln Emergency: оп: --·-·--·--·--·--·--·-··-··-·--·--·--·--- CALL FOR Н ELP ■ - -■ - -■--■-- Cal 1 2222 for Е: mergency Team Тrвc:�tomy tuhe, siz:e: ·--·--·--·-·--·--·- -·--·--·-·--·--· (Мхе: Тhе r� 1- .. ;." ' .: ._- ..m i--=- иррет ailway тау pmvide an illtact aitway) l : .. 1 .. -. .:. .:.. = - т --� 1 1 1 1 - - . 3 .. .. . • [ .. -. "... ... -.. ""' . .. .. Tracheostomies are performed on about 24% of patients in ICU, so what are their benefits • To facilitate sedation reduction • Reduction in WOB ( up to 50%) • Improved secretion clearance • Reduction in trauma to oropharynx and larynx • Reduction in VAP • Reduction in length of mechanical ventilation (pro- weaning ) • Reduced length of ICU and hospital length of stay ( Bouderker MA et al 2004, Rumback MG et al 2004) 'Red flags' • Early warning signs that may indicate tracheostomy is blocked / displaced • Subdivided into: • Airway red flags • Breathing red flags • Tracheostomy red flags • General red flags Airway red flags • Look / listen / feel at mouth and stoma: • With the cuff up, presence of: • Speech, grunting, snoring, stridor • Audible air leaks • Bubbles of saliva at mouth or nose Is there gas escaping above the cuff???? May indicate cuff is damaged or tube tip not correctly sited Breathing red flags Look / listen / feel at mouth and stoma: • • Apnoea ( USE CAPNOGRAPHY !!) • Hypoxia • Dyspnoea/difficulty breathing • Accessory muscle use • Increased respiratory rate • Higher airway pressure / lower tidal volumes • Making whistling noises/noisy breathing Tracheostomy red flags Look / listen / feel at mouth and stoma: • • Visible displacement of trachy tube ( if an adjustable flange check previous documented positioning) • Blood / bloody secretions tracheostomies can bleed a little) • Increased discomfort / pain • Increasing amounts of air needed to keep cuff inflated ( damaged cuff, air leak, displaced tube needing hyper-inflation to keep a seal ! ) (Note: fresh General red flags Any physiological changes in condition may be due to an airway problem: • • Respiratory rate • Heart rate • Blood pressure • Level of consciousness • Anxiety, restlessness, agitation, confusion Now let's save Trachy Tracey! The first three steps • Call for help • Look, listen and feel at the mouth and tracheostomy. Is patient making any respiratory effort? Look at end tidal CO2 trace - is it there? Has it changed? • Apply high flow oxygen to both face and tracheostomy • Think - how will you do this with your patient in your bedspace? Type of 02 mask/flow rates/humidification ??) • Think - what are the potential benefits / pitfalls of using a C -circuit? Assessment of respiratory effort/ lung compliance- YES Further airway compromise/trauma/surgical emphysema !!! The displaced trachy • What would happen if you bagged through this tracheostomy tube? (Further airway compromise/trauma/surgical emphysema ?!!!) • Think: what evidence do I have that the trachy tube is in the trachea? • ETCO2 ?? Assess trachy patency • Remove speaking valve or cap if present. Remove inner tube • Can you pass a suction catheter? • Yes : the trachy tube is at least partially patent • No : deflate the cuff - look / listen / feel at mouth and stoma - look at end-tidal CO2.trace CO2 Trace Normal /absent/obstructed ? Cuff up vs cuff down With the cuff down, you may be able to entrain air past a displaced tracheostomy Is the patient stable or improving? • Oxygen saturations stable and >88%? • Yes: continue ABCDE assessment. Await medical assessment • No: REMOVE THE TRACHEOSTOMY. Reapply oxygen to face. 'Bag' if necessary. Cover stoma with occlusive dressing. Key points • If you cannot see ETC02 with every breath on the capnograph it is safer to assume the tracheostomy is not in the trachea. If you cannot pass a suction catheter it is safer to assume the tracheostomy tube is not in the trachea • DO NOT give assisted breaths via a C Circuit unless you have evidence the trachy tube is in the trachea eg. capnograph trace. • Oxygenation is always your priority!! Tracey says......... 2.Look , listen and feel at the mouth and stoma. Look at capnograph!! 1.Call for help!! 3.Give oxygen at the mouth and tracheostomy!!! Tracey says.... A girl needs oxygen to survive!! If my trachy tube is blocked or displaced and I am deteriorating..TAKE IT OUT!!!! Any Questions ? Useful educational resources • UK National Tracheostomy Safety Project www.tracheostomy.org.uk • https://www.nice.org.uk/guidance/ipg462 • www.e-lfh.org.uk/programmes/tracheostomy-safety SCENARIO’S Scenario 1- Blocked Tracheostomy Clinical setting and history (may be adapted to candidates’ background) S. B. A. R. Bedside nurse in intensive care unit, calling for assistance with patient in an isolation cubicle. 