Question 11

College answer

• This is a life-threatening emergency. Declaration of the emergency and communication to all members of the team. 
• The most likely diagnosis is misplacement of the tracheostomy tube. 
• Differential diagnosis includes (tension) pneumothorax, (tension) mediastinum, secondary to lung injury major airway injury – e.g. from dilatation / bougie / bronchoscopy / ETT etc. used in procedure or endotracheal tube exchange.
•  
• First priority is to establish the tracheostomy is in place with ETCO₂ / bronchoscopy (should have been used in tracheostomy insertion so readily available).
•  
• If tracheostomy is in place, A=Airway is established, and problem is related to large airway/lung leak. This is likely to be under tension requiring decompression.  
•  
• If tracheostomy not in place, or unable to confirm then patient should be re-intubated with ETT from above and distal tip advanced below the tracheostomy site, and ventilation confirmed.  

Immediate assessment and resuscitation

• Will need management by a multi-disciplinary team. May need to summon help from senior anaesthetist +/- ENT surgeon. Multiple co-ordinated simultaneous actions.
• Check position of the tracheostomy tube (confirm misplacement)
  • Check capnography
  • Pass a bronchoscope down tracheostomy tube

Reintubation

• Cease ventilation via tracheostomy
• Remove tracheostomy tube.
• Gentle ventilation by bag valve mask +/- oro-pharyngeal airway if possible.
• Remove tracheostomy tube.
• Prepare for re-intubation. (including difficult airway Kit)
• Position the oral ETT more distally so that the hole in the trachea is excluded from circuit.
• Confirm position of ETT with capnography and bronchoscope.
• CXR post reintubation to check for pneumothorax.

Further management:

Assess for other related damage:

• Trachea
• Oesophagus
• Venous
• Arterial
• Thoracic duct

Re-evaluate need for tracheostomy

• Re-do by ENT or most experienced operator
• Consideration for use of Uniperc / adjustable flange if regular tube too short for thick neck

Thorough answer should consider –

• Care of the patient NOK- including open disclosure etc.
• Systems issue- e.g. incident reporting, case review, adherence to guidelines or lack of
• Prevention of future events.

Additional Examiners‟ Comments:

A significant number of candidates described removal of the tracheostomy tube without checking position/patency and/or did not mention use of capnograph or bronchoscope.

Discussion

Important differentials:

• Dislodgement
• Pneumothorax
• Posterior tracheal puncture
• Oesophageal puncture
• Wound too wide (escape of air)

Immediate management:

• Increase the FiO2 to 100%
• Disconnect from the ventilator, and manually bag-ventilate them.
• If the bag ventilation is difficult, one must conclude that the patient or the tracheal cannula are the problem.

If the bag ventilation is easy and the patient improves with it:

• The differentials are posterior tracheal perforation, oesophageal perforation, or escape of gas into the subcutaneous tissues though a wound which is too wide.
• Solutions to these problems do not need to be sought in a panic. The patient is improving.
• First:
  • Tighten sutures around the wound (or, if there are no sutures, add them)
  • Inflate the cuff to a higher pressure
  • Decrease the PEEP as much as is permitted by the patient's condition
• Next: one may perform imaging
  • Bronchoscopy or nasendoscopy to exclude tracheal tear and bronchial injury
  • CT of the neck and chest to investigate oesophageal injury (endoscopy is probably a stupid idea, given that it would require manipulation and potentially gas inusfflation of a damaged oesophagus)

If the bag ventilation is difficult and the patient is still unwell:

• Exclude tension pneumothorax
  • Check trachea: is it in midline?
  • Auscultate the chest.
  • Obviously, if you find a tension pneumothorax, you decompress it.
• Attempt bronchoscopy to assess patency
  • If the tracheostomy was just inserted, the bronchoscope should still be nearby
  • This will rapidly exclude tracheostomy dislodgement
• If no bronchoscope is available, attempt to pass a suction catheter
  • Does it pass easily?
  • Does ventilation improve with suction?
  • Suction the patient, looking for fresh blood and clots
• If the catheter is difficult to pass
  • Consider that the tracheostomy is blocked. Check the inner cannula: is it blocked with clot or secretions? Is the patient easier to bag without the inner cannula?
  • Consider that the tracheostomy is dislodged.

If the tracheostomy being dislodged is a real possibility:

• If the tracheostomy is fresh (i.e. less than 7 days old), do not attempt to reinsert it, blindly or via bougie. It is safest to re-intubated orally.
• Remove the tracheostomy
• Place an occlusive dressing over the wound
• Ask an additional staff member to keep pressure on the wound
• Bag-mask ventilated the patient in preparation for oral intubation
• After intubation, contact ENT surgical team to revise the tracheostomy in a controlled setting.

Options for reinserting an "older" tracheostomy

• Direct (just shove it in)
• Fingertip-guided (use the finger to find the hole in the trachea, then guide the tube into the hole)
• Nasogastric tube as a guidewire (i.e. using the NGT to guide the tube in, Seldinger-style)

Collateral damage:

• Make sure you remember to sedate the patient for all this
• Assess for possible complications of a poorly positioned tracheostomy:
  • Posterior tracheal tear
  • Tracheal cartilage fracture
  • Oesophageal perforation
  • Venous or arterial vessel damage
  • Thoracic duct injury
  • Thyroid isthmus injury

Wisdom issues

• Does this patient even need a tracheostomy?
  • Re-do by surgical team, ENT or a more experienced intensivist
  • Use of a different tube (eg. adjustable flange tube if the problem was an excess of pretracheal tissue)
  • Consideration for delayed extubation - perhaps the patient nears a possible safe extubation, and may only require another week of ventilator weaning.
• "How could this have happened?", etc
  • Incident management system to be launched, eg. root cause analysis
  • Open disclosure to family and patient
  • Review of tracheostomy insertion and care guidelines