Emergency)tracheostomy)management)/)Patent)upper)airway)

Transcription

1 Emergency)tracheostomy)management)/)Patent)upper)airway) Call,for,airway,expert,help,,Look,,listen,&,feel,at,the,mouth,and,tracheostomy) A)Mapleson)C)system)(e.g.) Waters)circuit ))may)help)assessment)if)available) Use)waveform,capnography)when)available:))exhaled)carbon)dioxide)indicates)a)patent)or)par6ally)patent)airway) No) Call)Resuscita6on)Team) CPR,if,no,pulse,/,signs,of,life,, Is,the,pa0ent,breathing? ))Assess)tracheostomy)patency) Yes) Apply)high)flow)oxygen)to)BOTH) the)face)and)the)tracheostomy) ) Remove)speaking,valve,or)cap,(if)present)) Remove)inner,tube, )Some)inner)tubes)need)re/inser6ng)to)connect)to)breathing)circuits) Can,you,pass,a,suc0on,catheter?, No) Deflate)the)cuff)(if)present)),Look,,listen,&,feel,at,the,mouth,and,tracheostomy, Use)waveform)capnography)or)Mapleson)C)if)available) Is,the,pa0ent,stable,or,improving?,, No) Yes) Yes) The,tracheostomy,tube,is,patent, Perform)tracheal)suc6on)) Consider)par6al)obstruc6on) Ven6late)(via)tracheostomy))if) not)breathing)) Con6nue)ABCDE)assessment Tracheostomy,tube,par0ally, obstructed,or,displaced) Con6nue)ABCDE)assessment, ) REMOVE,THE,TRACHEOSTOMY,TUBE,,,Look,,listen,&,feel,at,the,mouth,and,tracheostomy.)Ensure)oxygen)re/applied)to)face)and)stoma) Use)waveform)capnography)or)Mapleson)C)if)available) Call)Resuscita6on)team, CPR,if,no,pulse,/,signs,of,life) No) Is,the,pa0ent,breathing? Yes) Con6nue)ABCDE) assessment) )Primary)emergency)oxygena6on) Standard)ORAL)airway,manoeuvres) Cover)the)stoma)(swabs)/)hand).)Use:)) )))))Bag/valve/mask) )))))Oral)or)nasal)airway)adjuncts) )))))SupragloWc)airway)device)e.g.)LMA Tracheostomy,STOMA,ven6la6on) )))))Paediatric)face)mask)applied)to)stoma) )))))LMA)applied)to)stoma Secondary)emergency)oxygena6on)) AEempt,ORAL,intuba0on Prepare,for,difficult,intuba0on, Uncut)tube,)advanced)beyond)stoma AEempt,intuba0on,of,STOMA, Small)tracheostomy)tube)/)6.0)cuffed)ETT) Consider)Aintree)catheter)and)fibreop6c) scope)/)bougie)/)airway)exchange)catheter National Tracheostomy Safety Project. Review date 1/4/16. Feedback & resources at

2 Management of tracheostomy emergencies A Critical Care Workbook It is 3 am. Your patient has just been repositioned in bed. He is a 69-year old man in his second week of intensive care following an emergency aortic aneurysm repair. He underwent surgical tracheostomy 2 days ago. You notice he now appears to be quite distressed. The ventilator begins to alarm. Your patient appears to be struggling to breathe. What will you do?

3 Background Tracheostomy is a commonly-performed procedure for critically ill patients 1 since it appears to improve comfort, enable secretion clearance and facilitate respiratory weaning and rehabilitation in patients requiring more prolonged mechanical ventilation. Physical rehabilitation while mechanical ventilation administered via tracheostomy. Figure from Hodgson et al. 2 However, significant problems relating to temporary tracheostomies occur in the vast majority of critical care units within the UK 3. The recently published NAP4 audit reported a number of deaths in critically ill patients due to tracheostomy problems 4 and concerns were raised regarding staff education and decision-making, and the lack of availability of equipment at these events. 2

