1. Airway obstruction
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INTRODUCTION

This requires immediate treatment and is why we as ICU physicians and anaesthetists drill so thoroughly to deal with these situations.

Remember, patients die because of failed oxygenation and ventilation; not failed intubation. Basic airway management skills (e.g. bag and mask ventilation using simple airway adjuncts) are therefore paramount! Do not delay and avoid task fixation; simple measures FIRST.

CAUSES

  • Internal obstruction
    • Foreign body or tumour
    • Airway bleeding/trauma
    • Aspiration vomit
    • Upper airway infection (e.g. epiglottitis, retropharyngeal abscess)
  • Swelling/oedema
    • Angio-oedema (ACE inhibitors, aspirin, hereditary C1-esterase deficiency
    • Anaphylaxis
    • Following upper airway interventions or surgery (including post-extubation laryngeal oedema)
    • Airways burns or inhalation of smoke/toxic fumes
  • External obstruction
    • Swelling/oedema: neck trauma, external mass or tumour
  • Haematoma (especially in coagulopathic or anti-coagulated patients)
  • Neck trauma
    • Following thyroid or carotid surgery
    • Following internal jugular line insertion
  • Neurological causes
  • Diminished level of consciousness (e.g. intoxication, head injury/CVA,cardiac arrest)
  • Laryngospasm (especially in semi-conscious patients)
  • Paralysis of vocal cords
    • Neurological disease (e.g. myasthenia gravis, Guillain Barré, poly- neuritis, or recurrent laryngeal nerve damage)
    • Inadequate reversal of muscle relaxants

PRESENTATION / ASSESMENT

  • Partial obstruction
    • Anxiety
    • Patient prefers sitting, standing or leaning forward
    • Inability to speak or voice change (muffled or hoarse voice)
    • Stridor (inspiratory noise accompanying breathing) or noisy breathing
    • Obvious neck swelling
    • Lump in throat, difficulty in swallowingChoking
    • Coughing
    • Drooling
  • Respiratory distress
    • Tachypnoea and dyspnoea
    • Use of accessory muscles of respiration
    • Paradoxical breathing: indrawn chest and suprasternal recession
    • Tracheal tug
    • ‘Hunched’ posture
  • Total or near-total obstruction
    • Hypoxia, cyanosis, hypercapnia
    • Bradycardia, hypotension
    • Diminished or absent air entry
    • Decreased consciousness
    • Cardiac/respiratory arrest, where bag and mask ventilation impossible

INVESTIGATIONS

WAIT UNTIL STABLE!!

  • ABGs (hypoxia, hypercapnia)
  • FBC (increased WCC in infection)
  • Clotting screen (coagulopathy)
  • Blood cultures and oropharyngeal swabs
  • Imaging
    • neck X-ray (AP & lateral)
    • CXR
    • CT scan may be required
  • Fibre-optic endoscopy or direct laryngoscopy
    • Although nasendoscopy will potentially allow a view of the airway and aid diagnosis, it requires skill to be done safely
    • Direct laryngoscopy should not be attempted unless the airway is already secured, or all preparations are in place to immediately secure the airway (see section on immediate management)

****Airway interventions in a patient with a partially obstruct- ed airway can provoke complete airway obstruction

DIFFERENTIALS

  • Equipment failure (e.g. incorrectly assembled self-inflating ambu-bag)
  • ETT or tracheostomy obstruction
  • Conditions which result in noisy breathing
    • Bronchospasm
    • Hysterical stridor
  • Conditions which result in difficulty breathing spontaneously or high airway pressures when ventilating patient
    • Bronchospasm
    • Tension pneumothorax
  • Conditions which result in patients adopting a sitting or leaning for- ward position
    • SVC obstruction
    • Cardiac tamponade


EMERGENCY MANAGEMENT

  • 100% O2, pulse oximetry
  • Assess condition of patient and likely cause of airway obstruction
  • Support ventilation with bag and mask if required

If patient has suffered cardiac/respiratory arrest:

