Trach Travails: Need-to-Know ED Tricks for Airway Emergencies in Tracheostomy Patients

Authors: J. Tyler Schwartz, MD, MPH (Chief Resident, Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center); Skyler Lentz, MD (@skylerlentz, Critical Care Fellow and Instructor in Medicine, Dartmouth-Hitchcock Medical Center); Matthew Roginski, MD, MPH (@mattroginski, Assistant Professor of Medicine, Sections of Emergency and Critical Care Medicine, DHART Assistant Medical Director, Dartmouth-Hitchcock Medical Center) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Case 

A 65-year-old man with a history of obesity hypoventilation syndrome, heart failure, and obstructive sleep apnea with recurrent admissions for hypercarbic respiratory failure prompting placement of permanent metal tracheostomy tube five years ago is admitted to an outside community hospital with dyspnea.  He is treated with diuretics for presumed heart failure exacerbation.  On hospital day #2, he begins to develop altered mental status and worsening dyspnea.  He is hypoxic to the mid 80s on pulse oximetry.  Quick suctioning of his tracheostomy tube improves his oxygenation, but the patient continues to grow increasingly obtunded.  A venous blood gas shows a pCO2 of 108 and a pH of 7.12. The providers recognize that the patient’s uncuffed custom metal trach cannot be ventilated and call for a trach exchange.  The in-house respiratory therapist, general surgeon, and on-call CRNA do not feel comfortable exchanging the patient’s bespoke metal trach.  The hospitalist calls the downstairs emergency physician for help… 

Common Trach Emergencies

The emergency medicine physician must know how to address common airway problems in tracheostomy patients.  This ability requires knowledge of upper airway anatomical features in patients with neck stoma and a toolbox of tricks for clearing, troubleshooting, and exchanging uncuffed or malfunctioning trach tubes. The following article aims to provide the emergency medicine physician with quick, effective, practical strategies for managing common trach airway emergencies.  Hemorrhagic complications related to trachs, such as the appropriately feared tracheoinnominate fistula, or TIF, will not be discussed.

In the inpatient environment, the nature of the patient’s airway anatomy is known, but for the undifferentiated “neck breather” presenting in respiratory distress to the ED, the first step is determining whether the patient has a simple tracheostomy or a total laryngectomy. Tracheostomy patients have a stoma in the anterior neck but still have intact upper airway anatomy and can potentially be intubated from above, recognizing that the trach may have been originally placed due to the patient being a difficult intubation.  Total laryngectomy patients also have stoma in the anterior neck but, in contrast to simple tracheostomy patients, have no airway access from the nose or mouth; they are obligate breathers through the neck stoma, as seen in Figure 1.  If the patient or chart review is unable to provide this history, placing end-tidal CO₂monitoring on the patient’s nose and looking for a capnographic waveform will quickly determine whether or not there is communication to the trachea; trach patients will have some degree of CO₂exchange through the nose and mouth if the cuff is down or an uncuffed tube is in place; laryngectomy patients will not.¹  The remainder of this report will focus exclusively on simple tracheostomy patients.

Take Home Point: The approach to a total laryngectomy patient vs. a simple tracheostomy patient with normal upper airway anatomy is different.  Those with simple tracheostomy can potentially be intubated or bagged from above; those with a total laryngectomy are obligate “neck breathers.”  Differentiate between them with ETCO₂at the nose.

Patients may have tracheostomies for a variety of reasons and, depending on the reason, will have different types of tracheostomy tubes.  The patient may have a prolonged need for mechanical ventilation.²  In this case, a cuffed tracheostomy tube is placed, such as a Shiley Ⓡ.  There are also standard and non-standard sizes, such as a proximal XLT (extra long trach proximally for large necks), distal XLT (extra long distally for a long neck or for a need to bypass an obstruction), etc. Many tracheostomy tubes, but not all, have a disposable inner cannula that can be easily exchanged when it becomes clogged.  Examples are shown in Figures 2 and 3.  For those tubes with inner cannula, the inner cannula is necessary to connect to a bag-valve mask; the tube will not connect to bag-valve masks or ventilators without the inner cannula.  The size of the tracheostomy tube is usually noted on the flange, and the presence of a cuff is evidenced by a pilot balloon.  Patients without a need for mechanical ventilation may have uncuffed tracheostomy tubes of various types, with or without speaking valves or caps for phonation in those with an intact larynx.  These attachments should be removed if there is an emergency.¹ There are additional permutations of tracheostomy tubes beyond these basics, and the more unusual the tube, the more likely the provider will encounter an atypical and challenging airway.

