|
| |
Charles Gomersall, Thomas Li, Gordon Choi, Gavin Joynt
This is a potentially life threatening emergency, particularly if the
tracheostomy was inserted for upper airway obstruction, a cuffed tracheostomy
tube is being used or if the situation is not managed appropriately and rapidly.
An algorithm for initial management of possible tracheostomy tube blockage is
given below.
- administer 100% oxygen until the patient's condition has improved and is
stable
- use self-inflating resuscitator with reservoir bag via mask or
tracheostomy as appropriate
- a key step in management is to determine whether the patient's
respiratory distress is due to obstruction of the tracheostomy tube or due
to some other cause
- if the patient has a double lumen tracheostomy tube (eg Shiley) remove
the inner tube. This may, in itself, relieve the obstruction if the inner
tube is blocked.
If this does not result in a marked improvement in the
patient's condition or the inner tube is required to provide assisted
ventilation, replace the inner tube using a non-fenestrated tube (this is
important for subsequent diagnostic and therapeutic steps)
- passing a suction catheter down the tracheostomy tube has two purposes -
diagnostic and therapeutic. As well as confirming an obstruction it may be
possible to remove it by suction. Note that if the obstruction is due to
blockage of the tracheostomy tube it should not be possible to advance the
catheter by more than length of the tracheostomy tube (usually, but not
invariably, <10 cm)
- deflating the cuff of the tracheostomy may allow the patient to breath
around the obstructed tracheostomy tube, unless the patient has total upper
airway obstruction
- if the patient is unable to breath or be bag-mask ventilated around the
tube then the tracheostomy tube should be removed in most circumstances
- if the tracheostomy was recently created (<7 days) because the
patient had upper airway obstruction it may be advisable to attempt to
unblock the tracheostomy using a bougie or similar instrument instead of
removing the tracheostomy
- cover the tracheostomy wound with a dressing so that gas passes down
the trachea rather than through the wound when attempting bag-mask
ventilation via mouth/nose
- if it is necessary to re-insert an artificial airway the choices are to
re-insert tracheostomy tube, intubate (orotracheal) or provide
alternative airway (eg laryngeal mask). Decision depends on:
- anticipated difficulty of orotracheal intubation
- whether tracheostomy track is well formed (usually takes 7-10 days)
- unless orotracheal intubation is anticipated to be very
difficult it is generally not advisable to attempt to replace the
tracheostomy tube when the tracheostomy was formed <7 days earlier
- individual doctor's skills
- clinical urgency (in most circumstances, in skilled hands, it is
more reliable to intubate the patient via the orotracheal route)
© Charles Gomersall, Thomas Li, Gordon
Choi, Gavin Joynt June 2008
|