  • Follow BLS guidelines (Here)
  • Support/open airway; use adjuncts (oropharyngeal or nasopharyngeal airways) and suction
  • Remove obvious obstruction and commence CPR (ALS algorithm)

If patient is peri-arrest:

  • Call for skilled help: anaesthetist, ENT surgeon, your other ITU colleagues
  • Obstruction requires immediate laryngoscopy (direct with a laryngoscope!!)/tracheal intubation
  • Surgical airway i.e. cricothyroidotomy or tracheostomy for total obstruction if the above fails

If airway obstruction is due to diminished consciousness:

  • Call for skilled anaesthetic assistance
  • If traumatic: assume c-spine injury and asses for other injuries
  • Consider replacing hard-collar with manual in-line stabilization (often helpful when supporting airway, required prior to intubation)****Ensuring an adequate airway always overrides concerns about potential c-spine injuries
  • Support/open airway; use adjuncts (oropharyngeal or nasopharyngeal airways) and suction
  • Support ventilation with bag and mask if required
  • Proceed to definitive airway, most commonly rapid sequence intubation 
  • Cricothyroidotomy or tracheostomy is indicated in the event of failed intubation***If airway obstruction is due to airway swelling, infection or physical obstruction; call for senior help (anaesthetic and ENT)
  • Formulate an airway management plan and arrange for equipment to be available (e.g. plan A: endotracheal intubation; plan B: laryngeal mask airway; plan C: temporary cricothyroidotomy); CICV drill
  • Arrange equipment for inhalational induction (anaesthetic machine with anaesthetic gas sevoflurane or halothane)
  • Consider transferring patient to operating theatre where above equipment is present if patient stable enough
  • Temporary measures which may be used whilst arranging the above include: nebulised adrenaline (5mg / 5ml 1:1000 in a nebuliser) and/or humidified oxygen or heliox

***Early intubation should be considered to reduce the risk of sudden deterioration and airway obstruction

  • Cricothyroidotomy or tracheostomy is indicated in the event of failed intubation and ventilation, or as initial management plan under local anaesthesia


Other considerations requiring simultaneous treatment:
  • Anaphylaxis
    • IV or IM adrenaline, steroids, anti-histamines
  • Haematoma after neck surgery
    • remove dressings, cut open sutures
  • Airway bleeding
    • correct coagulopathy
  • Facial trauma
    • simultaneous assessment of c-spine and other associated trauma
  • Laryngospasm:
    • support ventilation with bag and mask ventilation
    • apply PEEP (easier using a Water’s or C-circuit)
    • low dose propofol, 10-20mg IV, and low dose suxamethonium, 10-15mg IV have been successfully used
    • intubation must be immediately available
  • Inadequate reversal of muscle relaxants
    • treat for laryngospasm
    • consider reversal with IV neostigmine 2.5mg mixed with glycopyrronium bromide 0.5mg (only works if reversing a non-depolarising muscle relaxant that is already beginning to wear off)
    • alternatively suggamadex 2-4mg/kg IV may reverse muscle relaxation with vecuronium or rocuronium
  • Post extubation oedema
    • nebulised adrenaline, IV steroids
  • Angiooedema which is non-allergic
    • this should be treated as allergic in the first instance
    • where there is a clear history of hereditary angiooedema consider C1 esterase inhibitor concentrate, icatibant, tranexamic acid, or danazol (seek specialist advice first)

***In stable patients where diagnosis/degree of obstruction is in doubt nasal endoscopy performed by an experienced ENT surgeon may help. Be prepared to intubate or per- form cricothyroidotomy/tracheostomy if total airway obstruction is provoked

  • Once Airway and Breathing are stabilised continue ABC approach – Transfer to critical care environment for close observation

FURTHER STABILISATION

  • Only if condition is stable and the airway obstruction has been relieved
    • Nurse patient 30-45 ° head up to promote venous drainage
    • Consider iv dexamethasone to reduce any further airway swelling
    • Ventilation and sedation for a number of days on ICU may be required for intubated patients until the cause of obstruction resolves
    • Adopt a lung-protective ventilation strategy (Link needed)
    • Surgical or microbiology opinions may be required
    • Supportive measures for sepsis may be required
    • Assess airway swelling (laryngoscopy and/or cuff-leak test) prior to extubation
    • Where intubation is likely to be prolonged, or airway obstruction may recur after extubation, consider elective tracheostomy

!!!NOTES AND NIGHTMARES!!!

