Tracheostomy Troubleshooting by Dr. Steven D. Rosenblatt
and Dr. Nikolaus E. Wolter.
My name is Steven Rosenblatt, and I'm
a pediatric otolaryngologist.
In this lecture, we will discuss common issues
managing tracheostomy tubes.
If you have not viewed the Tracheostomy Primer
video, please do so before watching this video.
In pediatric medicine, it's not uncommon to encounter
infants and children with tracheostomies.
Here, we will review common tracheostomy-related problems,
and outline the initial management steps
in a case-based fashion.
I have no disclosures for this video.
Please remember this is in no way
a comprehensive review of tracheostomy management.
And it is always critical to keep in mind
that the tracheostomy tube may represent
a child's only airway.
This lecture will hopefully help provide
a framework for your response to common tracheostomy-related
issues, with the understanding that scenarios are often
more complex than the ones presented in this lecture.
And remember, never be afraid to ask for help.
Case Number One.
You're paged by a nurse in the middle
of the night about your patient with a tracheostomy tube.
She tells you that she was trying
to suction through the tube, and is now having difficulty
passing the suction catheter.
While on the phone with the nurse,
initial questions should include,
"Is the patient desaturating?"
"Are they hemodynamically stable?"
"Are there changes in the ventilation parameters?"
"Were there any instigating factors,
like changes in position, that may be easily correctable?"
If there are any signs of instability,
instruct the nurse to call a code,
and proceed immediately to the bedside.
You should also ask if there is a flashlight, overhead light,
or headlamp available for your use.
If not, ensure that you bring one
or that one can be provided for you.
You should ask if the patient has IV access,
and is there appropriate oxygen delivery setup in the room?
As you're heading over to evaluate the patient,
you should consider the following differential.
Is this a problem with the tracheostomy
tube itself or is this a problem with the trachea?
Tube-related issues may include crusting
within the tube from dried blood or mucus,
or displacement of the tracheostomy tube
from the trachea.
And always ask yourself, "Why does this patient have
a tracheostomy?"
and "Are they intubatable from above?"
Common tracheal issues can include changes
in neck position so that the lumen of the tube
is facing the anterior, or more commonly, the posterior
tracheal wall, or sitting in a tracheal diverticulum that
resulted from an anatomic abnormality,
prior injury, or surgery, or the presence of granulation tissue
formation around the tip of the tracheostomy tube
from local irritation.
Once you arrive in the patient's room,
remember to approach the issue in a stepwise fashion.
First, assess the patient's overall clinical picture.
Are they stable?
Do they have increased work of breathing?
What is their oxygen saturation?
Are they at their baseline mental state?
If the patient is experiencing severe oxygen desaturations,
significantly increased work of breathing,
or changes in mental status, this is a red flag
and you should call for help immediately,
which may require calling a code or otolaryngology STAT.
If the patient is clinically stable,
try the following steps.
Try gently passing the suction yourself.
If it's getting stuck, try to get
a sense of where this is occurring,
either within the lumen of the tube or distal to the tube
itself.
If the tracheostomy tube has an inner cannula,
try replacing it with a new one, and then try
passing the suction again.
If there's no inner cannula, try instilling a small amount
of sterile saline, no more than 2 ccs or so,
into the tracheostomy tube lumen, followed
by gentle suction with a flexible suction catheter
to loosen up any dry crust, blood, or mucus.
Select the largest suction catheter
that easily fits within the tracheostomy tube lumen.
You'll likely need to suction a few times to clear a crust
or mucus plug.
Point of clarification.
Consider bag ventilation with assistance
from a respiratory therapist or a nurse
when performing suctioning of a tracheostomy.
If saline suctioning doesn't help,
try repositioning the patient.
If a change in positioning preceded the problem,
try returning the patient to a neutral resting position.
If not, try positioning the patient supine
with the neck gently extended, if not
otherwise contraindicated.
If none of these maneuvers helped,
the tracheostomy tube may need to be replaced.
If this is a well-established tracheostomy tract,
changes may be performed by respiratory therapy
or by an experienced member of the primary team.
Replacement should not be attempted without a specialist
present if there is a fresh tracheostomy
or if there's a history of difficult tracheostomy tube
changes, unless it's an emergency.
If you still can't pass suction after the previous steps
or if the patient's condition does not
allow you to perform these steps safely,
call otolaryngology for assistance,
as tracheoscopy may be required.
Case Number Two.
The nurse pages you regarding a patient
with a tracheostomy tube.
He just noticed some bright red blood coming
from the tracheostomy site.
While on the phone, you want to ensure
that there is an appropriate suction and oxygen delivery set
up ready for you in the room.
You should also ensure that the patient has IV access
and is on a monitor.
Again, lighting, ideally hands free, will be needed.
While going to see the patient, remind yourself
of any relevant history, including indications
for the tracheostomy, how long the tracheostomy has
been in place, and if the patient is anti-coagulated
or has a coagulopathy.
Upon entering the room, ensure the patient
is connected to a monitor and assess
their overall clinical stability.
