Describe your  management  of  a  patient who  develops  neck  swelling with  palpable crepitus, difficulty  in ventilation and rapid desaturation  immediately following  a percutaneous tracheostomy.

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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.
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  • 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

References

References

HUTCHINSON, ROBERT CHARLES, and RODNEY DICKSON MITCHELL. "Life-threatening complications from percutaneous dilational tracheostomy." Critical care medicine 19.1 (1991): 118-119.

Eisenhauer, Brenda. "DISLODGED TRACHEOSTOMY TUBE." Nursing2015 26.6 (1996): 25.

Seay, Shirley Jordan, Sonja L. Gay, and Melvin Strauss. "Tracheostomy Emergencies: Correcting accidental decannulation or displaced tracheostomy tube." AJN The American Journal of Nursing 102.3 (2002): 59-63.

Pattanong, Paradorn. "Dislodged tracheostomy." The Journal of Prapokklao Hospital Clinical Medical Education Center-วารสาร ศูนย์ การ ศึกษา แพทยศาสตร์ คลินิก รพ. พระ ปก เกล้าฯ 24.4 (2012): 304-308.

Chew, John Y., and Robert W. Cantrell. "Tracheostomy: complications and their management." Archives of Otolaryngology 96.6 (1972): 538-545.

Casserly, P., et al. "Assessment of healthcare professionals' knowledge of managing emergency complications in patients with a tracheostomy." British journal of anaesthesia 99.3 (2007): 380-383.