  • Delaying intubation may make a difficult intubation impossible
  • Deterioration to complete obstruction may progress rapidly over a few hours
  • Cardiovascular collapse may mask airway signs
  • Airway interventions in a patient with a partially obstructed airway can provoke complete airway obstruction
  • Insertion of oropharyngeal or nasopharyngeal airway in patients with retropharyngeal abscess may burst the abscess and soil the airway
  • It is important to recognize patients in whom endotracheal intubation is likely to be difficult
  • Obtaining a definitive airway via endotracheal intubation or surgical tracheostomy can be challenging in the face of airway obstruction, the priority is always to maintain oxygenation
  • Cricothyroidotomy (Link needed) should only be attempted by inexperienced operators in circumstances where the patient is otherwise likely to die

2. AIRWAY BURNS

Everyone’s nightmare situation! These can rapidly cause airway obstruction within hours, therefore the utmost vigilance is needed and the good old uncut dangly ET tube! The other thing to think about is the fact that there may be noxious gases involved that may ultimately impair gas exchange.

What’s breathed in up top will inadvertently cause damage to the primary airways and lung too, so be prepared!

CAUSES

  • Direct contact thermal burns to the face or airway
    • Airway fires (rare outside operating theatres)
    • Trapped/unconscious near a heat source
    • Inhalation of hot or corrosive gas
  • Entrapment near a burning substance (house fire, car fire)
  • “Flashbacks” of hot gases (foundry accidents, aerosol can fires)
  • Inhalation of steam or drinking hot fluids
    • Drinking corrosive fluids (e.g. bleach)

WHAT TO LOOK FOR

Look for these cardinal warning signs of impending airway obstruction!!!

Face

  • Facial oedema is already present
  • Marked facial burns are present (blistering, pealing skin)

Inside of the mouth and nose

  • Airway oedema or blistering/pealing of mucosal membranes present

Neck

  • Circumferential or marked anterior neck burns are present
  • Laryngeal structures are no longer palpable

General

  • Difficulty swallowing, drooling
  • Carbonaceous sputum
  • Inability to speak or vocal changes (muffled or hoarse voice) – Inspiratory stridor or noisy breathing
  • Respiratory distress (looks like a croup child!)
    • Tachypnoea, dyspnoea, wheeze, cough
    • Use of accessory muscles of respiration, tracheal tug
    • Paradoxical breathing
    • Patient prefers sitting, standing or leaning forward

Investigations

***Secure the airway first before mucking about with tests!!

  • ABGs (hypoxia, metabolic acidaemia)
    • Lactate (may be increased)
    • Carboxyhaemoglobin using co-oximetry (COHb may be increased)
  • FBC, cross match, U&Es
    • CXR
    • C-spine and trauma-series X-rays (if appropriate)


EMERGENCY MANAGEMENT

  • 100% O2, pulse oximetry
  • Assess degree of burn and airway obstruction
  • If associated trauma simultaneously assess C-spine and other injuries

 If patient already has evidence of airway obstruction:

  • Call for senior help (anaesthetic and ENT)
  • Consider nebulised adrenaline (5mg/5ml 1:1000 in a nebuliser)
  • Consider nasal endoscopy to asses degree of airway oedema
  • Prepare equipment for Rapid Sequence Intubation or inhalationalinduction (anaesthetic machine with anaesthetic gas sevoflurane)
  • Prepare difficult airway equipment 
  • Laryngoscopy/intubation will be required (use uncut endotrachealtubes in case of later facial swelling)
  • Cricothyroidotomy or tracheostomy is indicated in the event offailed intubation, or as the first-line technique***If patient is at risk of airway obstruction early, more elective intubation should be performed using an uncut endotracheal tube
  • Once Airway and Breathing are stabilised continue ABC approach
  • Follow trauma/ATLS principles as part of primary survey
  • Assess any associated chest and lung burns 
  • Urgent management of circumferential burns (especially neck and chest) may be required
  • Raised COHb levels require an FiO2 of 100% initially
  • Fluid resuscitate using a burns protocol