70-year-old patient admitted 3 weeks ago with Flu A. Previous history of MI treated by coronary stenting. Percutaneous tracheostomy performed 1 week ago to facilitate ventilation weaning. Patient presently being treated for a VAP continues to have a productive chest with MP2-3 secretions. Nurse is concerned about patients reduced SPO2 to 82%, reduced chest expansion and increasing agitation. RR 40 shallow obstructive pattern Inspired O2 has been increased from 30% to 100%. Assessment is required urgently as patient’s condition is not improving. Clinical course       Patient ventilation worsening, SPO2 82%, poor chest expansion, agitated Poor C-Circuit compliance, capnography reading 14 kpa Speaking valve removed- no change in condition Unable to pass suction catheter Patient not improving, SPO2 78%, capnography reading 20 kpa Post removal of tracheostomy, oxygen applied and assisted ventilation, SPO2 improving to 92%, capnography waveform present , reading 8 kpa Interventions                Call for expert airway help Look, listen and feel at the mouth and tracheostomy - use C-Circuit/ waveform capnography Is the patient breathing? YES Apply high flow oxygen to BOTH the face and the tracheostomy Assess tracheostomy patency- remove speaking valve/cap if present, remove inner tube Attempt to pass suction catheter Unable to pass suction catheter Deflate the cuff- look, listen and feel at the mouth and tracheostomy - use C-Circuit/ waveform capnography Is patient improving- NO REMOVE THE TRACHEOSTOMY TUBE Place high flow oxygen on the face and tracheostomy stoma site. Look, listen and feel at the mouth and tracheostomy site - use C-Circuit/ waveform capnography Is the patient breathing? YES Assist ventilation as indicated. Standard oral airway manoeuvers- cover stoma site with occlusive dressing. Use BMV/OPA/NPA/I-gel /LMA to support breathing as indicated until expert help arrives. Consider tracheostomy stoma ventilation- paediatric face mask or LMA applied to stoma site with BMV if oral BMV/assist not effective Handover Expert airway help arrives. Preparation made for difficult intubation. Patient is successfully reintubated orally, uncut OETT advanced beyond stoma Scenario 2- Displaced Tracheostomy Clinical setting and history (may be adapted to candidates’ background) S. B. A. R. Bedside nurse in intensive care unit, calling for assistance with patient 68-year-old patient admitted 2 days ago from cardiothoracic ICU. Previous history of an AVR performed 3 weeks ago, IHD, HTN, NIDDM and OA. Percutaneous tracheostomy performed 1 week ago to facilitate ventilation weaning. Patient recently hoisted back to bed. Following return to bed the patients MV has significantly reduced, SPO2 have dropped to 85% and capnography waveform is non rec ordable. The tracheostomy tube appears to be angled in a different position than had previously been noted prior to moving the patient back to bed. There is an audible leak. Inspired O2 has been increased from 40% to 100%. Patient has been positioned upright. Assessment is required urgently as patient’s condition is not improving Clinical course       Patient condition worsening, SPO2 80%,poor chest expansion, increasingly agitated No independent C-Circuit ventilation, no capnography reading Speaking valve removed- no change in condition Unable to pass suction catheter Patient not improving, SPO2 75%, no capnography reading Post removal of tracheostomy, oxygen applied and assisted ventilation, SPO2 improving to 90%, capnography waveform re-established, chest expansion improved Interventions                Call for expert airway help Look, listen and feel at the mouth and tracheostomy - use C-Circuit/ waveform capnography Is the patient breathing? YES Apply high flow oxygen to BOTH the face and the tracheostomy Assess tracheostomy patency- remove speaking valve/cap if present, remove inner tube Attempt to pass suction catheter Unable to pass suction catheter Deflate the cuff- look, listen and feel at the mouth and tracheostomy - use C-Circuit/ waveform capnography Is patient improving- NO REMOVE THE TRACHEOSTOMY TUBE Place high flow oxygen on the face and tracheostomy stoma site. Look, listen and feel at the mouth and tracheostomy site - use C-Circuit/ waveform capnography Is the patient breathing? YES Assist ventilation as indicated. Standard oral airway manoeuvers- cover stoma site with occlusive dressing. Use BMV/OPA/NPA/I-gel /LMA to support breathing as indicated until expert help arrives. Consider tracheostomy stoma ventilation- paediatric face mask or LMA applied to stoma site with BMV if oral BMV/assist not effective Handover Expert airway help arrives. Preparation made for difficult intubation. Patient is successfully re intubated orally, uncut OETT advanced beyond stoma Scenario 3- Blocked Tracheostomy Clinical setting and history (may be adapted to candidates’ background) S. B. A. R. Bedside nurse in intensive care unit, calling for assistance with patient being ventilated via a tracheostomy 74-year-old patient admitted 4 weeks ago following OOHCA. Previous history of MI, stenting, LVSD, DM, PVD and COPD. Tracheostomy