Anesthesia Patient Safety Podcast
The official podcast of the Anesthesia Patient Safety Foundation (APSF) is hosted by Alli Bechtel, MD, featuring the latest information and news in perioperative and anesthesia patient safety. The APSF podcast is intended for anesthesiologists, anesthetists, clinicians and other professionals with an interest in anesthesiology, and patient safety advocates around the world.
The Anesthesia Patient Safety Podcast delivers the best of the APSF Newsletter and website directly to you, so you can listen on the go! This includes some of the most important COVID-19 information on airway management, ventilators, personal protective equipment (PPE), drug information, and elective surgery recommendations.
Don't forget to check out APSF.org for the show notes that accompany each episode, and email us at podcast@APSF.org with your suggestions for future episodes. Visit us at APSF.org/podcast and at @APSForg on Twitter, Facebook, and Instagram.
Anesthesia Patient Safety Podcast
#274 Critical Decision Points in Emergency Tracheostomy Management
Tracheostomy complications occur at an alarming rate, affecting nearly half of all patients during their initial hospitalization. When these emergencies strike, having a systematic approach can make the difference between life and death.
We dive deep into the critical steps for managing a malfunctioning tracheostomy, beginning with immediate actions like cuff deflation and rapid information gathering about the tracheostomy's history. You'll learn how to systematically troubleshoot ventilation problems, from checking for simple obstructions to determining if the tracheostomy has become dangerously displaced into subcutaneous tissues.
The episode walks through the crucial decision points when standard ventilation fails: Should you attempt oral intubation or go through the stoma? We break down the specific factors that should guide this high-stakes decision, including patient anatomy, tracheostomy maturity, and clinician experience. You'll discover practical techniques for both approaches, including helpful adjuncts like bougies and bronchoscopes that can increase your chances of success.
Perhaps most valuable are the ready-to-use tools shared in this episode - standardized bedside signs and emergency algorithms that can be implemented in your practice immediately. These resources ensure that critical information follows patients throughout their hospital stay and provides a clear pathway for any provider responding to a tracheostomy emergency.
Whether you're an experienced anesthesia professional or still in training, this episode provides essential knowledge for some of the most challenging airway emergencies you'll face. Subscribe now and download our next episode, where we'll continue this vital discussion on emergency tracheostomy management.
For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/274-critical-decision-points-in-emergency-tracheostomy-management/
© 2025, The Anesthesia Patient Safety Foundation
You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.
Speaker 2:Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. For our show today we are continuing to cover the excellent articles from the June 2025 APSF newsletter. But first up we have a sneak peek from the 2025 APSF Stolting Conference on Transforming Maternal Care Innovations and Collaborations to Reduce Morbidity and Mortality.
Speaker 3:And so our challenge is, as an anesthesiologist or as a hospitalist, OB is how you develop trust in five minutes or less. So I think we all can develop our own strategies, but that's a conscious thing you have to be working on. How do you develop trust in under five minutes? And a lot of it is about sitting down and asking what they want out of this opportunity.
Speaker 2:If you want to hear more, you can check out the live stream by heading over to apsforg and clicking on the conferences and events heading. Then select APSF Stolting Conference 2025, where you will see the recordings. You can also check out the APSF YouTube channel and keep downloading this podcast, because we will have an upcoming Stolting Conference podcast series that you don't want to miss. Before we dive further into the episode today, we'd like to recognize GE Healthcare, a major corporate supporter of APSF. Ge Healthcare has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, ge Healthcare. We wouldn't be able to do all that we do without you. Our featured article today is Keeping Patients Safe During Emergency Tracheostomy Management by Jack Buckley. To follow along with us, head over to APSForg and click on the newsletter heading First. One down is the current issue and then scroll down until you get to our featured article today. You can also find the June 2025 APSF newsletter in the newsletter archives and, don't worry, I will include a link to the show notes as well.
Speaker 2:Have you provided anesthesia care for a patient undergoing tracheostomy? Patients may need a tracheostomy for prolonged mechanical ventilation, inability to protect their airway or upper airway obstruction from pathology of the oropharynx. Complications following this procedure are common, so you may have also been called on to provide anesthesia care for a patient with a malfunctioning tracheostomy. With a malfunctioning tracheostomy, there is a 2017 single center study of 100 patients undergoing tracheostomy that revealed a complication rate of almost 50% during the initial hospitalization. Here is a breakdown of the complications Tracheostomy obstruction 19%. Bleeding 16%. Infection 14%. Tracheostomy obstruction 19%. Bleeding 16%. Infection 14%. And accidental decannulation 13%. Anesthesia professionals need to be prepared for these complications to help keep patients with tracheostomy safe. We are going to go through the management steps of a potentially malfunctioning tracheostomy, as well as what to do when a patient presents to the operating room with the tracheostomy in place for a different surgical procedure, and special considerations for patients with laryngectomies.
