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Overview of Obstruction and Displacement

How common are tracheostomy emergencies?

Reported incidence of tracheostomy displacement varies widely
- Rates of accidental displacement in critical care reported between 0.35% and 15%
In a NPSA 2 year report of critical care patients with tracheostomies:
- 453 incidents were reported
- 338 incidents led to harm
- 15 incidents contributed to death
- 60% were due to blocked or displaced tracheostomies

What are the risk factors for accidental tracheostomy decannulation?

How does the age of the tracheostomy affect the ability to replace a decannulated tube?

≤ 7 days

Most concerning because of the lack of mature stoma formation and narrower tract:
- Increases the risk of airway loss
Replacement should be attempted only with direct visualization via fibreoptic endoscopy:
- Reduces the risk of creating a false passage into the soft tissue
- If unavailable or is unsuccessful oral intubation may be necessary

>7 days

Often easier to replace as stoma matured
Important not to delay as even a mature stoma may significantly narrow over the course of hours making delayed recannulation more challenging

Regardless of the age of the tracheostomy, if resistance is met, a smaller tracheostomy tube should be selected and insertion reattempted
If recannulating is unsuccessful, bag-valve ventilation and oral intubation may be necessary if the patient fails to oxygenate or ventilate

What are the causes of tracheostomy obstruction?

What are the risk factors for tracheostomy tube obstruction?

What are the ‘red flag’ signs of impending tracheostomy displacement or obstruction?

Management of Tracheostomy Obstruction or Displacement

What is the stepwise approach to a tracheostomy emergency?

Call for airway expert help
Assess the tracheostomy quickly:
- Look, listen & feel at the mouth and tracheostomy
- Use a ‘Waters circuit’ and capnography if available
If not breathing call for the emergency team and commence CPR if no signs of life
If breathing apply oxygen to both the mouth and tracheostomy
Assess the tracheostomy patency:
- Remove inner tube and any valves / caps
- Try to pass a suction catheter
If unable to pass a catheter deflate cuff
If not improving remove the tracheostomy tube
- If breathing and stable continue assessment
- If not breathing call arrest team and attempt primary means of oxygenation
Primary attempts at oxygenation:
- Standard oral airway manoeuvres / LMA with stoma covered
- LMA or paediatric facemask applied to stoma
Secondary attempts at oxygenation if still unsuccessful
- Oral intubation with uncut tube past stoma
- Stoma intubation:
  - Size 6.0 ETT over bougie
  - Consider fibreoptic scope and Aintree catheter as first line

Management of Laryngectomy Obstruction or Displacement

What is the stepwise approach to a laryngectomy emergency?

Call for airway expert help
Assess the laryngectomy quickly:
- Look, listen & feel at the mouth and laryngectomy
- Use a ‘Waters circuit’ and capnography if available
If not breathing call for the emergency team and commence CPR if no signs of life
If breathing apply oxygen to the laryngectomy stoma (and mouth if in doubt of stoma type)
Assess the laryngectomy patency:
- Remove inner tube and any valves / caps
- Try to pass a suction catheter
If unable to pass a catheter deflate cuff
If not improving remove the laryngectomy tube
- If breathing and stable continue assessment
- If not breathing call arrest team and attempt primary means of oxygenation
Primary attempts at oxygenation:
- LMA or paediatric facemask applied to stoma
Secondary attempts at oxygenation if still unsuccessful
- Stoma intubation:
  - Size 6.0 ETT over bougie
  - Consider fibreoptic scope and Aintree catheter as first line

Overview of Bleeding

How common is bleeding following tracheostomy?

NCEPOD 2014 report highlighted a rate of:
- Major bleeding: 1.2%
- Minor bleeding: 4.4%

What are the causes of bleeding from a tracheostomy?

Early

Late

What is tracheo-innominate artery fistula (TIAF)?

The most feared haemorrhagic complication of a tracheostomy:
- Incidence of approximately 0.7% of patients with tracheostomy
- Mortality is greater than 90%
Occurs due to the development of a direct connection between the trachea and the innominate artery branch of the aorta

Why does tracheo-innominate fistula develop?

Tracheal tube can cause pressure on the anterior wall of the trachea
Results in mucosal ischemia and fistula formation with the posterior wall of the innominate artery:
- Commonly involved as crosses behind the trachea at the 9-12th tracheal rings
- Within range of the tip of the tracheostomy tube
Risk is increased with:
- Cuffed tracheostomy tube
- Low tracheostomy placement
- High cuff pressure
- High riding innominate artery
- Excessive neck movement
- Tracheostomy infection