If the patient is hemodynamically unstable,
or if there are significant changes in the patient's
baseline status, don't be afraid to call
a code and otolaryngology STAT.
Tracheostomy bleeding should be thought
of in two distinct categories.
Number one, bleeding from around the tracheostomy tube, that is,
bleeding from the wound itself, or bleeding
from within the tracheostomy tube.
In your initial evaluation, try to determine
if the bleeding is coming from around the tracheostomy tube
or from within the tracheostomy tube lumen.
Use a light to examine the tracheostomy site,
and have suction ready.
Have an assistant support the tracheostomy tube
so that you may safely manipulate
the flanges of the tube or remove the dressing
to visualize the site.
As you examine the site, in addition
to determining the location of the bleeding,
try to assess the rate of bleeding.
A slow ooze will have a different differential
diagnosis than a pulsatile bleed,
and oftentimes, slow bleeding can be managed conservatively.
Bleeding from around the tracheostomy site
is not uncommon.
This is seen most often in the early post-operative period,
and usually relates to bleeding from the surgical site itself.
Common sources of bleeding can be
from the wound edges, the thyroid gland,
or the anterior jugular veins.
In the early stages, fresh wound edges may ooze after surgery.
Later on, granulation tissue near the wound edges
may form and bleed intermittently.
If it appears that the bleeding is coming
from the tracheostomy wound itself,
and if the patient has a cuffed tracheostomy tube in place,
ensure the cuff is up to prevent blood
from going down the airway.
Next, take a clean gauze, and apply gentle pressure
over the bleeding region.
It's OK to apply pressure directly
over the flanges of the tracheostomy tube.
Constant pressure should be held for about five to ten minutes,
and often this will be enough to stop the bleeding.
Remember to intermittently suction
through the tracheostomy tube to ensure blood
isn't going down into the airway.
If bloody secretions are coming from the tube,
suctioning with saline squirts will help to clear the clots.
If local pressure alone doesn't address the bleeding,
or if there's active bleeding coming
from the lumen of the tracheostomy tube,
call otolaryngology.
Point of clarification.
Bleeding from lumen of the tracheostomy tube
can represent the following: granulation tissue
of the trachea, possibly from tracheal infection,
inflammation, or overzealous suctioning,
or erosion of the tracheostomy tube into a great vessel,
such as the innominate artery.
In this case, a "sentinel bleed" from the trachea
may be a warning of a major bleeding event forthcoming.
Calling otolaryngology will result
in fiberoptic examination of the trachea and determination
of the source of the bleeding, and urgency of the problem.
In patients with a coagulopathy, or are on anti-coagulants,
bleeding will likely not be addressed by local measures
alone, and correction of their coagulopathy
is often necessary.
Case Number Three.
The nurse pages you about a patient with a tracheostomy
because the vent is now alarming.
Peak pressures are higher than baseline.
While on the phone, ask about the patient's oxygen saturation
and tidal volumes.
Significant decreases in these parameters
can suggest an impending decompensation,
and need to be attended to emergently, with more
senior help.
Again, you'll want to ensure that you'll
have adequate lighting, suction, and oxygen delivery
when you arrive in the patient's room.
The patient should also be on a monitor.
As you're walking to the patient's room,
again, review the initial indication
for the tracheostomy, and if this is a new or established
tracheostomy.
Your differential diagnosis will include
problems with the tracheostomy tube,
problems with the trachea, or primary pulmonary issue.
Of course, you'll also need to consider
a primary mechanical issue too, as the problem can
be with the equipment itself.
Upon entering the room, assess the overall clinical condition
and stability of the patient.
If the patient is unstable, don't be afraid to call a code.
And if a primary tracheostomy issue is suspected,
call otolaryngology.
Assuming the patient is stable, first
assess the tube for obstruction by removing
the inner cannula, if present, or attempting gentle suction
with saline.
This may help remove crusting or mucus that is obstructing
the tracheostomy tube.
If the problem persists after gentle suctioning,
try repositioning the patient supine
with gentle neck extension, if not otherwise contraindicated.
If repositioning doesn't help, it's
possible that the tracheostomy tube
may have become dislodged from the trachea
and entered a false passage between tissues,
or may not be completely in the airway.
This may be apparent by an inability
to pass a suction and difficulty with ventilation.
In this case, the tracheostomy tube
will need to be replaced to ensure appropriate positioning.
If this is a well-established stoma,
the tracheostomy change could be attempted
by respiratory therapy or by an experienced member
of the primary team.
Otherwise, otolaryngology should be
called, as a tracheoscopy may be needed
to ensure proper positioning and to rule out
a more distal obstruction.
Point of clarification.
If the tracheostomy tube is to be changed,
be aware of the child's airway status,
and have a backup plan in order to maintain the airway.
Determine whether the patient is intubatable from above,
if bag mask ventilation is possible,
and if you can intubate with an endotracheal tube
through the stoma.
If the tracheostomy tube itself is OK,
the issue may be in the trachea or below.
