Tracheostomy Flashcards
(7 cards)
You have been called urgently to attend a ventilated patient on the ICU who has become acutely agitated, hypertensive, and profoundly hypoxic. A percutaneous tracheostomy was performed 18 hours ago and they are being weaned from ventilatory support.
List the possible causes for this patients acute hypoxia
Patient issues
Pneumothorax
Haemothorax
Pneumomediastinum
Haemomediastinum
Surgical Emphysema
Atelectasis, inadequate ventilation due to overly rapid weaning
Aspiration
Equipment Problems
Tracheostomy Tube Blocked (e.g. with secretions or blood)
Dislodged Tube
Cuff Puncture or deflation
Cuff Inflated with speaking / passie mur valve in situ
Ventilator circuit blockage or disconnection
Inappropriate ventilator settings
Inappropriately low fraction of inspired oxygen
What indications are there for tracheostomy insertion
Prolonged Mechanical Ventilation / To Facilitate weaning from mechanical Ventilation
To avoid the complications of long term intubation when weaning
To allow cessation of sedation and communication with the patient during weaning from mechanical ventilation
Pulmonary hygiene in patients unable to clear their secretions
Airway protection in patients with reduced airway reflexes e.g. neurological conditions resulting in bulbar dysfunction or reduced conscious level
As part of a surgical procedure, for example head and neck cancer surgery such as a laryngectomy or in surgery where immediate reintubation would be challenging such as after a maxillofacial free flap
In upper airway obstruction both emergency or elective due to for example vocal cord palsy, trauma, burns or infection
List the possible indications for surgical placement of a tracheostomy over percutaneous insertion
When the tracheostomy is being formed as part of a surgical procedure
Morbid obesity
Cervical Instability
Challenging Anatomy such as:
A short neck
Limited Neck extension
Tracheal Deviation
Concerns about aberrant vessels crossing the insertion site
What significant complications that may be encountered at the time of surgical or percutaneous tracheostomy insertion
Loss of airway:
Obstruction by blood, secretions or foreign body
Dislodgement of tracheostomy tube
Damage to airway:
Fracture of tracheal cartilages, damage to posterior wall of the trachea
Pneumothorax
De recruitment with consequent hypoxia
Aspiration
Haemorrhage
Recurrent Laryngeal Nerve injury
You are called called urgently to review a patient on the intensive care unit who has a percutaneous tracheostomy to facilitate weaning from mechanical ventilation. The patient is awake and appears to be struggling to breathe. The nurse caring for him has applied high flow oxygen over the patient’s mouth and tracheostomy. List the steps you would take to access patency of the tracheostomy
Remove and speaking valve or cap and the inner tube
Attempt to pass a suction catheter via the tracheostomy
Deflate the cuff if unable to pass the suction catheter
A patient whose tracheostomy tube (there is a patent upper airway) you have established is not patent, there is also no bag movement when the tracheostomy is connected to a Mapleson C circuit nor is there a capnography trace.
What are your immediate actions
Remove the tracheostomy tube and assess again for breathing
If they are not breathing call the resuscitation team / commence CPR if no pulse or signs of life
Oral airway maneuvers, while covering the stoma, bag valve mask, oral or nasal airway adjuncts, supraglottic airway device
Ventilation via stoma using a paediatric face mask or LMA applied to the stoma
N.B. this patient has a connection between their mouth and lungs- if the patient has had a surgical tracheostomy as part of surgery for a laryngectomy this would not be the case and hence ventilation can only occur via the stoma (at least initially)
If you are unsuccessful trying to ventilate through a tracheostomy stoma site (having removed the tracheostomy due it no longer being patent) and the patient is now becoming cyanosed what options do you have to secure the airway
Oral intubation (with an uncut tube) and advance beyond the stoma
Attempt stomal intubation with a small tracheostomy tube or a size 6.0 cuffed endotracheal tube
Intubation of stoma with Aintree Catheter and Fibre optic Scope
Use of bougie or airway exchange catheter to facilitate stomal intubation
