Tracheostomy

All tracheostomy bleeds are TIF until proven otherwise - Erica Lee

HWN Suggests

Tracheostomy Emergencies - Dr. Lounsbury

Prepare your airway adjuncts when replacing a trach including an elastic bougie, size 6 endotracheal tube, and fiberoptic scope

Any late trach bleed should be considered to be a tracheo-innominate fistula (TIF) until proven otherwise. TIFs are often preceded by a sentinel bleed which should not be ignored! Any massive trach bleed should be managed by either hyperinflation of the trach cuff or by manual compression of the tracheo-inomminate fistula.

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Featured

Tricks of the Trach: Approach to Tracheostomy Patients in the Emergency Department

In this post, we will review the anatomy, essential history, and common presentations of tracheostomy patients in the ED, including obstruction, decannulation, bleeding, tracheal stenosis, and infection.

Troubleshooting the Crashing Patient with a Tracheostomy

Patients presenting to the ED with respiratory distress and a tracheostomy can unnerve almost any provider, and management is often fraught with preventable errors. This recognition has led to the development of treatment algorithms from groups including the U.K. National Tracheostomy Safety Project to improve the safety and quality of care for patients with tracheostomies.

Previously Featured

Tracheostomy and Trach Emergencies

Tracheoinnominate Artery Fistula (TIA)-causes severe airway bleeding which can be fatal. Consider hyperinflating the cuff to tamponade bleeding as temporizing measure. In differential of any bleeding >48 hours after placement.

Troublesome Tracheostomies

Troubles with tracheostomy tubes can be some of the most anxiety provoking complaints we see in the Emergency Department. Airway master and Dr. IC Cordes himself, Dr. Steven Carleton, MD PhD joined me on the podcast to help demystify 2 common tracheostomy related complaints - the bleeding trach site and the displaced tracheostomy tube.

Approach to tracheostomy emergencies in the ED

Algorithm... Covers the common emergencies post tracheostomy.

Breathing from the neck: Tracheostomy emergencies

This chapter reviews commonly encountered tracheostomy emergencies. It briefly discusses tracheostomy placement and anatomy, including the anatomy of the innominate artery and the ideal location for tracheostomy placement. It then covers the various emergent presentations related to tracheostomies, focusing on tracheostomy bleeding and tracheo-innominate artery fistulas. It discusses etiologies of bleeding, concerning signs and features, and methods of evaluation as well as initial management.

Common Tracheostomy Issues

Complications can be immediate, short term or long term after placement.

Complications of Tracheostomy

There are many immediate or late complications that can occur from tracheostomy. Tracheostomy may be associated with numerous rare acute, perioperative complications. Although complications are rare, the rate of death for all causes is high (22%) in this population (Halum, 2012). There are also numerous late complications as well, including those due to anatomic and physiologic changes. It is imperative that clinicians are aware of these complications because they effect the management and treatment of these patients.

CORE EM: Common Tracheostomy Issues

The tracheostomy tract is considered mature after 7 days. Prior to this, blind replacement of the tracheostomy is discouraged. Any bleeding from or around the tracheostomy should be considered due to a tracheo-innominate fistula and is a surgical emergency. All tracheostomy bleeding should be evaluated by a surgeon preferably in the OR. If the patient cannot ventilate through the tracheostomy take it out and either replace it or intubate from above.

Critical Care Device Series: Tracheostomy Complications and Troubleshooting in the ED

Have a stepwise approach for tracheostomy patients who present to the ED. Consider the life-threatening complications such as decannulation, obstruction, and hemorrhage, which are rare but require immediate intervention. Subacute complications such as tracheoesophageal fistula formation, tracheal stenosis, and infections may also occur. If a tracheostomy becomes dislodged within 7 days of placement, do not replace the tracheostomy. Instead, intubate from the oropharynx.

Deep Breath: How to Handle Tracheostomy Emergencies

If you find yourself needing to replace the tracheostomy tube, consider using an exchange catheter or bougie even if the trach is well established. This provides extra safety. Consider sizing down, especially if changing brands (e.g. Shiley have larger outer diameters than Portex of same inner diameters). Replace with a cuffed tracheostomy tube to aid you in resuscitation even if the original tracheostomy tube was uncuffed.

Field Notes on Tracheostomy Part 1: The Basics

Hello! This is not a comprehensive textbook on how to manage patients with tracheostomies. This is a humble collection of practical brief notes, as requested by a twitter friend. This is a primer. For more extensive information, feel free to consult the big texts.