OTHER CONSIDERATIONS

  • Assess and treat other traumatic injuries as part of secondary survey
  • If intubated, consider ventilation and sedation on ICU for a number ofdays until airway inflammation has resolved; assess airway swelling (by laryngoscopy and/or cuff-leak test using ventilator) before extubation
  • Consider transfer to burns unit, anaesthetic assessment of airway risk may be required in un-intubated patients
  • Treat inhalational injury
  • Consider giving antibiotics and check tetanus status

!!NOTES AND NIGHTMARES!!

***If in doubt intubate, as delay may make a difficult intubation impossible. Complete airway obstruction can occur  extremely rapidly!!***

  • Hoarse voice is an early sign of laryngeal oedema
  • Trauma including chest, head and neck injuries are common

***Using suxamethonium >48 hours after burn may cause hyperkalaemia**

DO NOT UNDERESTIMATE A BURN PATIENT!!!

 

3. AIRWAY INFECTION

There will be further detail on this topic later, this is a brief introduction.

CAUSES

  • Extrinsic
    • Pharyngeal, retropharyngeal or peri-tonsillar abscess
  • Ludwig’s angina (soft tissue infection of the floor of the mouth)
  • Deep-neck infections

Can be caused by streptococci or staphylococci, but may be polymicrobial and include anaerobic or Gram-negative organisms

  • Intrinsic
    • Diphtheria: airway inflammation and a greyish pseudo-membrane in the respiratory tract (caused by Corynebacterium diphtheriae)
    • Epiglottitis: inflammation of epiglottis, vallecula, aryepiglottic folds, and arytenoids (commonly Haemophilus species, but also Strep. pneumoniae and S. aureus)

RISK FACTORS

  • Poor dental hygiene
  • Recent sore throat, tonsillitis, pharyngitis, URTI
  • Recent oral/pharyngeal surgery/trauma

PRESENTATION AND ASSESSMENT

  • Depending on cause, may include:
    • Tachypnoea, dyspnoea, hypoxia and cyanosis
    • Stridor
    • ‘Hunched’ posture; sitting forward, mouth open, tongue protruding – ‘Muffled’ or hoarse voice, painful swallowing, drooling
    • Neck swelling, cervical lymphadenopathy
    • Trismus, neck pain, neck stiffness
    • Fever and signs of systemic sepsis
    • Diphtheria exotoxin may cause CNS symptoms or cardiac failure
    • Infection may spread causing: pneumonia, mediastinitis, pericarditis,

INVESTIGATIONS

  • FBC (raised WCC)
  • Blood cultures and throat swabs*
  • Laryngoscopy (indirect/fibre-optic) performed by a skilled operator*
  • CXR (if mediastinal/chest involvement suspected)
  • Lateral soft tissue neck X-ray may demonstrate soft tissue swelling and ‘thumb sign’ and ‘vallecula’ signs in epiglottitis
  • CT or MRI of head and neck

***Airway interventions in a patient with a partially obstructed airway can provoke complete airway obstruction***

DIFFERENTIAL DIAGNOSIS

  • Airway foreign body or tumour

IMMEDIATE MANAGEMENT

  • Humidified 100% O2, pulse oximetry
  • Rapid assessment (note that manipulating airway or adjusting patient position may completely obstruct airway, particularly in children)

!!If in extremis!!

