The document discusses tracheostomy emergencies, including indications for tracheostomies, different types of tracheostomy tubes, and approaches to emergencies such as tube obstruction or displacement. Case studies are presented on blocked and dislodged tracheostomy tubes. Key steps in managing emergencies include providing oxygen, suctioning, changing to a cuffed tube if needed, and ensuring correct tube placement. Understanding tracheostomy emergencies is important for emergency nurses as more patients are discharged home with long-term tracheostomies.

1. Trachy Emergencies!
By Kane Guthrie

2. Objectives
• A brief look at tracheostomy emergencies.
• Indications for tracheostomy.
• The different types of tracheostomy tubes.
• Approach to the trachy emergency.
• Case studies.

3. The Trachy!
Tracheotomy:
‘is a surgical incision into the trachea for the
purpose of establishing an airway”
Tracheostomy
‘is the stoma (opening) that results from the
tracheotomy”

4. The Tube’s
• Tracheostomy tubes are devices that aid
passage of air into the lungs for effective
respirations.

5. Trachy Emergencies
Most common emergencies you will face:
– Obstruction
– Displacement
• More Pt being D/C home with long term
Trachies!
= ED nurses need to know what to do when
things go wrong!!

6. Anatomy

7. Indications!
• To maintain the airway
• To protect the airway
• For bronchial toilet
• For weaning from IPPV

8. Cautions & Contraindications
• Difficult anatomy
• Moderate coagulopathy
• Proximity to site of recent surgery or trauma
• Localised infection
• Severe gas exchange problems
Patients generally requiring an emergency trachy don’t have the luxury of having these
conditions corrected before hand!

9. Patient Benefits!
• Less risk of long-term airway damage.
• Patient comfort – no tube in mouth!
• Some can eat & talk!
• Tube more secure some patients can mobilise.

10. The Types!
Surgical:
Percutaneous:

11. Surgical
• Normally done electively (ICU,OT)
• Can be done @ bedside (emergently)
• 3-5cm incision 1 cm below cricoid
• Done under general or local anaesthetic.
Procedure
– Dissection down to the trachea, surgical incision is
made in “T” shape, between 2nd& 3 rd tracheal
rings.

12. Percutaneous
• Done in emergency circumstance where
theater is not an option.
Procedure:
– No surgical incision required- opening is made via
percutaneous “stab” into trachea.

13. Emergency
• Emergency circumstance requiring extreme
measure to secure the airway
• Cricothroidotomy
• Procedure:
– Percutaneous stab into trachea to provide an
opening and allow ventilation.
– Scalpel-bougie, Scalpel –finger, Ball point pen!

14. The Types
Cuffed:
Uncuffed:

15. The Types
1. Cuffed and uncuffed
2. Fenestrated and unfenestrated
3. Those with inner cannulas and those without

16. Cuffed Vs Uncuffed
• Used initially • Used long term
• Reduces aspiration, • Pt needs reasonable
foreign matter in bulbar function to clear
airway. own secretions
• Prevents air escape in
MV.
• Cuff pressure 15-
25mmHg.
• Use in emergencies!

17. Fenestrated
Fenestrated:
• Has pre-cut opening in posterior aspect of
tube.
• Facilitates air entry through the tube and
allows speech.
• Has 2 tube’s one that allows suctioning, eating
& during sleep, the other allows talking.

18. Inner cannula
• Have an inner tube that allows removal if
becomes obstructed to allow removal &
cleaning
• Reduce potentially life threatening
complications.
• Increases the WOB.

19. The Size’s
www.resusroom.com

20. Immediate Complications
• Bleeding
• Pneumothorax or pneumomedistinum
• Injury to adjacent structures
• Post obstructive APO

21. Early Complications
• Bleeding RT - HT or coughing
• Mucous Plugging
• Tracheitis
• Cellulitis
• Displacement of tube- false passage
• SubQ emphysema
• Atelectasis

22. Late Complications
• Swallowing problems
• Tracheal stenosis
• Tracheo-inominate artery fistula
• Tracheoesophageal fistula
• Granuloma formation

23. When to Suction?
• Course breath sounds (crackles)
• Noisy Breathing
• ∧or ∨ resp rate
• ∨ Sp02
• Copious secretions
• Pt attempting but unable to cough or clear
secretions
• Distressed or agitation

24. Factors that can Contribute to
Emergencies!
• Overproduction of sputum
• Coughing
• Irritation of the trachea
• Undue movement of the tube
• Multiple suctioning attempts
• Dry, hardened secretions –sputum plug
• Cuff integrity compromised
• Vomitus or aspiration of stomach contents

25. The Approach
• Is the tracheostomy tube displaced or
obstructed?
• Is the tube cuffed or uncuffed?
• How old is the tract?
• What is the size of the tube?
• Why was the tube placed?

26. Case 1
• 28 male P1 ambulance
• Known Quad with long term trachy.
• P/C: ?Blocked trachy
• 0/A: Cyanosed lips, not moving air.
• V/S: Spo2 70%, HR 145, GCS 8
What do you do?

27. Blocked Trachy
• Apply O2 to mouth and trachy
• Try Suctioning – remove inner cannula.
• Partial occlusion use saline Nebs,
humidification, suctioning.
• If fail try BVM – push down occlusion into
lungs.
• Change trachy tube or re-intubate!

28. The Blocked Trachy

29. Case 2
• 74 male known throat ca
• Long term trachy - fenestrated
• P/C Trachy fallen out
• O/A: Mild resp distress, unable to talk/
• V/S: RR 22, Spo2 90%, Bp 138/84,
• What do you do?

30. The Dislodged Trachy
• Completely dislodged vs. false passage!
• Most prevalent in newly created trachy!
• Occurs with forceful coughing and poorly
secured trachy.

31. The Dislodged Trachy
• Replace with same size or smaller.
• May need trachy dilators and bougie to assist.
• Trachy set not available use small ETT.
• Check correct placement – pass suction
catheter, Etco2, clinical improvement,
auscultation, CXR.
• R/F to ENT.

33. Take Home Points
• Trachy emergencies generally uncommon!
• Have an approach!
• Know how to suction!
• Provide O2 to trachy and to mouth if
distressed!
• Always change to cuffed tube in emergencies!
• Same size or smaller or just use an ETT!

34. Questions?

35. References:
• www.resusroom.com/
• SCGH- Tracheostomy Education package.
• Hess, D. (2005). Tracheostomy Tubes and Related
Appliances. Respiratory Care. 50(4), 497-510.
• De Leyn, P. et.al. (2007). Tracheotomy: clinical
review and guidelines. European journal of
Cardio-thoracic surgery. 412-421.
• Jordan, S. & Gay, S. (2002).Tracheostomy
Emergencies. American Journal of Nursing.
102(3), 59-63.