Dislodged tracheostomy

This chapter addresses the scenario where a recent receptient of a tracheostomy suddenly suffers a respiratory deterioration. Such a scenario has come up in Question 11 from the second paper of 2016. The patient in that scenario also desaturated and developed subcutaneous emphysema. In brief, the approach consists of rapidly excluding dislodgement of the tracheostomy by an attempt at manual bag ventilation and suctioning. If manual ventilation is met with solid resistance and the catheter does not pass easily, one must assume that the tracheostomy has become dislodged. Other causes of subcutaneous emphysema and respiratory failure need to be discussed (i.e. tension pneumothorax, and accidental perforation of god only knows what hollow structures in the neck) but these are probably not as rapidly fatal as the loss of the airway.

This scenario is not something that is usually handled very well, and a 2007 interview study found "significant gaps in knowledge among healthcare professionals regarding the management of specific tracheostomy-related emergencies.". For something as important and ICU-ish as this topic, there is surprisingly little literature. A Google Scholar search reveals case reports (eg. Hutchison et al, 1991)  and simulation scenarios (eg. Eisenhauer, 1996). A good article about reinserting a more mature tracheostomy can also be found in the (Pattanong, 2012). At the bottom of this chapter, the suggested techniques are  from this article.

The following (non-canonical) approach is suggested, and is used as the answer to Question 11 from the second paper of 2016.

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