4 Aims and objectives of this workbook This workbook is intended to be a stand-alone tool to enable critical care staff gain a greater understanding of the causes of airway complications in critically ill patients with temporary tracheostomy and to develop a more systematic approach in dealing with these emergencies. The specific learning objectives are to ensure you: Understand how airway complications may arise in the critically ill patient with a tracheostomy Know what risk factors there are for airway complications to arise in these patients Know how to assess the critically ill patient for presence of airway obstruction in the presence of a tracheostomy Know what simple interventions to perform in order to preserve life in the context of airway obstruction in the tracheostomised patient Reinforce what factors relating to the tracheostomy emergency are important to communicate to other clinical colleagues Have considered what additional equipment may be required to deal with the tracheostomy emergency Format of this workbook Appreciating the variable experience of critical care staff regarding tracheostomy emergencies, the workbook utilises an interactive format to ensure that any core knowledge gaps regarding tracheostomies are rectified and that key concepts are understood, and to encourage application of knowledge regarding tracheostomies in hypothetical circumstances. You will be asked questions with respect to knowledge of tracheostomy formation and tracheostomy tubes, consider what can go wrong in a clinical context, and ultimately you will be encouraged to formulate an algorithm for assessing and managing tracheostomy emergencies. Q This icon features at the top of question pages A This icon features at the top of pages with information in answer to questions R This icon is indicates an activity involving reflection on experience and learning Main learning points are identifiable by blue boxes Suggestions for further development are appended, and completed feedback forms would be gratefully received at the address provided. 3

5 Q 1. Patients undergoing tracheostomy Thinking about patients you have managed in critical care, why might critical care patients undergo or have undergone tracheostomy? 2. Tracheostomy procedure Broadly speaking, how might the tracheostomy procedure have been performed? A "standard" cuffed tracheostomy tube is displayed below. What are the alternative tracheostomy tube types displayed alongside, in a and b? a b Standard cuffed tracheostomy tube a. b. 4

6 A 1. Patients undergoing tracheostomy Many critically ill patients undergo temporary tracheostomy because of a need for prolonged intubation (for example, when there is reduced conscious level or poor secretion clearance) and/ or need for respiratory support (especially in the context of acute or chronic respiratory dysfunction or neuro-muscular weakness). Occasionally, tracheostomy will be performed because of acute airway obstruction or because of head and neck surgery, e.g. neck dissection or even laryngectomy. In patients with history of airway obstruction, it is important that you can communicate the nature of the airway pathology or prior surgery to other members of the clinical team, as this will have a big impact on options available for re-establishing airway patency. 2. Tracheostomy procedure In many intensive care units, the majority of tracheostomies are performed using a percutaneous dilatational method, rather than by a traditional surgical tracheostomy. Percutaneous tracheostomy Surgical tracheostomy It is likely that following tracheostomy tube displacement, particularly in the early period (< 1 week) following the tracheostomy formation, that a surgical tracheostomy will preserve its tract to a greater degree than the percutaneous one. The time and type of tracheostomy procedure will be another important point to be aware of when discussing with colleagues options to re-establish airway patency. Some tracheostomy tubes (e.g. Shiley, as in figure a) come with an inner tube to facilitate cleaning and some have an adjustable flange for use in patients with thicker necks (as in figure b). When assessing tracheostomy patency, presence of a tracheostomy inner tube implies there is another potential assessment and treatment option, i.e. can I re-establish airway patency by removing and replacing the tracheostomy inner tube? 5

7 Q 3. Emergency tracheostomy airway complications Look at the image of the tracheostomy tube displayed below. What could go wrong with the tracheostomy tube to cause breathing difficulty? What other causes of acute breathlessness are common among critically ill patients? Why do you think certain groups of tracheostomised patients might be at risk of airway complications? 6

8 A 3. Emergency tracheostomy airway complications In considering breathing difficulty in the critically ill patient with a tracheostomy, the major causes of airway complications are tracheostomy tube displacement and blockage 3. Clearly there are causes of breathing difficulty other than tracheostomy blockage or displacement, such as sputum retention and bronchial obstruction, atelectasis, pneumonia, pulmonary oedema, pleural effusion, pulmonary embolism and pneumothorax. However, as we shall see in the next section, it should be possible to quickly identify whether breathing difficulty is due to an airway complication (i.e. displacement or blockage) or other cause, using simple bedside tests. Surgical emphysema following percutaneous tracheostomy. Image from Fikkers et al Figure illustrating the potentially greater risk of standard tracheostomy tube displacement when distance from skin to tracheal lumen is greater than "normal" When depth from surface of skin to tracheal lumen is increased (typically in obesity, but also in context of significant surgical emphysema, as shown in figure above), there is a greater risk of tracheostomy tube displacement, particularly when a tracheostomy tube without an adjustable flange has been sited. 7