Field Notes on Tracheostomy Part 2: The Problems

Our beloved patients need to be empowered through education. The tracheostomy tube is a marker of severe life threatening illness.

Management of Acute Respiratory Distress in a Tracheostomy Patient

Dislodgement and Obstruction are the two most common causes of respiratory complications in tracheostomy patients. After removal of the inner cannula, attempt to pass a suction catheter, if unable to pass then the tube is most likely obstructed. If you are able to pass a suction catheter, then dislodgement is more likely.

Managing the Tracheostomy Patient

Real-world strategies for handling this difficult airway.

Mini Tracheostomy

Narrow bore tracheostomy tube inserted through the cricothyroid membrane.

Percutaneous Tracheostomy

Percutaneous Tracheostomy involves Seldinger technique and dilatation of trachea between rings.

Respiratory distress in the patient with a tracheostomy (update)

In patients with normal upper airway anatomy, you are going attempt to ventilate or intubate orally. In patients with a laryngectomy, or with large tumors that occlude the airway, skip those steps.

The Dreaded False Passage: Management of Tracheostomy Tube Dislodgement

Accidental decannulation before a stable tract has formed can result in loss of airway. Factors that predispose to accidental decannulation include loosened straps or sutures securing the tracheostomy tube, edema of the neck, swelling and friable tissue, excessive coughing, agitation or undersedation, morbid obesity, and a tracheostomy tube that is too short for the tract.

Trach Basics: Pediatric Trach Types

Most trach tubes these days are made of plastic or silicone, though on rare occasions a metal trach tube may be used.

Trach Travails: Need-to-Know ED Tricks for Airway Emergencies in Tracheostomy Patients

The following article aims to provide the emergency medicine physician with quick, effective, practical strategies for managing common trach airway emergencies. Hemorrhagic complications related to trachs, such as the appropriately feared tracheoinnominate fistula, or TIF, will not be discussed.

Tracheo-innominate Fistula

Dr. Weingart shares with us what he has learned about how to manage massive hemoptysis in tracheostomy patients, and in particular, a step-wise approach to managing a tracheo-innominate fistula.

Tracheostomy

This is the LITFL CCC master page for tracheostomy...

Tracheostomy Emergencies

More than 110,000 tracheostomies are placed annually in the United States. The overall complication incidence is 40% to 50%. Thankfully, the vast majority of these complications are minor. One percent of tracheostomy patients, however, will suffer a catastrophic tracheostomy-related complication.

Tracheostomy Emergencies

Sometimes difficult to replace trach with same sized one, its ok to downsize. You can replace with ETT, would recommend using 6.0 cuffed tube.

Tracheostomy Emergencies and Neck Infections

The two most common complications are obstruction and dislodgement.

Trouble with Trachs - Recannulating the Stenosed Trach Site

You’ll need to get something back in there but because the hole is rapidly closing, you aren’t likely to be able to put in the same size tracheostomy tube. Oftentimes a tracheostomy tube one size smaller will even be too big to put in its place. You could always just put a very small ET tube or tracheostomy tube in place temporarily, but the patient is going to be better off if you can dilate the tract and replace the same size tracheostomy tube.

Resources

DOPES

DOPES is not just a memory tool. It give you a structured approach to taking care of vented patients with vital sign changes.

National Tracheostomy Safety Project

We have collaborated widely with the key stakeholders in tracheostomy care and developed guidance by consensus. These resources are supported by extensive e-learning packages developed with the Department of Health e-learning for healthcare project.

National Tracheostomy Safety Project

The National Tracheostomy Safety Project has collaborated with colleagues, patients and families from around the world to improve tracheostomy care. We have brought ideas and know-how from exemplar sites to the UK as part of the Global Tracheostomy Collaborative(GTC).

The Global Tracheostomy Collaborative

Our mission is to partner with hospitals and providers around the world, and to work together to improve the care, safety and quality of life of every individual with a tracheostomy.

The Global Tracheostomy Collaborative

The Global Tracheostomy Collaborative believes that through collaboration we will be able to disseminate the best tracheostomy practices. Safe, effective tracheostomy care on a global scale, achieved through data-driven innovations of interprofessional teams of physicians, nurses, respiratory therapists, speech therapists, patients, and families.