Management of Acute Respiratory Distress in a Tracheostomy Patient

Management of Acute Respiratory Distress in a Tracheostomy Patient
Author: Greg Nabers, MD (EM Chief Resident, LSU Health Shreveport) // Editors: Jennifer Robertson, MD and Alex Koyfman, MD (@EMHighAK)

Scenario: You receive a call from EMS stating they are on the way to your emergency department with a 60 year-old male in acute respiratory distress. VS: HR 105, RR 30, BP 126/68, SpO2 83%. No further information is provided.

What preparations need to be made for patient arrival? Any patient in acute respiratory distress should be put in a closely monitored room and immediately placed on a cardiorespiratory monitor. Airway equipment should be easily accessible and if available, respiratory therapy should be notified.

How will you begin assessment on this patient? As with any patient in respiratory distress, you must begin with assessing the patient’s airway, breathing and circulation (ABCs). The ABCs should be immediately managed and monitored.

The patient arrives, awake, alert and oriented in visible respiratory distress and to your surprise has a tracheostomy in place! How does this change your management? Initial assessment does not change. Always default to the ABCs, but they should be customized to the specifics of tracheostomy patients, described below.

A: AIRWAY – is the tracheostomy secured in place? Are there secretions that need to be controlled? Can the patient be oxygenated with a bag-valve mask (BVM)? If the patient has a cuffed tube, is there an air leak? If the patient is on a ventilator, what are the airway pressures?

B: BREATHING – Are there bilateral breath sounds with equal chest rise? Is the trachea midline? What is the pulse oximetry level (SpO2), respiratory rate (RR) and the end tidal CO2 (ETCO2)?

C: CIRCULATION – Are pulses present? What is the heart rate? Is the patient’s color pink, pale or cyanotic?
Begin CPR if indicated. If the patient is on a ventilator, take the patient off the ventilator and use a BVM to attempt oxygenation. If the patient is breathing on his or her own, administer high-flow oxygen to the ostomy and use a face mask or non-rebreather (NRB) to assist with passive oxygenation through the mouth and nose.

EMS has obtained intravenous (IV) access and placed a facemask over the tracheostomy but has performed no other interventions. What should you do next?

As you assess the airway, you remove the inner cannula and suction the ostomy. The inner cannula is covered with secretions. You provide oxygenation via NRB while keeping the facemask over the ostomy. The patient’s saturations improve to 93% and the RR decreases to 18. Breath sounds are heard equal bilaterally. You replace the inner cannula with a new one and the patient is able to maintain stable vital signs without additional support. The patient’s chest x-ray (CXR) and lab tests are normal.

Assume the inner cannula was patent and the patient still did not improve with its removal. You attempt to pass a suction catheter through the tracheostomy and it passes without resistance. The patient’s RR continues to increase and his SpO2 is dropping. How would you proceed?

As you deflate the cuff on the ostomy, the patient continues to deteriorate. He or she is now apneic, but still has a pulse. You remove the tracheostomy, cover the opening, and begin BVM ventilation via the nose and mouth; however this does not seem to help. You then obtain a small laryngeal mask airway (LMA), cover the stoma site and oxygenate via the LMA. The patient’s SpO2 improves. You attempt endotracheal intubation but are unsuccessful after multiple attempts. You then grab a bougie, a 6-0 endotracheal tube (ETT) and replace the tracheostomy tube with the ETT via the stoma. The patient’s SpO2 continues to improve with BVM via the new ostomy. The patient is then successfully placed on a ventilator and admitted to the ICU. He or she is extubated the next day.

Helpful Tips:
Like the intubated patient, evaluation of respiratory distress in the tracheostomy patient can be done using the mnemonic DOPE:
D: Dislodgement
O: Obstruction
P: Patient (pneumothorax, PE, pulmonary edema, etc.)
E: Equipment

Dislodgement and Obstruction are the two most common causes of respiratory complications in tracheostomy patients. After removal of the inner cannula, attempt to pass a suction catheter, if unable to pass then the tube is most likely obstructed. If you are able to pass a suction catheter, then dislodgement is more likely.

If you suspect dislodgement, then the tube needs to be replaced. If the tube is less than 7 days old, immediately consult otolaryngology (ENT) and do not attempt to replace the tube.
To replace tubes > 7 days old: Remove the tube, cover the stoma site, and attempt oxygenation through the mouth and nose (in laryngectomy patients, there is no need to attempt oxygenation through the mouth). If this is unsuccessful, then try oxygenation via the stoma. If this is still unsuccessful, then attempt endotracheal intubation. If this does not work, then attempt cannulation via the stoma site using a 6-0 or smaller ETT or a small tracheostomy tube. Consider using bougie or tube exchanger to pass a new ETT or tracheostomy tube into the airway.

If you suspect obstruction, start by instilling a small amount of saline and suctioning the airway in attempt to remove a possible mucous plug. If this is unsuccessful, then the inner cannula should be replaced. If oxygenation and ventilation are still unsuccessful after replacement of the inner cannula, then consider dislodgement and proceed as above.

Use of CXR and ETCO2 monitoring can help you determine if a tube is plugged or displaced. In addition they may assist in determining if pneumothorax, pulmonary edema, or pneumonia are possible culprits for a patient’s respiratory distress.

An easy way to evaluate equipment is to actually take patients off the ventilator . If patients can be oxygenated and ventilated easily with a BVM or NRB, then the problem most likely is due to ventilator malfunction or the need to adjust settings.

Evaluating and managing patients with acute respiratory distress can be stressful. When you add a tracheostomy to the scenario, it is easy to get overwhelmed. Remember to go back to the basics of the ABCs and use DOPE when dealing with a tracheostomy patient in respiratory distress, and never hesitate to get help from consultants if needed.

References / Further Reading:
– Life in the Fast Lane CCC – Respiratory distress in a tracheostomy patient
– Life in the Fast Lane CCC – Tracheostomy tubes
– UK National Tracheostomy Safety Project
– Resus.me – LMA to stoma ventilation
– Intensive Blog – Tracheostomy Emergencies
– http://www.ncbi.nlm.nih.gov/pubmed/23200336

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