  • Call for senior help (anaesthetic and ENT)
  • Elective intubation is required, prior to complete airway obstruction
  • Prepare difficult airway equipment and equipment for inhalational induction (anaesthetic machine with sevoflurane)
  • Consider transferring patient to operating theatre or critical care area where above equipment is present, if this is quicker
  • Surgical tracheostomy by a skilled surgeon is indicated in the event of a ‘failed intubation’, or as the first-line technique
  • If there is a need to “buy” time waiting for senior help consider: Heliox or nebulised adrenaline (5mg/5ml 1:1000 in a nebuliser)

 

In more stable patients:

  • Transfer to critical care environment for close observation
  • The risk of airway obstruction may still mandate early intubation

Once Airway and Breathing are stabilised continue ABC approach

  • Take blood cultures and pharyngeal/epiglottic swabs
  • Obtain IV access and consider steroids (dexamethasone 8mg IV)
  • Empirical antibiotics will depend upon the type of infection (seek microbiological advice), but may include:
    • Epiglottitis: cefotaxime 1-2g IV 12-hourly
    • Deep-seated neck infections: clindamycin 600mg IV 6-hourly, benzyl penicillin 600mg IV 6-hourly, metronidazole 500mg IV 8-hourly
    • For diphtheria: clarithromycin 500mg IV 12-hourly, and possibly anti-toxin (if strain is toxin producing)**For those patients in-extremis, blood cultures and epiglottic swabs should not be obtained until airway is secured**
 

FURTHER MANAGEMENT

  • Ventilation and sedation may be required for a number of days until inflammation has resolved
  • Surgical drainage of abscesses and collections may be required
  • Supportive measures on the ICU for septic patients 
  • Assess airway swelling (laryngoscopy/cuff-leak test) before extubation

!!NOTES AND NIGHTMARES!!

  • Delaying intubation may make a difficult intubation impossible
  • Failure to appreciate how rapidly these conditions can progress, normal to complete airway obstruction in only a few hours

 

4. AIRWAY HAEMORRHAGE

This section may be particularly poignant when treating patients requiring instrumentation, tracheostomy of those with autoimmune / vascular states.

CAUSES

  • Following airway surgery or interventions (e.g. tonsillectomy)
  • Following upper airway interventions, especially tracheostomy
  • Upper airway infection
  • Airway or neck trauma
  • Airway or neck tumours
  • Smoker or previous history of cancer
  • Coagulopathic or anticoagulated patients
  • Epistaxis may occasionally be so severe as to compromise the airway

PRESENTATION AND ASSESSMENT

  • Anxiety
  • Haemoptysis, epistaxis, or spitting blood
  • Airway obstruction: stridor (inspiratory noise accompanying breathing), use of accessory muscles, paradoxical breathing
  • Alveolar soiling: cough, widespread crepitations, diminished air entry
  • Respiratory distress
    • Paradoxical breathing: indrawing chest and suprasternal recessionAltered consciousness, hypoxia, cyanosis, and bradycardia, are preterminal signs
    • Tachypnoea and dyspnoea
    • Respiratory accessory muscle usage, diminished/absent air entry

Where tumour is the cause, the following may also be present:

  • Recurrent or persistent pneumonia
  • Hoarse voice and/or persistent cough
  • Cervical, supraclavicular, or axillary lymphadenopathy
  • Obstruction or respiratory distress of gradual onset

INVESTIGATIONS

  • Diagnosis is clinical; investigations may have to wait until airway is secure
    • ABG
    • FBC, cross match
    • Coagulation screen
    • Blood and sputum cultures if there is evidence of co-existing infection
  • Imaging: CXR, neck X-ray CT scan
  • When possible endoscopy, direct laryngoscopy will aid diagnosis and allow interventions to restore airway patency

DIFFERENTIAL DIAGNOSIS

  • Haemoptysis due to pulmonary haemorrhage – Pulmonary oedema
  • Upper airway infection
  • Foreign body
 