Speaker 2:Here we go. We go. Patients undergoing mechanical ventilation may have occlusion or accidental decannulation of their tracheostomies, leading to high airway pressures or loss of tidal volume and loss of end tidal carbon dioxide. This is a serious concern and it is important to troubleshoot quickly, to determine the cause and intervene prior to patient deterioration.
Speaker 2:The first step is to deflate the tracheostomy cuff to allow for spontaneous breathing, if possible. At the same time, you need more information about the tracheostomy. How long ago was it placed? What was the indication? What is the type of tracheostomy surgical or percutaneous? Next up, determine if the patient has a patent upper airway for mask ventilation or oral intubation and consider the potential for a difficult oral intubation as well For spontaneously breathing patients who are moving air well around the deflated cuff. You can place an oxygen mask on the patient's mouth or tracheostomy stoma to provide supplemental oxygen and monitor ventilation with waveform capnography. The next step is to make sure there is no obstruction. You can remove the inner cannula if it is there. The inner cannula should be easy to remove for cleaning of mucus and other materials which may occlude the tracheostomy tube. Check out figure 1 in the article for a picture of a cuffed tracheostomy, an obturator that is used to help with placement of the tracheostomy and the removable inner cannula.
Speaker 2:If ventilation is still not adequate, it is time to suction through the tracheostomy tube with a suction catheter into the distal trachea. This is also a good test for an occlusion or malposition. If the suction catheter does not advance beyond the end of the tracheostomy, then the tip of the tracheostomy may be positioned against the tracheal wall or be occluded by an over-inflated cuff. Ventilation is still not adequate, so we need to continue to troubleshoot. If the suction catheter does not advance beyond the tip of the tracheostomy, the tracheostomy may have become displaced from the trachea and now be positioned in the subcutaneous tissue in the neck. We need to know where the tracheostomy tube is now located. At this point you may want to attempt to gently provide positive pressure ventilation with a bag valve mask. If end-tidal CO2 is not present or there are high airway pressures, then the tracheostomy tube is most likely no longer in the trachea. Time to grab a bronchoscope if available and advance down the tracheostomy tube to confirm the location.
Speaker 2:Keep in mind that continued attempts at positive pressure ventilation with the tracheostomy tube that has migrated to the subcutaneous space may cause serious complications, including subcutaneous emphysema, pneumothoraces and pneumomediastinum, and difficult intubation, since the pressurized air can track into the subcutaneous tissues of the upper airway. Check out figure 2 in the article for a chest x-ray of a patient with a malpositioned tracheostomy tube who received positive pressure ventilation leading to a pneumothorax on the left and subcutaneous emphysema in the neck. So now we have a tracheostomy tube that may be in the subcutaneous tissue and our patient is not ventilating adequately, it is time to remove the tracheostomy. The next step is to evaluate ventilation, again through the stoma and orally. If ventilation is adequate, then we are on a non-emergent pathway and can wait for additional help to arrive. If ventilation is inadequate and the patient is desaturating, the next step is to attempt mask ventilation orally while occluding the stoma, or through the tracheostomy stoma. You may consider using a pediatric mask for a better fit while attempting ventilation through the stoma. If mask ventilation remains inadequate, it is time to move on to oral intubation or via the tracheostomy stoma.
Speaker 2:Keep in mind that the decision of where to intubate depends on the following Payton, upper airway, expected difficulty of oral intubation, experience of the clinicians, present and age of the tracheostomy. Here are some of the factors that support oral intubation Inexperience in replacing tracheostomies, history of easy oral intubation. No oral pharyngeal pathology present. If it is a new tracheostomy, which includes a surgical tracheostomy less than four days or percutaneous tracheostomy less than seven to 10 days With a fresh tracheostomy stoma, there is a risk of inadvertently advancing the tube into the subcutaneous tissue and creating a false track. A surgical tracheostomy matures earlier because the surgical tracheostomy has a portion of the trachea that is sutured to the skin, which decreases the risk of advancing a tube into the subcutaneous tissue. Here are some of the factors that support intubation through the tracheostomy stoma instead of oral intubation Comfort and experience with replacing a tracheostomy.
Speaker 2:History of difficult intubation or known oropharyngeal pathology that will make oral intubation difficult. A mature tracheostomy with a well-healed stoma. A mature tracheostomy with a well-healed stoma. If the stoma is mature, with a moderate-sized opening and a clear path to the trachea, then the tracheostomy tube can be simply advanced back into the trachea. If the stoma is small or difficulty is expected, then an endotracheal tube is recommended, since it may be less likely to advance into a false passage. An intubation bougie can be placed into the stoma first and used to feel for tracheal rings in a fashion similar to oral intubation. Another option is to use a bronchoscopy scope to advance into the stoma first while attempting to identify the trachea into the stoma first. While attempting to identify the trachea.
