Tracheotomy Challenges for airway specialists Elizabeth H. Sinz, MD Professor of Anesthesiology & Neurosurgery Associate Dean for Clinical Simulation Disclosures Coeditor/author Associate Science Editor, American Heart Association Learning Objectives Recognize the difference between a tracheotomy and a tracheostomy. Manage cuffed and uncuffed tracheotomy tubes in the operating room. Respond intelligently to airway emergencies involving surgical airways. Apply familiar tools and knowledge to unfamiliar airway situations. 1
Case #1 Elderly man with head/neck cancer s/p resection. Tracheotomy performed at start of procedure due to difficult airway. Agitated POD #2 on floor. Family told to go home when they expressed concern. Code called at 2am Floor team initiated usual measures. Bag-valve apparatus applied to trach tube. Difficult to ventilate. Anesthesiologist responded to code for airway management; saw that patient had a trach and left. Team noted that anesthesiologist was not present. Called again. Anesthesiologist returned. What do you want me to do? He has a trach. Team called for a surgeon. A surgical resident was eventually found. Patient died. 2
Is the anesthesiologist responsible for managing this airway or not? Who is responsible for this airway? Case #2 Patient with tracheotomy for prone surgery Trach tube in place Pt positioned prone Case turned over New anesthesiologist notes low ventilation volume Tries to adjust but can t really see what is going on Stops procedure and has patient turned supine What did she find once the patient was turned over? 3
Case #3 ICU patient with tracheotomy placed about 10 days earlier Bleeding from trach site a few days ago; treated at bedside Copious bleeding from trach site now; decision to go to OR to manage Bleeding continues-suctioning clots from trach tube On transport to OR, patient arrests in elevator How would you have managed the situation? Surgical Airways: Just a hole in the neck? Tracheotomy: a hole in the trachea that is made surgically through the neck Tracheostomy: tracheal stoma. The trachea is diverted to the neck. Usually created when a patient undergoes a laryngectomy yg yso there is no longer a connection between the trachea/lungs and upper airway. Cricothyroidotomy: usually an emergency procedure where the trachea is surgically approached through the cricothyroid membrane. Terms are often used interchangeably 4
Laryngectomy/Tracheostomy Other clues: 5
Sometimes the airway is hidden Stoma Covers Oxygenation and Ventilation with a Tracheostomy Requires no equipment (such as a trach tube) to remain open. Oxygen given via nasal cannula or face mask will not reach the patient s lungs; supplemental oxygen must be administered over the tracheal stoma. Positive pressure provided by usual bag-valve-mask to face will not work. Options are: Insert a cuffed tube into the ostomy and apply positive pressure ventilation Apply a small mask to the neck over the tracheal opening Positive pressure ventilation through via a tracheal stoma 6
A patient with a tracheostomy following a laryngectomy has no connection between his nose or mouth and his trachea and lungs. Any ventilation approach via the upper airway will be unsuccessful. Patient s response to bad healthcare experiences Tracheotomy 7
Oxygenation and Ventilation with a Tracheotomy Will usually close over time unless there is a tube or plug to keep it in place. Spontaneous breathing may be through the nose/mouth or through the tracheotomy or both Respiratory distress may be due to: Blocked or partially blocked airway (upper or lower) Need for ventilatory assistance (pneumonia, pulmonary edema) Identify the underlying cause when difficulty breathing A patient with a tracheotomy can potentially have their airway managed via the trach or/ via their upper airway. To apply positive pressure ventilation, a seal is needed. To create the necessary seal, you have to know where the leaks are and how to plug them. 8
Trach equipment What are these? How will you ventilate this patient? Fenestrated Tracheotomy Tubes 9
What if a patient comes to the ICU with this? How will you ventilate this patient? Metal trach No cuff Need a cuff for positive pressure ventilation Intubate from above Replace with cuffed tracheotomy tube Replace with small ETT Non-disposable equipment Wash with warm soapy water (like doing the dishes) Save in a clean baggie or box with patient s ID No connector for circuit These are in mature trachs 10
Replacing a tracheotomy tube with an endotracheal tube T-tube How do you ventilate this patient? 11
Common Complications of Trachs Bleeding Obstruction Dislodgement Complications-Bleeding Bleeding intraoperatively or post-operatively is the most common complication from tracheotomies Minor bleeding may be controlled by light packing or pressure Severe bleeding warrants exploration and ligation or cauterization of vessels. Injury to the innominate artery in the anterior trachea can lead to life-threatening hemorrhage 12
Figure 1. Anatomic relationship between the trachea and the innominate artery (anteroposterior and lateral view). Kapural L et al. Anesth Analg 1999;88:777-777 1999 by Lippincott Williams & Wilkins Innominate artery fistula High pressure cuffs and excessive patient movement may contribute in patient with high-riding artery Patients sometimes have a sentinel bleed; may note pulsation of trach tube If suspected, immediate operative intervention is indicated Interventions: Tamponade hemorrhage Hyperinflate cuff Apply direct pressure Pass an ETT from above with goal of inflating cuff distal to the bleeding Suction!!! keep patient from drowning on the way to the OR Complications-Bleeding Bleeding may actually kill the patient by causing obstruction 13
Complications-Tube obstruction If you suspect obstruction, what is your first maneuver? A suction catheter or bronchoscope can be diagnostic and therapeutic if a trach tube becomes obstructed With acute tube obstruction, remove inner cannula to reopen the lumen and cleanse Foreign bodies lodged in the tube may be removed at bedside if easily accessible; if not easily accessbile or ventilation is impaired, this should be addressed in the OR What can cause obstruction? Mucous plug Blood clots Foreign body Granulation tissue Stenosis Tricky situations Foreign body-may need to push distally if unable to remove Granulation tissue-may create a ball-valve effect Material at the end of the tube-may be difficult to remove If the obstruction cannot be alleviated, the tube should be removed. It is a plug not a tube in this situation! Tube may not be obstructed-it may actually be dislodged 14
Complications-Dislodgement Early vs. Late Trachs Trachs are mature between 5-14 days After this, replacement is generally straightforward Before this, it may be impossible Inadvertent decannulation is an immediately lifethreatening complication Decannulation may be obvious or not If tracheotomy tube becomes dislodged Recognize Replace Manage the airway from above Avoid fixation errors! Ventilation is best confirmed with continuous waveform capnography. Assessing breath sounds is necessary because it is easy to enter a mainstem bronchus due to the short distance between trachea and carina. 15
Management of a tracheal tube that is inadvertently decannulated depends on the maturity of the underlying tract; if no tract is evident, attempts to reinsert should be abandoned in favor of airway management from above. If direct insertion of the tracheotomy tube is attempted, it should be limited to one or two attempts. If intubating from above when there is a tracheotomy, the endotracheal tube cuff should be beyond the hole Other complications The definition of insanity is doing the same thing over and over and expecting a different result source unknown Approach airway problems in a methodical way Call for specific help early, but don t wait to act Getting oxygen to the patient is the primary goal Tailor subsequent interventions based on the information you obtain from each maneuver-avoid repeating unsuccessful maneuvers. Use your knowledge of airway anatomy to guide your approach 16
Miscellaneous topics Lung isolation for patients with tracheotomies Remove trach tube and place a DL tube from above Use a bronchial blocker via the trach tube Place a small ETT into the mainstem bronchus of the lung you want to ventilate DL tubes are not recommended through tracheotomies due to the potential for injury Algorithm for lung isolation approach in patient with tracheotomy 17
Speaking Valve Original cases Dislodged ETT Tracheotomy tube in prone patient with inadequate ventilation Innominate artery bleed Questions? Thank you! 18