9 Q 4. Managing a tracheostomy emergency How would you first react to a patient with a tracheostomy who appears to have become suddenly breathless? How would you assess the patient? What further interventions could you undertake to assess airway patency? What steps could you take to improve the patient's condition? 8

10 A 4. Managing a tracheostomy emergency However skilled the individual caring for a patient with a tracheostomy emergency is, a number of tasks will need to be completed very quickly. You will need to call for help from colleagues in the vicinity in the first instance, and to call urgently the senior resident with appropriate airway skills (usually the "anaesthetic registrar"). Initial assessment Feeling or hearing breaths via the tracheostomy tube will help confirm that the tracheostomy tube is at least partly within the lumen. Feeling or hearing breaths via the mouth implies that the tracheostomy tube has become displaced (such that the cuff no longer occludes the tracheal lumen) or the cuff has deflated Applying high flow oxygen to both the mouth and tracheostomy tube will enrich with oxygen any airflow occurring via either route If the bag of the Water's circuit moves with patient respiratory efforts and capnography trace is normal, the tracheostomy tube must be at least partly within the lumen 9

11 A If there is good airflow at the tracheostomy lumen (and none at the mouth), good movement of the Water's circuit bag and a normal capnography trace, it is unlikely that there is a significant problem with the tracheostomy tube, and you will need to evaluate for other causes of breathing difficulty. Further assessment Where a tracheostomy tube with an inner tube is used, replacing the inner tube will identify or exclude inner tube blockage as a cause of airway obstruction. Successfully passing a suction catheter beyond the tip of the tracheostomy tube is evidence that that the tracheostomy tube is probably patent Further intervention If the Water's circuit bag moves with patient respiratory effort, capnography trace is normal and you can pass a suction catheter beyond the tip of the tracheostomy tube, the tube is sufficiently patent for assisted breaths to be given by the Water's circuit while waiting for airway expertise. Absent movement of Water's circuit bag, absent capnography and inability to pass the suction catheter suggest that the tracheostomy tube is significantly displaced or completely blocked. If the tracheostomy tube is significantly displaced or blocked, the cuff should be deflated to enable greater airflow via the mouth (assuming there has not been a laryngectomy). If the patient fails to improve, the tracheostomy tube should be removed and oxygen applied to face and stoma. If there is continued deterioration, the patient will need to be manually ventilated via mouth (occluding tracheal stoma), or via tracheal stoma (if there has been laryngectomy). 10

12 Q 5. Communication with colleagues What information is it important to convey to other clinical colleagues about your patient? What options might you expect your anaesthetic colleagues to consider? 11

13 A 5. Communication with colleagues The Institute for Healthcare Improvement advocate use of the SBAR technique for communication between different members of a healthcare team 5. In the context of the tracheostomy emergency, a highly stressful and time-critical situation, this situational briefing model seems particularly appropriate for discussion with colleagues (e.g. senior anaesthetist) not likely to be immediately present at the time of initial deterioration. The "Situation" may be, for example, "Mr X has an emergency tracheostomy problem following his repositioning in the bed. I suspect his tracheostomy is displaced." "Background" could refer to the fact that "Mr X is a 69- year old man recovering from an emergency aortic aneurysm repair. He underwent surgical tracheostomy 2 days ago, when a standard cuffed tracheostomy tube was sited." Your Asessment may refer to the fact that "Mr X is becoming increasingly hypoxic. There is no palpable airflow from the tracheostomy site. The bag of the Water's circuit doesn't move with respiratory effort. The capnograph trace is a flatline. I can't pass a suction catheter." Your Recommendation might be "I've deflated the tracheostomy tube, and we are oxygenating via a mask and Water's circuit at the mouth. I think we need to inform the ICU consultant and believe we need to sedate and intubate Mr X orally." 12