Speaker 2:We just covered an emergency algorithm for the management of a patient with a malpositioned tracheostomy tube and failed ventilation. Anesthesia professionals need to remain vigilant. Bedside signs and algorithm sheets that are readily available to help with management of these patients can be life-saving. Check out figure three and four in the article. Figure three is an algorithm for emergency tracheostomy management for a patient with a pain upper airway. Figure four is a tracheostomy bedside sign. These are excellent tools. You can have these available anytime you're providing anesthesia care for a patient with a tracheostomy and may be useful in other hospital departments, including the ICU and emergency department. The bedside sign should accompany patients with tracheostomies throughout their hospital stay. The sign says that this patient has a tracheostomy. There is a potentially patent upper airway. Intubation may be difficult. Then you can circle either surgical or percutaneous for the type of tracheostomy, with the following information Performed on tracheostomy tube size and hospital number. There is a picture of different types of tracheostomy, including percutaneous, b-uric, flap and slit type. There are notes on the card to help fill out the card. That state indicate tracheostomy type by circling the relevant figure. Indicate location and function of any sutures, laryngoscopy grade and notes on upper airway management Any problems with this tracheostomy. Then, in case of emergency, call anesthesia, icu, ent, maxfax and Emergency Team For more information. You can head over to tracheostomyorguk and I will include these figures in the show notes as well.
Speaker 2:Figure three covers emergency tracheostomy management. Let's go through it now. The first step is to call for airway expert help. Then look, listen, feel at the mouth and tracheostomy. A Mapleson C system may help assessment if available, and waveform capnography should be used. Exhaled carbon dioxide indicates a patent or partially patent airway.
Speaker 2:The next question is is the patient breathing? If yes, you are on the green pathway and you can apply high flow oxygen to both the face and tracheostomy. If no, you are on the red pathway and you need to call the resuscitation team and begin CPR if there is no pulse. Both pathways converge on assessment of tracheostomy patency, which involves removing the speaking valve or cap, removing the inner tube, but remember that some inner tubes will need to be reinserted to connect to the breathing circuit. The next question is can you pass a suction catheter? If yes, then the tracheostomy tube is patent. Follow-up steps include suction the trachea, consider partial obstruction, ventilate via the tracheostomy if not breathing, and continue to assess the patient. If no, then deflate the cuff and evaluate at the mouth tracheostomy site again, or use waveform capnography if available.
Speaker 2:The next question is is the patient stable or improving? If yes, then the tracheal tube is partially obstructed or displaced and you can continue to assess the patient. If no, remove the tracheostomy tube and evaluate at the stoma site and mouth again while making sure to provide supplemental oxygen. Is the patient breathing now? If yes, then continue your assessment. If no, call for the resuscitation team and begin CPR if needed. Team and begin CPR if needed.
Speaker 2:For primary emergency oxygenation, use standard oral airway maneuvers. Cover the stoma with swabs or a hand and use bag valve mask, oral or nasal airway adjuncts or a supraglottic airway device. You may consider tracheostomy stoma ventilation with a pediatric face mask or an LMA applied to the stoma. For secondary emergency oxygenation attempt oral intubation. Prepare for difficult intubation. Advance the tube beyond the stoma. Attempt intubation via the stoma with a small tracheostomy tube or a 6-0 cuffed endotracheal tube. Consider using an Aintree catheter, fiber optic bronchoscope, bougie or airway exchange catheter to help place the endotracheal tube. This algorithm is from the National Tracheostomy Safety Project and I will include it in the show notes as well. Safety Project and I will include it in the show notes as well.
Speaker 2:There is still more to talk about when it comes to emergency tracheostomy management, but you will need to tune in next week. Make sure you like, subscribe and download the Anesthesia Patient Safety Podcast so you don't miss it. If you have any questions or comments from today's show. Please email us at podcast at APSForg. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSForg for detailed information and check out the show notes for links to all the topics we discussed today.
Speaker 2:The APSF newsletter is the official journal of the Anesthesia Patient Safety Foundation. Readers include anesthesia professionals, perioperative providers, key industry representatives and risk managers. It is free of charge and available in a digital format with a focus on anesthesia related perioperative patient safety issues. The 40th anniversary of the APSF newsletter is right around the corner and we will have a special newsletter publication. That's right all new articles, the latest in perioperative patient safety and more ways for you to help keep yourself and your patients safe. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.