performed 3 weeks ago due to failure to wean ventilation secondary to poor cardiopulmonary reserve. Patient presently being ventilated on ASB with escalating times on a T-piece. Recently a humidified circuit has been established secondary to ongoing thick secretions. Having recently suctioned the patient, the nurse reports the patient has had a sudden drop on SPO2 to 84% and is becoming increasingly agitated. The nurse has increased the FIO2 to 100% from 45% and has attempted to suction the patient, unsuccessfully. Assessment is required urgently as the patient’s condition is not improving. Clinical course       Patient condition worsening, SPO2 80%, paradoxical chest movements, increasing agitation, ineffective ventilatory pattern Poor C-Circuit compliance, capnography reading unobtainable No speaking valve/cap present Unable to pass suction catheter Patient not improving, SPO2 75%, capnography still not recording Post removal of tracheostomy, oxygen applied and assisted ventilation, SPO2 improving to 90%, capnography waveform established, reading 10 kpa. Equal and bilateral chest expansion. Interventions                Call for expert airway help Look, listen and feel at the mouth and tracheostomy - use C-Circuit/ waveform capnography Is the patient breathing? YES Apply high flow oxygen to BOTH the face and the tracheostomy Assess tracheostomy patency- remove speaking valve/cap if present, remove inner tube Attempt to pass suction catheter Unable to pass suction catheter Deflate the cuff- look, listen and feel at the mouth and tracheostomy - use C-Circuit/ waveform capnography Is patient improving- NO REMOVE THE TRACHEOSTOMY TUBE Place high flow oxygen on the face and tracheostomy stoma site. Look, listen and feel at the mouth and tracheostomy site - use C-Circuit/ waveform capnography Is the patient breathing? YES Assist ventilation as indicated. Standard oral airway manoeuvers- cover stoma site with occlusive dressing. Use BMV/OPA/NPA/I-gel /LMA to support breathing as indicated until expert help arrives. Consider tracheostomy stoma ventilation- paediatric face mask or LMA applied to stoma site with BMV if oral BMV/assist not effective Handover Expert airway help arrives. Preparation made for difficult intubation. Patient is successfully re- intubated orally, uncut OETT advanced beyond stoma Scenario 4- Displaced Tracheostomy Clinical setting and history (may be adapted to candidates’ background) R. B. A. R. Bedside nurse in intensive care unit, calling for assistance with agitated patient 58-year-old patient admitted 2 weeks ago with CAP. Previous history of ETOH excess, smoker and poor nutritional state. Tracheostomy performed 2 days ago to facilitate venti lation weaning. Patient is delirious and CAM ICU positive, requiring regular haloperidol. He has been pulling at his tracheostomy and attempting to climb out of bed. Following an episode of agitation, the nurse reports she is unable to get a capnography trace, the patients SPO2 has dropped to 85% and there is a large air leak sound at the tracheostomy site. Inspired O2 has been increased to 100% from 40%, haloperidol has been administered and the nurse is attempting to monitor the cuff pressure from the tracheostomy tube, unsuccessfully. Assessment is required urgently as the patient’s condition is not improving. Clinical course       Patient condition worsening, SPO2 80%,patient increasingly agitated No independent C-Circuit ventilation, no capnography reading Speaking valve removed- no change in condition Unable to pass suction catheter Patient not improving, SPO2 78%, no capnography reading Post removal of tracheostomy, oxygen applied and assisted ventilation, SPO2 improving to 92%, capnography waveform re-established, bilateral chest expansion Interventions                Call for expert airway help Look, listen and feel at the mouth and tracheostomy - use C-Circuit/ waveform capnography Is the patient breathing? YES Apply high flow oxygen to BOTH the face and the tracheostomy Assess tracheostomy patency- remove speaking valve/cap if present, remove inner tube Attempt to pass suction catheter Unable to pass suction catheter Deflate the cuff- look, listen and feel at the mouth and tracheostomy - use C-Circuit/ waveform capnography Is patient improving- NO REMOVE THE TRACHEOSTOMY TUBE Place high flow oxygen on the face and tracheostomy stoma site. Look, listen and feel at the mouth and tracheostomy site - use C-Circuit/ waveform capnography Is the patient breathing? YES Assist ventilation as indicated. Standard oral airway manoeuvers- cover stoma site with occlusive dressing. Use BMV/OPA/NPA/I-gel /LMA to support breathing as indicated until expert help arrives. Consider tracheostomy stoma ventilation- paediatric face mask or LMA applied to stoma site with BMV if oral BMV/assist not effective Handover Expert airway help arrives. Stoma intubated using bougie and a Size 6 cuffed tracheostomy tube.