Invictus Reviews

Trach Emergencies

• Mel Herbert

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Tracheostomy and laryngectomy emergencies demand specific knowledge and immediate action to prevent devastating complications. Jess Mason delivers critical pearls on managing occluded, dislodged, and bleeding tracheostomies that are essential for both board exams and clinical practice.

• Cuffed tracheostomies have a pilot balloon and are required for positive pressure ventilation
• Uncuffed tracheostomies are more common in established patients but cannot be used with ventilators
• Occluded tracheostomies should be managed with oxygen first, followed by suctioning and inner cannula cleaning
• Dislodged tracheostomies require immediate replacement to prevent stomal narrowing
• Bleeding tracheostomies may signal a tracheo-innominate artery fistula, especially with "sentinel bleeds"
• Laryngectomies fundamentally differ from tracheostomies in that they have no communication between mouth/nose and lungs
• You can ONLY manage a laryngectomy patient's airway through their stoma

Visit us at Invictus for comprehensive board review resources that deliver continuous education through videos, audio, written summaries, question banks, and live events designed to help you maintain mastery of emergency medicine throughout your career.


Speaker 1:

I'm about to present to you one of Jess Mason's talks, just a section of it. It's on tracheal laryngeal issues that come up in the exams. I wanted to show it to you just to remind you what a great lecturer she is and what great information you get on the upcoming Invictus stuff and there's some pearls there that might also be useful for your practice tomorrow. We were just talking about this internally. Some more data has just come out about board service exams and how they've gone down again. So there was a big crisis a few years ago where it used to be that people would pass the in-service or the board exam at a rate of about 98% and then it went down and down and it looks like last year it went down again into the mid-80s or low-80s and that's terrifying. I don't have a great explanation for that, really, except that I think we've had such a growth of residencies but not a growth of great faculty. That delay is 10 years or more. So I think there's a lot of new residencies and that might be part of it is that they don't just have the faculty and therefore the grand rounds and the educational programs just aren't as strong as they used to be. That may be one of the reasons. It might be that this generation is just not as interested in passing boards. I find that one hard to believe because I think we're all anxious about passing these exams, but maybe there's a generational issue there. But you need to pass this exam. You've spent hundreds of thousands of dollars, years and years and years of training and you don't want to screw it up right at the end and I've said this before on the show. It's really important to show to your program managers, directors that you're really smart. So that's what we hope this Invictus program is going to be. It's going to be unlike any other board review series that you've got, where everybody just like come to Vegas and watch the show or buy the videos and you're on your own.

Speaker 1:

This is going to be comprehensive. It's going to be those videos. We're also going to have the audio. We're going to have written summaries. We're going to have question banks. We're going to have a podcast expanding on this one, but just for the paid people, and make it much bigger live events, and it's going to be continuous, like really continuous. This is going to be something that probably many of you are going to want, not just as you go through residency and you sit those exams, but many of you are going to want for the rest of your career, because I believe that emergency medicine requires you to go over the same stuff over and, over and over again, and so I think you're going to find this incredibly useful. In addition to something like MRAP, this would be just something that I do every week. Every month. I just go and do the Invictus BoardView stuff so that I can keep up with the mass of information that is occurring. So here we go, jess Mason just a section of her talk on tracheostomies and laryngectomies.

Speaker 2:

Brace yourself. We're going to do the tracheostomy complications. Okay, there's a lot to know here. I think the exam is going to test you on the critical management of either an occluded, dislodged or bleeding tracheostomy. These are stressful situations and so we need to know what to do. First, let's look at what is in the box if you open a tracheostomy. What's in there? So the actual trach, which has a face plate, also known as a flange, and that has information on it about the size and the inner diameter and outer diameter.