Take Home Point: Different tracheostomy tubes exist–most generally, cuffed vs. uncuffed. The tube must be cuffed for mechanical ventilation.

A trach tube obstructed by mucus or other matter is probably the most commonly encountered trach problem.  The first step is to attempt passage of flexible suction tubingthrough the trach tube.¹  If the suction removes a mucus plug, passes easily through the trach tube, and the patient’s oxygenation improves, then the etiology of the hypoxia was a simple mucus plug and the patient can likely be discharged after a period of observation.  If the suction tubing does not pass easily, then remove and clean or replace the trach tube’s inner cannula if it has one; this inner cannula exchange should remove any plug present in the tube and improve hypoxia.  If it does not, then the etiology of the tube malfunction is likely not related to plugging.  Move to assessing for malposition or dislodgement.

Malpositioned or partially dislodged trach tubes can precipitate respiratory failure. The tube may migrate overtime such that the tip abuts the tracheal wall and does not allow for gas exchange through the lumen of the tube; if the tube is cuffed, let down the cuff, as this may allow the tip to slide off of the tracheal wall and back into the tracheal lumen.¹  Attempt to pass fiberoptic or bougie for visual or tactile confirmation of tracheal location.  If the tube is still within the trachea, advance it along the fiberoptic or bougie. If this advancement does not work or if the position of the existing tube cannot be confirmed, then it needs to be exchanged.

Take Home Point: Mucus plugging is common.  Attempt suction of the tracheostomy tube and replace the inner cannula, if present.  Let down cuffs when repositioning the tube.

“My trach fell out!”  The strategy for fully dislodged trach tubes differs for new vs. established tracheostomies.  If the tracheostomy site is new, meaning less than 7-10 days, particularly if it was created percutaneously through dilation, then the stoma might collapse, and attempts to replace the trach tube through the stoma can easily lead to false passage.³  The provider should attempt to reach the surgical team responsible for the fresh tracheostomy.  Many surgeons place sutures on the trach flange as a sign that it is a new trach. If the tracheostomy site is old, greater than 7-10 days, then the stoma is usually well-established. One can often directly visualize the posterior trachea through the stoma and simply replace the trach tube.  For added security, one can pass a bougie or other airway catheter through the stoma and then pass the new trach tube over this catheter.  Always confirm position of the replaced trach tube with fiberoptic bronchoscopy, if available, or with ETCO₂.  As an aside, for emergent cricothyroidotomies, the tube can likewise be adjusted and correct position verified by bronchoscopy.

Take Home Point: If a tracheostomy is < 7 days old, endotracheal intubation may be safer than replacing the trach tube.  If a tracheostomy is >7-10 days old, replacement of trach tube with immediate confirmation using fiberoptics or ETCO₂  should be possible.

If all else fails to reestablish airway patency in a tracheostomy patient and the trach tube cannot be successfully exchanged, remove the existing trach tube and attempt intubation from above.  As a temporizing measure, the provider can attempt to use a bag-valve mask on the patient’s face as normal, with a finger over the neck stoma to seal it; alternatively, the neck stoma can be (poorly) oxygenated and ventilated with a pediatric BVM or LMA placed tightly over the stoma.¹  Make sure the ETT from above goes past the stoma when intubating.

Though this article has not focused on total laryngectomy patients, trach tube dislodgement at less than 7 days post-laryngectomy should be truly feared.  The only access to the airway is through the new stoma, and creating a false trach passage is a significant risk.  If there is time, call the surgical team, but if the patient is crashing, careful attempts at cannulation should be attempted and immediately confirmed by fiberoptics or by ETCO_2. We would recommend preparation similar to that of a surgical airway.

