Tracheostomy Emergency Management

Introduction

• Tracheostomies are artificial airways that allow for protected, unobstructed access to the trachea through the neck for ventilation. A laryngectomy involves the removal of the larynx, the subsequent disconnection of the upper airway from the trachea, and suturing of the trachea to the neck, generating a permanent stoma.¹ Due to their artificial nature, these airways can present special management challenges during emergencies.
• Given the special challenges posed by tracheostomies and laryngectomies, the NTSP, based in the United Kingdom, has developed a range of resources, tools, and emergency algorithms to specifically address these issues. These are all heavily referenced throughout this summary, and are openly available at www.tracheostomy.org.uk
• In patients breathing room air, desaturation can occur within minutes of breathing cessation, making rapid assessment and intervention crucial to prevent critical hypoxia.²
• For additional information regarding tracheostomy tubes and their intraoperative management, see our previously published summary on tracheostomy basics. Link
• Emergency front of neck access such as a cricothyrotomy has separate considerations and is beyond the scope of this summary.

Tracheostomy Warning Signs³

• Tracheostomy red flags (NTSP) Link
• Absence or change of capnography with ventilation
• Absence or change of chest wall movement with ventilation
• Increasing airway pressure or reducing tidal volume
• Inability to pass a suction catheter through the tube/stoma
• Discrepancy between actual and recorded tube insertion depth
• Surgical emphysema
• If the patient has a cuffed tracheostomy tube, additional signs such as air leakage or deflation and/or need for regular re-inflation of the balloon may also be useful indicators of a potential airway emergency.

Management Steps

• Management algorithms, such as those developed by the NTSP (see below), are vital for enabling proper interventions during an airway emergency to rapidly restore oxygenation and ventilation to the patient.⁴
• Before beginning emergency management, always call for help to ensure a team and the proper supplies are available to assist in stabilizing the patient.
• During any emergency situation, it is important to be familiar with all relevant patient information, particularly details regarding the patient’s tracheostomy or laryngectomy.
  • Bedhead signs can help promote shared understanding and rapid access to critical patient information in the event of an airway emergency.⁵
  • Knowing why a tracheostomy was placed (e.g., head & neck cancer treatment vs long-term ventilation needs), when a tracheostomy was placed (e.g., 3 days vs 3 weeks ago), and what type of tracheostomy was placed (e.g., cuffed vs uncuffed) can help with differential diagnosis and management.
• It is important to emphasize oxygenation via the stoma, as this will work for patients with tracheostomies AND laryngectomies. Patients with a tracheostomy should also be oxygenated via the face to maximize potential oxygenation.⁴
  • Ventilation through the stoma can be achieved with a pediatric facemask or a laryngeal mask airway (LMA) placed over the stoma.⁵ As demonstrated in the embedded video in Figure 3.
• When considering management steps, the timing and/or type of issue can be extremely important for differential diagnosis and subsequent management, as highlighted in Figure 2 of the ICU One Pager infographic.
  • For example, removing a relatively new (e.g., less than 7 days after tracheostomy placement) tracheostomy tube and attempting to reinsert can generate a false tract, rendering ventilation impossible.

Laryngectomy Considerations⁵

• The most important difference between laryngectomies and tracheostomies is that laryngectomies lack a patent upper airway, leaving the stoma as the only route for oxygenation/ventilation.
• The default emergency action should be to apply oxygen to both the face and the stoma when there is any doubt about whether the patient has a tracheostomy or a laryngectomy.
• Patients without adequate ventilatory effort may be ventilated through the laryngectomy stoma via an LMA or pediatric facemask.
• Some laryngectomy patients may have a tracheoesophageal puncture valve in place, a small one-way valve that allows speech. During an airway emergency, there should be no attempts to remove the valve.