Tracheostomy Emergencies in Adults

Context

Tracheostomy-related emergencies are rarely encountered in the emergency department but carry high morbidity and mortality.² A lack of familiarity and exposure means emergency department practitioners should become well-drilled in the initial steps required to assess and stabilise these patients, pending the arrival of colleagues who can provide more advanced airway support.

The National Tracheostomy Safety Project (NTSP) is a collaboration that has produced extensive guidance and resources regarding the management of patients with tracheostomies. These materials are readily available on the website www.tracheostomy.org.uk and can be used or adapted for use in clinical settings where tracheostomy patients are being treated.

Learning bite

Emergency medicine doctors should be prepared for how they would manage a tracheostomy-related emergency.

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

Patients with a tracheostomy may present to the emergency department with these complications.

• Tube displacement
  • Accidental dislodgement
  • Migration due to cuff deflation/poorly secured tube
  • Erosion into tissues
  • False passage creation the tube can become lodged in between soft tissue planes around the neck
• Tube obstruction
  • Secretions
  • Blood
  • Lodged foreign body
  • Old or faulty humidification device
• Bleeding
  • Erosion into major vessel including tracheo-innominate fistula
  • Granuloma formation
  • Trauma secondary to suctioning

In a 2004 study, 60% of critical incidents directly affecting patients with tracheostomies involved tube obstruction or displacement, with a significant proportion of these contributing to patient harm.⁴

In 2014 an NCEPOD review identified 1.2% of tracheostomy patients experiencing major bleeding after tracheostomy.⁵ A potential cause of life-threatening bleeding is tracheo-innominate artery erosion, which has an incidence of around 0.1-1% in tracheostomy patients.^6,7 Tracheostomy bleeding and management is explained in more detail later.

Learning bite

Tube obstruction or displacement are the most common complications seen in patients with tracheostomies.

Patients with a tracheostomy should be assessed using an ABCDE approach, with tracheostomy-specific signs grouped under Exposure. These can be considered tracheostomy red-flags.¹

A

• Stridor or abnormal inspiratory noises narrowing or displaced tube
• Partial speech in the case of a cuffed tube, this signifies air leak around the cuff which may indicate displacement or cuff leak/puncture.
• Oral secretions

B

• Apnoea
• Tachypnoea
• Cyanosis and hypoxia
• Audible secretions
• Accessory muscle use
• If ventilated may see increased peak airway pressures, low tidal volumes, and loss of waveform capnography

C

• Tachycardia
• Hypertension or hypotension

D

• Patient indicating increased pain around stoma site
• Agitation and panic
• Reduced responsiveness

E

• Tracheostomy signs
  • Visibly displaced tracheostomy tube
  • Visible haemorrhage from or around the tracheostomy tube
  • Large volumes of air required to inflate cuff may indicate a leak or displaced tube

If any of these signs are present, or there is a concern that a patient with a tracheostomy is deteriorating, a systematic approach is required to manage the patients airway.

If bleeding around or from the tracheostomy is noted, specific management may be required.

Learning bite

A tracheostomy-focused ABCDE assessment should identify potential problems with a tracheostomy.

Environment

Patients with tracheostomies should be cared for in clinical areas with sufficient staff expertise, and appropriate emergency equipment and monitoring. This includes airway adjuncts and intubation equipment, alongside spare tracheostomy equipment.

Assistance

If there is concern regarding a tracheostomy, expert airway help should be called immediately.

Emergency Tracheostomy Management the Green Algorithm

The steps involved in the emergency assessment and management of the tracheostomy patient (who may have a patent upper airway), follow the Green algorithm, as set out by the NTSP.³

The algorithm is freely available from the NTSP online resources, produced for use in clinical areas likely to encounter tracheostomy emergencies, and can be found here.

The NTSP in collaboration with The Health Foundation has also created videos outlining the emergency assessment of patients with tracheostomies, following the Green pathway, which can be found here.

Initial management

1. Call for expert airway help

2. Assess airway patency and signs of life

• Use a look, listen and feel approach, while performing basic airway opening manoeuvres. Feel for airflow from the mouth and tracheostomy.
• If the patient is breathing spontaneously provide high flow oxygen to the mouth and tracheostomy
• If the patient is not breathing spontaneously or is only making occasional gasps, with no pulse, start CPR.

Oxygen can be provided via the mouth (by face-mask) and via the tracheostomy (by either a Waters circuit or bag-valve-mask applied directly to the tube, or by using a paediatric face-mask).

There is potential for harm if attempts are made to ventilate through a blocked or displaced tracheostomy. If a false passage is present, air will be forced into the soft tissues causing severe surgical emphysema. This may make further airway interventions and ventilation more difficult.

Waveform capnography aids airway assessment and allows monitoring of ventilation and cardiac output. The 4^th National Audit Project report from the Royal College of Anaesthetists and the Difficult Airway Society (NAP4) identified a potential for delayed diagnosis of displaced tracheostomy tubes through omission of capnography.⁸ They recommend that this be used at the earliest opportunity in tracheostomy emergencies and ventilated patients.