Tips for Trach Exchange

Emergency physicians may encounter a patient with an uncuffed trach tube who requires mechanical ventilation, such as in the case at the start of this article.  For these patients, their uncuffed tube will need to be safely exchanged for a cuffed trach tube in order to provide positive pressure ventilation.

Although an established tracheostomy can often have the tube exchanged simply using a new trach tube with an obturator, the safest method for exchanging a trach is via fiberoptic bronchoscopy or Seldinger technique with an exchange catheter. Passing the bronchoscope through the existing trach tube and visualizing trachea and carina confirms that the tube is correctly positioned within the airway.  Once the existing trach tube position has been confirmed, the bronchoscope is removed and preparation is made to exchange the existing trach tube for a new one with a cuff; a standard ET tube can be used a temporary fix if an appropriately sized trach tube is not readily available.  Several airway “exchange catheters” exist to assist with this process: the bougie, the Aintree, and the Cook Ⓡ.  See Figure 4.  The bougie is familiar to most emergency medicine physicians, is relatively thick in diameter and inflexible, and provides tactile confirmation of endotracheal position by feeling the tracheal rings.  The Aintree has an internal lumen, which can be connected to a BVM, by which a (small) amount of oxygenation can occur while exchanging the trach tubes; a pediatric fiberoptic scope can also be placed through the Aintree lumen to confirm endotracheal position.  Like the Aintree, the Cook catheter has an internal lumen for limited oxygen exchange, but it comes in several available diameters and can be more flexible and longer than the bougie, potentially allowing it to make sharper turns in the airway.  Different clinical scenarios may call for one or more of these devices, and emergency medicine physicians should be familiar with them.

Take Home Point: Bougie, Cook, and Aintree catheters can assist with trach tube exchange. Always confirm tube replacement with fiberoptic visualization or with ETCO₂.

The following videos describe the supplies and steps necessary to safely exchange a tracheostomy tube:

Case Conclusion

The outside hospital emergency physician passed a bougie through the patient’s existing metal trach and exchanged the metal trach for a 6-0 endotracheal tube.  After the exchange, the ETT cuff was inflated, and the patient was connected to a ventilator and transported to our tertiary care center.  Upon arrival to our hospital, the position of the ETT was confirmed by passing a fiberoptic bronchoscope through the tube and obtaining direct visualization of the trachea and carina.  Once the ETT position was confirmed, an attempt was made to exchange the ETT for a Shiley 6-0 cuffed trach over an Aintree catheter.  However, the relatively thick diameter Aintree was not flexible enough to allow for placement of the Shiley, nor was the bougie. The more flexible Cook catheter finally allowed for insertion of the Shiley.  After insertion, the Shiley’s position was confirmed by fiberoptic, the cuff was inflated, and the patient was ventilated.  Over the course of subsequent weeks in the ICU, the patient was weaned to a nocturnal vent to use with a cuffed permanent trach, and he was discharged to home.

Take home point: This could happen to you! Emergency physicians must be ready for anything.

Take Away Points

• Differentiate simple tracheostomy versus total laryngectomy patients by ETCO₂at the nose.
• Simple tracheostomy patients are (potentially) intubatable from the oropharynx. Total laryngectomy patients are not.
• Mucus plugging is common. Attempt suction and replace the tracheostomy tube’s inner cannula.
• Let down the cuff, if present, to reposition a tracheostomy tube.
• Use caution when replacing dislodged trach tubes in fresh tracheostomies. Consider orotracheal intubation instead.
• Bougie, Cook, and Aintree catheters can assist with tracheostomy tube exchange.
• Always confirm position of the exchanged tracheostomy tube by direct fiberoptic visualization or ETCO.

References/Further Reading:

1. McGrath BA, Bates L, Atkinson D, and Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia 2012; 67: 1025-41.
2. White AC, Kher S, O’Connor HH. When to change a tracheostomy tube. Respir Care. 2010; 55(8): 1069–75.
3. Morris L et al. Tracheostomy Care and Complications in the Intensive Care Unit. Crit Care Nurse October 2013; 33(5): 18-30.

FOAMed Resources:

For more FOAM content, please see this emDocs post on respiratory distress in the tracheostomy patient, EP Monthly approach to the tracheostomy patient, CORE EM and First10EM reviews, and Life in the FastLane.