14 R 6. An emergency tracheostomy management algorithm Considering the steps you may now believe important to enable you to assess your patient, to improve compromised breathing and communicate appropriately with colleagues, construct a pathway that reflects the processes you would undertake in assessing and managing a tracheostomy emergency in your patient. You may not feel you need to use all the boxes provided below. 13

15 7. Emergency Tracheostomy Management algorithm, produced by the National Tracheostomy Safety Project 5 14

16 R Which parts of this algorithm do you feel apply directly to your practice? Discuss any significant differences between this algorithm and the steps you recorded on Page

17 R 8. Consider the steps you think may be required in managing a tracheostomy emergency What equipment should you have immediately available (i.e. at the bed space) and what equipment should be available locally (i.e. within the critical care unit)? Tick whichever box you think appropriate Equipment Immediately available Locally available New tracheostomy tube Suction catheter Water's circuit Capnography Face masks Oro-pharyngeal airway Occlusive dressing Standard airway trolley, with endotracheal tube(s), laryngoscope(s), oro-pharyngeal airway (s), bougie Advanced airway trolley, with fibre-optic intubating scope 16

18 R 9. Reconsider the patient discussed in the introduction "Your patient has just been repositioned in bed. He is a 69-year old man in his second week of intensive care following an emergency aortic aneurysm repair. He underwent surgical tracheostomy 2 days ago. You notice he now appears to be quite distressed. The ventilator begins to alarm. Your patient appears to be struggling to breathe. What do you think is likely to have occurred to cause his acute breathing difficulty? How will you first react? How will you assess the patient? 17

19 R You shout for help and ask a colleague to fast bleep the on-call senior anaesthetist. On further assessment, there appears to be airflow via the tracheostomy nor via the mouth. The capnograph displays a flat line. A Water's circuit attached to the standard cuffed tracheostomy tube does not expand and contract with the patient's attempted respiration. You are unable to pass a suction catheter via the tracheostomy tube What further interventions will you undertake? What will you communicate to other clinical colleagues? What options do you think your anaesthetic colleagues should be considering? 18

20 R 10. Suggestions for further development You may find it helpful to discuss your reflections on this workbook with other nursing and medical colleagues. You might also like to attend theatre to see a surgical tracheostomy performed, which will not only demonstrate relevant anatomy, but may also reinforce your concepts relating to the exchange of one airway (in this case endotracheal tube) for another (tracheostomy tube). You may also wish to view the NAP4 audit document 4, which vividly describes case histories relating to a number of airway complications in intensive care, and investigate learning resources available at the National Tracheostomy Safety Project website ( Reflection on further relevant experience and reading References 1.TracMan investigators. TracMan study Full Protocol Accessed 9th March Hodgson C., Berney S, Harrold M, Saxena M, Bellomo R. Clinical review: early mobilization in the ICU. Critical Care 2012; 17: Gratix A, Graves E, Murphy P. Complications associated with the use of temporary tracheostomies: an ill-defined problem? Journal of the Intensive Care Society 2008; 9: Cook T, Woodall N, Harper J, Benger J. 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. British Journal of Anaesthesia 2011; 106(5): Institute for healthcare improvement. SBAR technique for communication: a situational briefing model. Accessed 9th March

21 Feedback Please record how successfully you feel this workbook has met its learning objectives. On a scale of 1 to 3, with 3 indicating that an objective has been fully met, 2 partially met, and 1 meaning that an objective was not met, circle the appropriate number in the table below. Learning objective Understand how airway complications may arise in the critically ill patient with a tracheostomy Know what risk factors there are for airway complications to arise in these patients Know how to assess the critically ill patient for presence of airway obstruction in the presence of a tracheostomy Know what simple interventions to perform in order to preserve life in the context of airway obstruction in the tracheostomised patient Reinforce what factors relating to the tracheostomy emergency are important to communicate to other clinical colleagues Have considered what additional equipment may be required to deal with the tracheostomy emergency Score Do you think the tasks and activities within the workbook helped your learning? Do you think the workbook s presentation aided your learning? YES / NO YES / NO Please make any comments regarding how you feel this workbook could be improved: Please detach and return your completed feedback form to: Dr Richard Pugh, Anaesthetics Department, Glan Clwyd Hospital, Bodelwyddan, LL18 5UJ 20