Speaker 2:

If there's a pilot balloon that tells you that this is a cuffed tracheostomy, okay, that's how you know. So you can see in this photo, this one has a balloon, it has a cuff. You wouldn't know that if it's in the patient's neck. The only way you know if it's a cuffed tracheostomy is because it has a pilot balloon and, just like with an ET tube, you know if that cuff is inflated or not by squishing down on the pilot balloon. Is it inflated or is it soft and flat? So how do you know if it's a cuffed versus uncuffed tracheostomy? You look for a pilot balloon, that's right. What you're seeing on the top is the outer cannula. In the middle is the inner cannula that slides into the outer cannula and usually like kind of clicks or locks into place. On the bottom we have an obturator that's there for placement of the tracheostomy and then it immediately comes out. Okay, so the obturator occludes the tracheostomy, you guide it into place and that's so that you don't get a bunch of secretions and everything backing up into the trach. It helps guide it into place and then you immediately remove the obturator. If you're placing the trach, the red thing at the bottom is a decannulation plug. We'll never use that in the emergency department. That's to test whether or not a patient with a trach can be decannulated or have the trach removed. So they plug it up and see how they do with their breathing, of course with no balloon or the balloon down. Okay, so once again, a cuffed tracheostomy has a pilot balloon. You must have a balloon that is inflated if the patient is to be bagged or to be put on a ventilator. Otherwise you don't have a seal and air will just flow right around the sides of it. An uncuffed tracheostomy you see in the picture here that does not have a pilot balloon. So that's how you immediately know by looking externally, and these are more common in patients who have had their tracheostomies for a while. Okay, when it's initially put in, it's probably going to have a cuff and then, over time, it's probably going to be transitioned to an uncuffed tracheostomy and then, over time, it's probably going to be transitioned to an uncuffed tracheostomy. Once again, if you need to put a trach patient on a ventilator, or if they're in respiratory distress and you need to bag them, you need to make sure they have an inflated cuff. You can't do that on an uncuffed trach, so you actually have to swap it in order to put them on a ventilator.

Speaker 2:

All right, now let's do the occluded tracheostomy. What to do? First of all, you may not know necessarily that it's occluded. They're just in respiratory distress and they have a tracheostomy. And the first thing we're always going to do for any trach patient in any distress is give them oxygen. So that could be nasal cannula, it could be face mask, it could be to the trach. Whatever way. Give them oxygen some way, and then we're going to attempt suction. Okay, so there's a video on this, but you're going to put the suction tubing into the tracheostomy and see what comes out. Hopefully that clears out whatever is occluding the tracheostomy, which is usually mucus. If it doesn't, then you should feel comfortable with removing the inner cannula and rinsing it out. Patients are supposed to do this at home or their caregivers take out the inner cannula, clean it out and put it back. You are causing no harm by removing the inner cannula as long as that outer cannula of the tracheostomy is still in place. You are causing no issue for them. By popping out the inner cannula and either rinsing it and putting it back, checking for an occlusion, it's totally fine. So I want you to feel comfortable with doing that.

Speaker 2:

Now, if you're going to replace the entire tracheostomy in any situation ever, if you're going to replace a tracheostomy, you always should be ready to manage a difficult airway by any means necessary. So you want all your tools available and you want that to also include a scope, the dislodged tracheostomy. How do we manage that? So, first of all, you should be ready for a difficult airway always. Why do they have a trach? Well, it might be because they had a difficult airway, or they might have chronic COPD or a number of other possible reasons head and neck cancers but always, always, always, it usually comes with knowing that they had a difficult airway to start with, give them oxygen. That's always the first step Oxygen to the nose, mouth, trach, stoma and then, as soon as possible, you're going to put in another tracheostomy or endotracheal tube.

Speaker 2:

Put something in the stoma, just like with a PEG tube or a G-tube that falls out. Our goal is to replace it immediately because it starts to close up. Same idea here. Do not wait, get something and put it into the stoma so it stays patent and you don't have to downsize, downsize, downsize. You can downsize, that's fine. You're going to replace it with, hopefully the same size, or go down one if needed.