Problems with the trachea may include obstruction
from crusting, mucus, granulation tissue,
or tracheomalacia, but you should also
consider problems below the trachea,
in the lungs themselves.
Pneumothorax or pneumomediastinum
should be considered in patients with recently-inserted
tracheostomy tubes, or patients with high ventilatory
pressures.
Exacerbation of a pre-existing pulmonary problem
or congestive heart failure in a cardiac patient
may also occur, and should be worked up in the usual manner.
Chest auscultation and a chest x-ray
are very helpful in these situations.
Ultimately, if the problem can't be
resolved with any of these measures,
call otolaryngology for help.
Case Number Four.
The nurse calls you about a patient
with a tracheostomy tube.
During routine trach care, the trach appears to have come out,
and is no longer properly seated in the stoma.
The first two things you want to know
are, number one, is the patient stable, and number two,
is this a fresh trach or not?
If the patient is unstable, alert the code team.
If this is a fresh trach, or if there
is any history of difficult trach changes,
call otolaryngology.
Once the trach tube is out, the main goal
is to reestablish a functional, safe airway.
The etiology of the problem can be
considered after the airway has been restored.
Call for help immediately, which can include
the nurse, a respiratory therapist, or one of your more
experienced colleagues.
Assuming the patient is stable, upon entering the room,
first assess vital signs.
And if possible, ensure that the patient is on a monitor.
Adequate lighting that allows you to have your hands
free is critical.
A headlight is ideal.
Remember to reassess vital signs frequently,
and consider the indication for the tracheostomy tube, as well
as intubation history.
If the trach was performed for upper airway obstruction,
the tracheostomy tract may be the patient's only airway.
If the trach is the only airway, then a trach
needs to be reinserted urgently.
This is best done by experienced personnel,
but we have outlined the basic steps
of performing a trach change.
In any instance, if vital signs become unstable,
the code team and otolaryngology should be called.
If this is a fresh trach, prior to the first trach change,
stay sutures will still be in place.
These are two sutures that are placed
during the procedure on either side of the opening
into the trachea.
They will be taped to the patient's neck or chest,
and marked right and left, or less frequently, up and down,
based on which side of the tracheostomy hole
they're attached to.
To aid with insertion, they're untaped from the chest,
grasped securely, and then pulled up
and outwards in the direction indicated on the marking.
This will bring the trachea up to the skin
and open the stoma like a book, significantly
aiding reinsertion.
After the first tracheostomy tube change,
stay sutures are typically removed.
This is because the tract is usually matured,
and the stay sutures are not required.
To replace a trach, if possible, lie the patient supine
with a small blanket or towel rolled under their shoulders
to extend the neck.
This will help expose the tracheostomy site
and make insertion easier.
The obturator should be inserted into the tracheostomy tube
prior to attempting reinsertion.
Then, under direct visualization,
reinsert the tracheostomy tube using the stay sutures,
if indicated.
A small amount of lubricant may be helpful.
You may also use an assistant or your non-dominant hand
to help retract the skin around the stoma,
giving yourself better exposure.
It's not uncommon to find a small amount of resistance
at the stoma itself, but if significant resistance is met,
consider using a smaller size tracheostomy tube,
or placing an endotracheal tube through the stoma.
While inserting the tracheostomy tube,
it's helpful to begin with the device rotated
90 degrees towards you, so the patient's chest
does not get in the way.
Once the tip of the tube has passed the stoma,
gently rotate the device, following the natural curve
of the trachea.
Then, remove the obturator, insert the inner cannula,
if present, and connect the circuit
if the patient is on a ventilator.
Once the tracheostomy tube is replaced,
ensure that a suction catheter can be passed easily,
before performing positive pressure ventilation.
This will help ensure proper positioning
and prevent ventilating a false tract.
Remember, always make sure someone
has a hand on the tracheostomy tube
until it's secured with a tie.
Tracheostomy ties should be snug,
allowing one small finger to fit between the ties and the neck.
If the ties are too loose, the tracheostomy tube
will move within the stoma, which
can lead to bleeding, granulation
tissue, false tracking, or allow the trach to fall out.
If a tracheostomy tube or endotracheal tube
can't be reinserted into the tracheostomy stoma in a patient
with upper airway obstruction, otolaryngology
should be called immediately.
A surgical tracheostomy kit should be
available upon their arrival.
In patients with indications other
than upper airway obstruction, remember
that bag mask ventilation and oral intubation
are always an option.
In this case, you need to finger occlude the tracheostomy site
while bag mask ventilating to create a closed circuit.
If the patient requires orotracheal intubation,
the endotracheal tube cuff must be
at the level of or below the tracheostomy site
to prevent air escape.
This concludes our discussion on managing common tracheostomy
issues.
In this video, we discussed basic troubleshooting
of issues, including difficulty passing suction, bleeding,
difficulty with oxygenation and ventilation,
and managing a dislodged tracheostomy tube.
Remember, airway issues should always be attended to urgently.
And never be afraid to ask for help.
Thank you for watching.
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