Describe your management of a patient who develops neck swelling with palpable crepitus, difficulty in ventilation and rapid desaturation immediately following a percutaneous tracheostomy.
- 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
- 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.
Assess for other related damage:
- 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.
- Posterior tracheal puncture
- Oesophageal puncture
- Wound too wide (escape of air)
- 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.
- 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)
- 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
- 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
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