Assessing the tracheostomy

At each stage, if an intervention is successful, maintain oxygenation and move on to perform an ABCDE assessment. If unsuccessful, proceed to the next step of the algorithm.

Pass a suction catheter

• Remove all external adjuncts including speaking valves, humidifiers and inner tubes.
• Attempt to pass a suction catheter beyond the end of the tracheostomy tube. If the catheter passes beyond the tip of the tube, the tube can be considered patent.
• Suction below and through the tube to remove any secretions causing partial obstruction

Deflate the cuff

• If it is not possible to pass a suction catheter, deflate the tube cuff (if one is present)
• Reassess airway patency using a look, listen and feel approach at the mouth and tracheostomy and look at waveform capnography.
• If deflating the cuff stabilises or improves the patients condition, it indicates that there is some airflow around the tube within the airway, and that the tracheostomy tube is obstructed or displaced.

Remove the tracheostomy tube

• Reassess using a look, listen and feel approach at the mouth and tracheostomy stoma, and using waveform capnography
• The NTSP advises against blind attempts at reinsertion of a tracheostomy tube before day seven, especially if the tracheostomy was performed percutaneously. There is an increased risk of creating a false passage, due to elastic recoil of the tissues covering the original opening.^1,3

Primary emergency oxygenation

If the patient is deteriorating or not breathing, there are now two options:

• Oxygenate and ventilate using standard oral airway techniques i.e. oral airway adjuncts, bag-valve-mask, supraglottic airway devices. Be sure to gently occlude the tracheostomy stoma simultaneously to prevent gross air leak. This can be done with gauze.
• Oxygenate and ventilate via the tracheostomy stoma. This can be achieved using a bag-valve-mask with a paediatric face-mask or by placing a laryngeal mask over the stoma.

Secondary emergency oxygenation

If the above techniques are not effective at oxygenating the patient, secondary airway techniques should be used. There are several important factors that may determine the chosen method, including the age of the stoma, the skillset of the team and the equipment and adjuncts available.

• Attempt oral intubation
  • Plan for a difficult airway, as this may have the original reason for tracheostomy.
  • Use an uncut tube as the extra length may allow the tube to pass below the stoma.
• Attempt intubation of the stoma
  • Size 6.0 cuffed endotracheal tube
  • Smaller sized tracheostomy tube
  • Fibreoptic intubation. This could include using an Aintree catheter mounted upon a fibreoptic bronchoscope

Learning bite

• Use waveform capnography as an adjunct to assess airway patency and ventilation.
• Be cautious using positive pressure ventilation through a tracheostomy until the patency of the tube has been established.

Emergency Laryngectomy Management the Red Algorithm

The management of patients with a laryngectomy differs to that of those with a tracheostomy, due to the anatomical differences between the two. As there is no continuity between the oropharynx and the trachea, the patient cannot be oxygenated via the mouth or nose.

If there is any uncertainty as to whether the patient has had a laryngectomy, oxygen should be delivered to the face and stoma or tracheostomy tube until this can be determined.

The Red algorithm for patients with a laryngectomy³ differs to the Green algorithm in the following ways;

• Oxygen to the mouth or nose is of no benefit and is therefore omitted.
• Primary emergency oxygenation omits the use of oral airway adjuncts, facial oxygenation and ventilation, and focusses solely on oxygenation via the stoma site.
• Secondary emergency oxygenation intubation is at the stoma site.

Laryngectomy patients may well present without a tracheostomy tube in situ, resulting in faster progression through the algorithm and earlier attempts at emergency oxygenation

The Red algorithm is shown below and can be found on the NTSP website here.

Learning bite

If there is any uncertainty as to whether the patient has had a laryngectomy, oxygen should be delivered to the face and stoma or tracheostomy tube until this can be determined.

Management tracheostomy bleeding

Bleeding can be classified as early or late, relating to time since tracheostomy insertion.

Causes of early bleeding:

• Direct arterial or venous injury e.g. thyroid vessels, skin
• Anticoagulant medication effects
• Mucosal or tracheal injury

Causes of late bleeding:

• Erosion into an artery e.g. innominate artery
• Mucosal injury e.g. suctioning
• Granulation tissue

Major bleeding may occur if a tracheostomy tube erodes into a major vessel.

Tracheo-innominate fistula (TIF)

The innominate artery (or brachiocephalic artery) is the first branch of the ascending aorta. It ascends anteriorly and to the right of the trachea, branching into the right common carotid and subclavian arteries.

Erosion into this vessel by a tracheostomy tube cuff or tip can cause profuse, life-threatening bleeding.

The incidence is 0.1-1% post-tracheostomy^6,7 and it is generally fatal without emergency surgical management.⁹

It has been suggested that any bleeding from 3 days to 6 weeks post-insertion should be considered as TIF until proven otherwise.¹⁰ Minor, transient bleeding or a sentinel bleed occurs in 50% of patients, and may precede the onset of severe acute bleeding.^11,12

In practice, this indicates that emergency department practitioners faced with even minor bleeding from a tracheostomy, should have a high suspicion for this diagnosis and should obtain urgent surgical review.

