Tracheostomy Emergencies / Occluded Tracheostomy

Click here to view the algorithm Identification and Management of the Occluded Tracheostomy Tube

Action rational for Identification and Mangement of the Occluded Tracheostomy Tube Explained
ACTION
RATIONALE
Occlusion of the tracheostomy tube suspected?
 
If the patient has any of the following clinical signs then tube occlusion should be considered:
  • Blood/tissue/phlegm visualised in the tracheostomy tube
  • Difficult or laboured breathing
  • Noisy breathing
  • Use of accessory muscles
  • No or limited air expired from the tracheostomy
  • Patient complaining of being unable to breathe
  • Patient agitation, decreased conscious level
  • Increased pulse and respiratory rate
  • Collapsed patient
  • Deteriorating gas exchange
  • Difficulty in ventilating using an ambubag
  • Difficulty in passing a suction catheter
 
SEEK EXPERT HELP
 
Expert help can be defined as any competent healthcare practitioner. This can be any member of the multidisciplinary team who has experience in caring for the patient with a tracheostomy.
 
Assess flow - OPTIMISE OXYGENATION
 
Airflow should be assessed by performing a head tilt and chin lift to open the airway and help visualise the tracheostomy site.
Look
  • at the opening of the tracheostomy to identify any possible obstruction and emove.
  • for chest movement. Remember that in complete airway obstruction there may be paradoxical
  • breathing but no air movement.
  • is the tracheostomy tube in the correct position?
Listen
  • at the opening of the tracheostomy for movement of air.
Feel
  • at the opening of the tracheostomy with your cheek
  • If the patient is still breathing increase/commence 100% O2.

 If airflow is present optimising oxygenation may prevent the patient developing a cardiac arrest.

 
Ask the patient to cough and /or perform
suction to clear obstruction
 
Asking the patient to cough may help relieve the obstruction or facilitate removal of the obstruction by suctioning. Even if the patient is able to cough and expectorate pass a suction catheter to ensure that the tube is patent and that the tracheostomy tube is not in the pretracheal space.
 
Able to pass suction catheter?
 
If it is not possible to pass a suction catheter beyond the tracheostomy tube into the patient’s trachea, complete obstruction should be suspected. If  fenestrated lumen in place it may not be possible to pass the catheter as it will catch on the fenestrations.
 
T
O
T
A
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O
C
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TOTAL tube occlusion suspected?
  • Remove the inner lumen (if double lumen to be used) and replace with spare non-fenestrated inner lumen
If the occlusion remains unresolved or a single lumen tracheostomy tube is used
  • deflate cuff (if present)
  • Remove the tracheostomy tube and replace
Attempts at recannulation should take no greater than 30 seconds - stop and and administer 100% 02 via patent stoma/tracheostomy/airway
TOTALOCCLUSION
 
Immediate management will depend on the type of tracheostomy tube (see above). The ability to remove the inner lumen of a double lumen  tracheostomy tube allows the airway to remain protected whilst relieving the occlusion.
 
If the occlusion persists despite the insertion of a non-fenestrated inner lumen
  • the cuff, if present, should be deflated to exclude cuff herniation
  • the tracheostomy should be removed.
 
Recannulation and/or insertion of a non-fenestrated inner lumen will facilitate suctioning and allow oxygenation to be optimised. Attempts at recannulation should take no longer than 30 seconds to prevent the patient becoming hypoxic.
 
If unable to insert a new tube refer to tube change failure/accidental decannulation algorithm.
 
P
A
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T
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 O
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PARTIAL tube occlusion suspected?
  • Remove the inner lumen (if double lumen to be used) and replace with spare non-fenestrated inner lumen
Consider utilising the following interventions
  • Trachea Suction
  • Humidification
  • Nebulised Saline/bronchodilators
  • Chest physiotherapy
  • Deflate cuff (if present)
  • Consider tube changes as a matter of clinical urgency
Having secured a patent  airway / tracheostomy/ stoma, administer 100% O2 and consider ongoing care.
 
If partial airway occlusion is present, a competent healthcare practitioner will decide if the tracheostomy tube requires to be changed as an emergency or whether alternative measures may relieve the occlusion. This will be based on the patient’s clinical condition and the degree of occlusion.
 
Care is focused on the removal of the occlusion. Removing the inner lumen of a double lumen tube, and/or implementing/reviewing the interventions described may facilitate the removal of the occlusion.
 
If the occlusion remains unresolved the tracheostomy tube must be changed.
 
 

 

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