IMMEDIATE MANAGEMENT

  • 100% O2, pulse oximetry
  • For trauma patients: simultaneously assess C-spine and other associated trauma
  • Assess the degree of bleeding and extent of lung soiling, if severe:
    • Call for senior help (anaesthetic and surgical/ENT)
    • The first priority is to secure patency of airway
    • Airway obstruction will require immediate laryngoscopy, suctioning of the upper airway and tracheal intubation
    • Two suction devices may be needed if bleeding is rapid
    • The aim should be to place the cuff of an ETT beyond the site of haemorrhage or insert Double Lumen Tube (DLT) if haemorrhage is pulmonary and unilateral in origin.
    • Surgical airway (cricothyroidotomy or tracheostomy) may be needed if intubation fails (See here)
    • Surgical control of bleeding should then be attempted
    • Urgent fibre-optic bronchoscopy may be required to removeclots from lower airways
  • Where bleeding is not severe airway obstruction may still be a risk,especially if airway tumour is present
    • Make as full assessment as possible as detailed above; including CT scanning if the clinical situation allows
    • Airway manipulation may provoke complete obstruction
    • Once Airway and Breathing are stabilised continue ABC approach
    • Establish IV access and restore circulatory volume with fluid/colloid – Blood and blood product transfusion may be required

FURTHER MANAGEMENT

  • Fibre optic laryngoscopy or bronchoscopy to assess the source of haemorrhage
  • Assessment by ENT surgeon and/or thoracic surgeon for more definitive management of bleeding
  • Sedate and ventilate in intensive care until haemorrhage is controlled or if oxygenation is poor despite a patent airway
  • Circulatory support including inotropes may be required
  • Antibiotics for prophylaxis or treatment of concurrent infection maybe required

!!NOTES AND NIGHTMARES!!

  • Deterioration may be rapid
  • Don’t use sedatives unless airway is secure
  • In extensive lung soiling hypoxia may not be relived by securing airwayand ventilation; also watch for development of pneumonia or ARDS

5. ET Tube Complications

 

These include:

  • Tube obstruction (malposition, cuff herniation, mucous plugging) – Cuff leak
  • Aspiration of gastric contents
  • Accidental extubation
  • Laryngeal damage or tracheal ulceration

CAUSES

  • Complications are more likely if:
    • Patients are agitated, very mobile, or have abnormal anatomy – During transfer
    • There are large amounts of airway secretions
  • Aspiration is more likely where patients have
    • Been intubated as an emergency, or by inexperienced operator
    • Had a full stomach at time of intubation, or intubation was delayedin a patient at risk of aspiration

PRESENTATION AND ASSESSMENT

  • Occluded, semi-occluded or malpositioned ETT:
    • Hypoxia, cyanosis, diminished or unilateral air-entry
    • Difficulty ventilating with high airway pressures
    • Loss of capnograph trace
    • ETT position at lips has changed
  • Cuff leak, audible leak on inspiration if ventilated
    • Ventilator may alarm indicating a leak, low airway pressure, or low expiratory volumes
  • Airway soiling with gastric contents:
    • Widespread crepitations, wheeze or high airway pressures
    • Hypoxia
    • Gastric contents suctioned from airway

INVESTIGATIONS

  • Diagnosis is clinical; investigations may have to wait until airway is secure
    • ABGs (hypoxia, hypercapnia)
    • Fibre-optic endoscopy (may reveal malpositioning, or airway soilingwith gastric contents)
  • CXR: to check ETT position (above carina)

DIFFERENTIAL DIAGNOSES

  • Bronchospasm
  • Pneumothorax
  • Pneumonia

IMMEDIATE MANAGEMENT

  • 100% O2, pulse oximetry 

  • Assess degree of airway obstruction 

  • Call for Anaesthetic help 

  • Check ETT position (average position at the lips for females is 20- 
22cm, and 22-24cm for males, but this varies with patient size) 

    • If too far try withdrawing tube slowly, preferably under direct vision using laryngoscope to avoid accidental extubation
  • Try manually ventilating with Water’s circuit, check ventilator tubing 
and connections 

  • Pass suction catheter via ETT (removes secretions and checks paten- 
cy of lumen) 

  • If patient is in-extremis or obstruction is severe:
    • Try deflating cuff, if it has herniated the obstruction should relieve quickly 

    • If this fails consider laryngoscopy to check tube position (cuff should be just below cords) 

  • Consider removing ETT and re-intubating, this will require:
    • Increasing / commencing sedation 

    • Muscle relaxants (suxamethonium, atracurium) 

