Tracheostomy Emergencies / Resuscitiation of the patient with tracheostomy tube

Click here to view the Cardiac arrest algorithm

Action rational for Cardiac Arrest in Patinet Breathing via a Tracheostomy Tube/Permanent Stoma Explained
ACTION
RATIONALE
 
Check responsiveness & call for help
Shake and shout – Are you all right?
If no response SHOUT FOR HELP
 
ASSESS AIRWAY PATENCY at tracheostomy tube/permanent stoma site
Head tilt and chin lift
Observe the tracheostomy tube/permanent stoma site for patency
Remove any potential obstruction
 
Check for signs of life    
ASSESS AIRWAY PATENCY at tracheostomy tube/permanent stoma site
Assess for 10 seconds
Breathing check for up to 10 seconds
 
Look
  • for chest movement. Remember that in complete airway obstruction there may paradoxical breathing but no air movement.
  • is the tracheostomy tube in the correct position?
  • for other signs of life
 
Listen
  • at the opening of the tracheostomy tube/permanent stoma site for movement of air.
Feel
  • at the opening of the tracheostomy tube/permanent stoma site with your cheek
 
Those experienced in clinical assessment may wish to assess the carotid pulse for not more than 10 seconds. This may be performed simultaneously with checking for breathing or after the breathing check
 
Call 2222
 
If there is no effective breath call the cardiac arrest team
Commence CPR 30:2
Give 30 chest compressions followed by 2 ventilations
 
PERMANENT STOMA
Bag Valve Soft Mask OVER STOMA with 100% O2
  • It is not possible to perform bag valve mask via the nose and mouth on a patientwith a permanent stoma
  • Place a small soft mask over the stoma and attempt to form a seal around the neck. The two person technique for bag valve mask ventilation is preferable. One person holds the face mask in place and an assistant squeezes the bag.
 
TRACHEOSTOMY TUBE
Connect ambu-bag with catheter mount with 100% O2
  • Using a catheter mount, connect the bag and valve to the tracheostomy tube. As the airway is secured, once the bag valve is connected ventilation can be a single person technique
During rescue breathing, observe for chest movement, if the breath is effective
the chest should rise and fall.
 
If no chest movement consider
causes of
AIRWAY OBSTRUCTION
If there is no chest movement, identify possible causes of airway obstruction. If after 2 attempts at effective breaths there is no effective chest movement carry on with chest compressions and during this time continue to attempt to identify and relieve the obstruction
 
POSSIBLE CAUSES OF AIRWAY OBSTRUCTION
  • Tracheostomy tube/permanent stoma obstruction
  • Accidental decannulation
  • Patient positioning
  • Inappropriate use of equipment
  • Tracheostomy tube migration/positioning
  • Tracheostomy tube in pre-tracheal space
  • Tracheostomy tube cuff herniation
Tracheostomy tube/permanent stoma obstruction
  • Can any obstruction be visualized around or within the opening of the tracheostomy tube
  • If the tracheostomy tube is a double lumen tube ensure the inner lumen is patent – remove it and check. If the tracheostomy tube is a single lumen tube quickly pass a suction catheter down the tube, if this passes with ease the tube is patent and other causes should be considered, if the catheter does not pass then consider removing the tracheostomy tube as it may be occluding the patient’s airway (this should only be carried out by a competent healthcare practitioner).
 
Accidental decannulation
  • If the tracheostomy tube is no longer in the correct position consider
    • passing a new tube
    • using tracheal dilators to open the airway
    • ET intubation (not in patients with permanent stoma)
 
Patient positioning
  • Is the patient unable to support their head allowing the neck/chin to occlude the opening of the tracheostomy tube/permanent stoma site. A simple head tilt and chin lift will resolve this
 
Inappropriate use of equipment
  • If adjuncts are being used during the weaning process or as part of a treatment regimen remove these immediately
 
Tracheostomy tube migration/postioning
  • Has the tracheostomy tube moved?
  • In some patients the tracheostomy tube may become occluded due to the distal end of the tracheostomy tube pressing against tissues
  • Attempt to reposition the tube
  • Try passing a suction catheter, if the catheter cannot be passed consider removing the tracheostomy tube
Tracheostomy tube in pre-tracheal space
  • If incorrectly inserted the tracheostomy tube can be placed in the tissues between the neck opening and the trachea
  • If suspected pass a suction catheter. If unable to pass the catheter consider removing the tracheostomy tube and reinserting a new tube into the stoma
 
Tracheostomy tube cuff herniation
  • Fully deflate the cuff and reinsert air into the cuff while ventilating until a seal is obtained, this usually occurs in cuffs that are overinflated
 
Circulation present – continue rescue breaths
 
Ensure effective ventilation. Provide 10 breaths per minute. Each minute stop for a pulse check.
Circulation present – continue rescue breaths
The type of tracheostomy tube in use will dictate the appropriate
management in order to secure the patient’s airway
Consider type of Tracheostomy Tube
 
Is there a permanent stoma?
  • Provide 30:2 compression:ventilation ratio
  • Consider insertion of a cuffed tracheostomy tube 
It is not possible to perform oral/nasal intubation on a patient with a
permanent stoma. During ALS a secure airway can be obtained by
inserting a cuffed tracheostomy tube into the stoma.
Is there a CUFFED tracheostomy tube?
 
  • Fully inflate cuff
  • Provide asynchronous compression:ventilation
 
OR
Is there an UNCUFFED tracheostomy tube
Attempt to ventilate via tracheostomy tube
  • Provide 30:2 compression:ventilation ratio
  • A cuffed tube should be inserted as soon as is practical by competent healthcare practitioner
 
Inflating the cuff of the tracheostomy tube allowing effective ventilation.
Ventilation is possible via an uncuffed tracheostomy tube however the airway is NOT secured therefore a cuffed tube should be inserted as soon as is practical.
Is there a DOUBLE LUMEN tracheostomy tube?
 
Check inner lumen for fenestrations
 
NON-FENESTRATED INNER LUMEN
  • re-insert and continue
 
FENESTRATED INNER LUMEN
  • Replace the inner lumen with the non-fenestrated inner lumen
 
Ventilation is possible via a fenestrated tracheostomy tube however the airway is NOT secured therefore non-fenestrated inner lumen should be inserted as soon as possible.

Return to list of content

next