Management

Management of tracheostomy bleeding^9,13

General resuscitation measures:

• Sit the patient up
• Administer high flow oxygen
• Urgent anaesthetic and ENT support
• Ensure large bore IV access
• Group and crossmatch blood – consider major haemorrhage protocol
• Consider anticoagulant reversal

Specific measures^9,13-15

• If the tube cuff is inflated do not deflate the cuff until expert help has arrived; the rational being to maintain any tamponade effect the cuff may be exerting on the bleeding point.
• Hyper-inflate the tube cuff to augment any tamponade effect.
• Bronchoscopy should be used to assess the source and severity of bleeding and to evaluate the patency of the main bronchi.
• If there is ongoing severe bleeding, endotracheal intubation should be performed and the tube advanced to just above the carina.
• Apply direct digital pressure by inserting a finger into the stoma and compressing the brachiocephalic artery against the posterior wall of the manubrium. If this requires removal of the tracheostomy tube, only perform this after successful endotracheal intubation and with expert help present.
• This may act as a temporising measure pending transfer to theatre for immediate surgical intervention.

Learning bite

• Any bleeding from a tracheostomy tube should be considered potentially life-threatening.
• In the case of a tracheo-innominate fistula, hyper-inflating the tracheostomy tube cuff may act as a temporising measure until expert help arrives.
• Emergency surgical intervention is the only definitive treatment for tracheo-innominate fistula

• Focussing on the tracheostomy. It is easy to become focussed upon the tracheostomy as the cause of deterioration in a patient. If tube patency has been ascertained using a structured approach, be sure to complete a thorough ACBDE assessment to exclude other conditions causing respiratory distress e.g. pneumothorax.
• Attempting to ventilate through a displaced tracheostomy tube. This may cause more harm than good and can make further attempts at airway access and management more difficult.
• Ignoring minor tracheostomy bleeding. Treat any bleeding from a tracheostomy site with an extremely high degree of suspicion and obtain expert review.
• Being unfamiliar with tracheostomies and associated equipment. Regularly simulate tracheostomy emergency algorithms and familiarise self with patient-specific tubes and adjuncts if time is available on presentation.

1. McGrath B, (ed.). Comprehensive tracheostomy care: the national tracheostomy safety project manual. John Wiley & Sons Ltd, 2014.
2. Laura J. Bontempo, Sara L. Manning. Tracheostomy Emergencies. Emergency Medicine Clinics of North America, Volume 37. Issue 1. 2019. Pages 109-119. ISSN 0733-8627. ISBN 9780323654531.
3. McGrath BA, Bates L, Atkinson D, Moore JA; National Tracheostomy Safety Project. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012 Sep;67(9):1025-41.
4. McGrath BA, Thomas AN. Patient safety incidents associated with tracheostomies occurring in hospital wards: a review of reports to the UK National Patient Safety Agency. Postgrad Med J. 2010 Sep;86(1019):522-5.
5. Mcgrath B, Wilkinson K. The NCEPOD study: on the right trach? lessons for the anaesthetist. British Journal of Anaesthesia. 2015 Aug;115(2):155-8. https://doi.org/10.1093/bja/aev147
6. Allan JS, Wright CD Tracheoinnominate fistula: diagnosis and management. Chest Surg Clin N Am. 2003; 13: 331-341
7. Dyer RK, Fisher SR Tracheal-innominate and tracheal-esophageal fistula. in: Wolfe WG Complications in Thoracic Surgery: Recognition & Management. Mosby Year Book, St Louis 1992: 288-306
8. Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth. 2011 May;106(5):632-42.
9. C. A. Grant, G. Dempsey, J. Harrison, T. Jones, Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical review, BJA: British Journal of Anaesthesia, Volume 96, Issue 1, January 2006, Pages 127131, https://doi.org/10.1093/bja/aei282.
10. Nelems JM. Tracheo-innominate artery fistula. Am J Surg. 1981;141(5):526-527. doi:10.1016/0002-9610(81)90038-6
11. Jones JW, Reynolds M, Hewitt RL, Drapanas T. Tracheo-innominate artery erosion: Successful surgical management of a devastating complication. Ann Surg. 1976;184(2):194-204.
12. GrilloCG: Tacheal fistula barchiocephalic artery, in GrilloCG (ed): Surgery of the Trachea and Bronchi. Hamilton, Ontario, BC Decker, Ch. 13, 2003, pp 1-9.
13. Warrilow S, Ward J, McMurray K. National Tracheostomy Safety Project. Tracheostomy Emegerncies: Bleeding. [Cited date 20/08/21].
14. Bloss RS, Ward RE. Survival after tracheoinnominate artery fistula. Am J Surg. 1980;139(2):251-253. doi:10.1016/0002-9610(80)90266-4
15. Pool, C, Goyal N. Operative management of catastrophic bleeding in the head and neck. Operative Techniques in Otolaryngology-Head and Neck Surgery. Volume 28, Issue 4, 2017, Pages 220-228, ISSN 1043-1810.

Additional resources

• The National Tracheostomy Safety Project