    • Suction immediately available 

    • Consider changing ETT over bougie or airway exchange catheter 

  • In the event of accidental extubation:
    • Assist ventilation via bag and mask with airway adjuncts (oropha- ryngeal/nasal airways) if required 

    • Consider re-intubation (sometimes not required as patient may achieve adequate ventilation breathing spontaneously without support or with non-invasive ventilation) 


If there is a cuff leak try further inflating cuff, if this fails or gradually deflates consider electively changing tracheal tube if patient stable. 
If ever in doubt, oxygenate by any means possible. This may mean removing ETT and inserting an LMA, or using bag and mask ventilation until help arrives 


  • Once Airway and Breathing are stabilised continue ABC approach
- Check to ensure adequate ventilation, if poor consider the possibility 
of pneumothorax
- In the event of airway soiling pass suction catheter.

FURTHER MANAGEMENT

  • Continue ventilation in an ICU setting – If the patient has airway soiling:
  • Send tracheal aspirate samples to microbiology
  • Consider bronchodilators, chest physiotherapy and regular suction


6. Tracheostomy Complications

Complications can arise on first or on subsequent insertion of tracheostomy tubes and can include:
-

  • Aspiration of gastric contents
  • Bleeding
  • Surgical emphysema
  • Pneumothorax
  • air embolism
  • Malpositioning (including para-tracheal tracheostomy placement)
  • Infection
  • Tracheostomy occlusion (malposition, cuff herniation, mucous plug)
  • Cuff leak, or accidental decannulation (removal)
  • Mucosal erosion with tracheo-oesophageal fistula formation

 

CAUSES

Complications are more likely if:

  • The tracheostomy performed as emergency procedure, or by inexperienced operator
  • The tracheostomy is performed in a patient who has
    • A full stomach
    • Severe chest problems (FiO2 >60% and/or PEEP >10 cmH2O)
    • Coagulation abnormalities or platelet dysfunction
    • Large amounts of airway secretions
    • Patients have abnormal anatomy, or are very mobile/agitated

 

PRESENTATION AND ASSESSMENT

  • Occluded/semi-occluded airway:
    • Agitation
    • Hypoxia and cyanosis
    • Diminished air entry
    • Difficulty ventilating with high airway pressures
    • Loss of capnograph trace
  • Malpositioning:
    • Difficulty ventilating with increased airway pressures
    • Rapidly developing respiratory insufficiency and hypoxia
    • Pneumothorax, pneumomediastinum or subcutaneous emphysema
    • Loss of capnograph trace
  • Airway soiling with gastric contents:
    • Widespread crepitations, wheeze or high airway pressures
    • Hypoxia
  • Bleeding:
    • Obvious blood loss from or around tracheostomy
    • Presence of blood in airway
    • Increased airway pressure
  • Hypoxia
  • Cuff leak:
    • Audible leak on inspiration if ventilated
    • Ventilator may alarm indicating a leak, low airway pressure, or low expiratory volumes
    • Able to talk past cuffed tube
  • Infection
    • Cellulitis
    • skin erosion, or frank pus

 

INVESTIGATIONS

Diagnosis is clinical; investigations may have to wait until airway is secure:

  • ABGs (hypoxia, hypercapnia)
  • FBC, coagulation studies (coagulopathy)
  • Fibre-optic endoscopy (may reveal malpositioning, or airway soiling with blood or gastric contents)
  • CXR (to check tracheostomy position, to exclude pneumothorax, above carina)

 

DIFFERENTIAL DIAGNOSIS

  • Bronchospasm
  • Pneumothorax

 

IMMEDIATE MANAGEMENT

  • 100% oxygen, pulse oximetry, capnography
  • Apply oxygen to face and tracheostomy tube
  • Call for anaesthetic help and prepare difficult airway equipment
  • Check tracheostomy position, attach Water’s circuit
    • Is water’s circuit and chest moving normally with respiration?
    • If YES: check ventilator tubing and connection
    • If NO: hand ventilate cautiously; if no capnograph trace and difficult to bag consider malposition
    • Remove inner tube
    • Pass suction catheter to remove secretions and asses patency
    • Deflate cuff, if it has herniated the obstruction should relieve 
quickly

