Definition

A tracheostomy is an artificial opening from the anterior neck into the trachea. Tracheostomies can be performed surgically or percutaneously. Around 5000 surgical and 10,000-15,000 percutaneous procedures are estimated to take place in England each year.¹

Indications for a tracheostomy include:

• Long term mechanical ventilation and weaning
• Management of airway secretions
• Prevention of aspiration and airway protection e.g.  in neuromuscular disorders
• Facial or upper airway trauma

Laryngectomy is generally performed for laryngeal carcinoma.

The major distinction between tracheostomy and laryngectomy is that patients with a tracheostomy have the potential for a patent upper airway which is amenable to orotracheal intubation, in contrast to patients with a laryngectomy who have no continuity between the larynx and trachea.

The NTSP have therefore created two separate algorithms for the management of airway emergencies in patients with tracheostomies (Green) and laryngectomies (Red), dependant on this potential for a patent upper airway.³ It is important to note, however, that the initial reason for tracheostomy may have been a difficult or impossible intubation.

Learning bite

• Patients with a tracheostomy may have a patent upper airway so oxygenation via face-mask, upper airway adjuncts, supraglottic devices and orotracheal intubation may be possible.
• In patients with laryngectomies, the above interventions are not possible.

Types of tracheostomy adjuncts

There are numerous types of tracheostomies that may be encountered in the emergency department. The type of tube and inner tube determines whether a cuff can be deflated, the safety and effectiveness of suctioning, and how a tube connects to a breathing circuit.

Common types of tracheostomy tubes:

• Cuffed Inflation of a cuff in the trachea prevents airflow around the tracheostomy tube and secures the airway in situations where positive pressure ventilation or definitive airway protection is required e.g ineffective cough or gag reflex.
• Uncuffed Uncuffed tubes allow airflow around the tube and up through the oropharynx, thereby enabling some degree of speech. As there is a path around the tube within the trachea, they are less suitable for positive pressure ventilation (as air leakage occurs) and they have an inherent risk of aspiration.
• Fenestrated Holes within the walls of the tracheal tube and inner tube allow airflow through the oropharynx, allowing some degree of speech. There is an associated aspiration risk, as with uncuffed tubes.

When passing a suction catheter through the tracheostomy tube, the catheter may travel through a fenestration as opposed to the primary tube opening. This may mislead the clinician regarding tube placement and potentially lead to ineffective suction or false passage creation in the soft tissues.

Inner tubes may or may not be present, and can be with or without fenestrations.

Inner tubes can be easily removed, cleaned and reinserted or replaced, reducing the effects of adherent secretions and associated narrowing of the lumen.

Patients in the community should have spare inner tubes in their tracheostomy care kits. This should be checked at the earliest opportunity when patients attend the emergency department, and appropriate alternatives sourced if not.

If an inner tube is required to connect to a breathing circuit, be sure to replace a fenestrated inner tube with a non-fenestrated tube if positive pressure ventilation is required or in a cardiac arrest scenario.

Other adjuncts

Laryngectomy Adjuncts

Patients who have undergone laryngectomy may present without a tracheostomy tube in situ. However, laryngectomy adjuncts may be visible, which may help to identify patients with a laryngectomy.

Trache-oesophageal Puncture (TEP) This is an implant that connects the upper posterior trachea to the oesophagus, which can serve to direct exhaled air through the mouth, allowing oesophageal speech.

The patient can occlude the stoma site, or a valve can be incorporated into the TEP to direct air through the oropharynx. These can be visible through the stoma usually as a circular button-like implant (see Fig. 4).

If present, a TEP should not be removed in an emergency, owing to the increased risk of aspiration and tissue trauma, with no additional benefit to oxygenation and ventilation.¹

Laryngectomy patients may also wear or carry stoma covers or humidifiers.

Learning Bites

• Uncuffed and fenestrated tubes have an associated aspiration risk.
• Fenestrated inner tubes can be replaced with solid tubes in positive pressure ventilation and cardiac arrest situations.
• Ascertain in advance whether the tracheostomy tube can directly connect to breathing apparatus or whether an inner tube is required.
• If assessing a patient with a tracheostomy, always ensure that there is an appropriately sized spare tracheostomy tube and inner tube available.
• A TEP should not be removed during an airway emergency