If patient is in-extremis or obstruction is severe:

  • Try deflating cuff
  • If this fails STOP ventilating through tracheostomy tube
  • Remove tracheostomy & apply occlusive dressing to neck
  • Ventilate using:
    • Bag, valve, mask + adjuncts
    • Or insert LMA
    • Or re-intubate
  • In the event of accidental decannulation:
    • Call for anaesthetic help
    • Attempt ventilation via a bag and mask using airway adjuncts (oro-pharyngeal/nasal airways) if required
  • If the tracheostomy was sited for upper respiratory tract obstruction attempt to resite the tracheostomy as soon as possible
    • Some tracheostomy stomas if >7 days old will remain patent and ventilation may be assisted via the stoma
    • If tracheostomy >7 days old attempt to resite the tracheostomy as soon as possible
    • Use fibre-optic bronchoscope +/- airway exchange catheter to re-insert tracheostomy under direct vision
    • If this is not possible consider endotracheal intubation
  • In the event of airway bleeding:
    • Call for skilled help – senior anaesthetist and ENT
    • Assess degree of bleeding and extent of lung soiling
    • Fibre optic laryngoscopy or bronchoscopy to assess the source of haemorrhage
  • If minor bleeding from tracheostomy site:
    • Apply direct pressure +/- suture to obvious bleeding point. If still bleeding consider soaking a haemostatic dressing (e.g. Kaltostat) in 1 in 80,000 adrenaline and pack bleeding site
  • If major stoma bleeding:
    • Suction upper airway and tracheostomy to remove clots
    • Orally intubate, use uncut tube and ensure cuff is inflated below tracheostomy stoma
    • Achieve haemostasis of stoma using digital pressure, packing or sutures 

    • Arrange theatre for definitive haemostasis
    • Urgent endoscopy may be required to remove clots from airway and lungs 

  • If major bleeding occurs late it may be due to erosion of right brachiocephalic artery (usually preceded by insignificant sentinel bleed):
    • Bleeding can by massive and life threatening
    • 100% oxygen, call for senior help 

    • Suction airway 

    • Inflate tracheostomy cuff with 50ml air to provide local tamponade 

    • Apply digital pressure to root of neck in sternal notch
    • Commence IV fluid resuscitation, cross-match blood
    • Arrange an emergency theatre team, may also require vascular & 
cardiothoracic surgeons

If ever in doubt, secure airway using endotracheal intubation. Once Airway and Breathing are stabilized, continue ABC approach

  • Check to ensure adequate ventilation, if poor consider the possibility of pneumothorax 

  • Urgent endoscopy may be required to remove clots from airway and lungs 

  • Fluid/colloid/blood to restore circulatory volume 

  • Correct any coagulopathy if there is airway bleeding 


 

FURTHER MANAGEMENT

  • If condition is stable and any severe airway obstruction has been relieved:
    • Continue ventilation in an ICU setting
  • If obstruction only mild or after the airway is re-established using ETT:
    • Re-explore tracheostomy wound and re-insert tube, this can be difficult, particularly via recent (<7 days) percutaneous tracheostomy wounds, senior anaesthetic or ENT help may be required
    • Resiting over an endoscope may help to ensure correct positioning
  • If the patient has airway soiling or cellulitis:
    • Send wound or tracheal aspirate samples to microbiology
    • Use appropriate antibiotics
    • Consider bronchodilators, chest physiotherapy and regular suction
  • If the patient has airway bleeding:
    • Assessment by ENT surgeon and/or thoracic surgeon for more definitive management of bleeding
    • Circulatory support including inotropes may be required

 

!!NOTES AND NIGHTMARES!!

  • Malpositioning may not be immediately obvious
  • Capnography is mandatory
  • Tracheostomy displacement often occurs during turns and transfers
  • If patient is not hypoxic, or has undergone recent neck surgery, await 
senior help before removing tracheostomy