Speaker 2:

Make sure the replacement tracheostomy is lubricated and then you're going to slide it in following the curvature of the trach. It's best to do this with a scope, if you have one, but you definitely need to confirm placement. You can do that with a scope afterwards or you can replace it on the scope. So you scope and then slide the trach in and then you're going to look for color change or waveform capnography. You need to confirm placement somehow, because the concern is possibly creating a false tract.

Speaker 2:

All right, now what if a new tracheostomy cannot be placed? Okay, so they come in. The trach fell out. Do you need to rush and stick in a new tracheostomy right away, or what if you can't do it? Well, stop for a moment. Does this patient need an emergent airway? Maybe they're breathing okay at the moment without one? If that's the case, don't panic. Call the specialist that's managing or place the trach. Have them come down and see if they're able to replace it. Now. If you do need to place it emergently, then once again, if you don't find the right tracheostomy size, get an endotracheal tube and put that in, and you can either put that straight into the stoma or, if that's challenging for whatever reason, you can orally intubate the patient. Okay, it's getting scarier.

Speaker 2:

The bleeding tracheostomy Remember what we're worried about here. With a bleeding tracheostomy, the horrible complication is a tracheo-anominate artery fistula. And what happens with these? Just sort of like a subarachnoid bleed, where you might get a sentinel bleed and a severe headache and then the catastrophic bleed comes later. Same concept here you can get a sentinel bleed from a tracheo-anominate artery fistula. A little bit of bleeding and then it stops, and then a few days later, a few hours later, you get the catastrophic hemorrhage. So a sentinel bleed usually occurs within three weeks of tracheostomy placement. Once you get further along once you get outside of six weeks. It's rare, it can still happen, but it's more and more rare.

Speaker 2:

Now if they come in with the history that it bled at home and it is not actively bleeding and they look stable, you can get a CT angiogram to see if there's a tracheo-anomalous artery fistula and call the managing specialist. Now what if you don't have that luxury? How are you going to manage a large volume hemorrhage from a bleeding tracheostomy? First you're going to call for help as you start doing the next steps. So have someone mobilize your specialist whether that's vascular surgery, ir, ent get help on the way.

Speaker 2:

Then you're going to apply pressure at the sternal notch. You're going to put pressure right there and then, if it's a cuffed tube hopefully it is you're going to put pressure right there and then, if it's a cuffed tube hopefully it is you're going to over-inflate that cuff with the concept being balloon tamponade, essentially onto the site that's bleeding. Theoretically these can hold a max of 50 mLs of air. I'd be a little nervous to do that, that I'm going to rupture the balloon and then have no tamponade whatsoever, but supposedly these can hold a higher volume of air. Now, if it's an uncuffed tracheostomy and you know that once again, because there's no pilot balloon on the face plate. There's no pilot balloon. You know, it's an uncuffed tube. Now you have to put something in there that's cuffed. So take it out, put in an endotracheal tube and you can over-inflate the cuff on that.

Speaker 2:

Okay, now what if it's not large volume hemorrhage, but it's just small volume, a little bleeding, a little oozing, and it's an established trach. It's someone who's had a trach for a couple of years but it's just sort of oozing around there. Could it be a tracheo-nominate artery fistula? Yes, but that's less likely. Other possibilities are bleeding granulation tissue. That happens all the time. It could actually be hemoptysis. Right, it looks like it's coming from the trach, but it's actually coming from the lungs and they're coughing up blood and it's coming out of the trach. So you could have that from pneumonia, bronchitis, a pulmonary embolism. And then, of course, there's non-tracheostomy related etiologies as well. So anything further down in the lungs is going to be the main concern.

Speaker 2:

Now let's look at some infections. Infection that spreads into the tracheostomy is basically tracheitis. Take a look at this photograph here. This looks so painful and what we see is a pretty severe candidal infection of the stoma and the skin around the stoma, and then, when I just sort of slid that tracheostomy out a little bit, you could see all of that purulent discharge on the tracheostomy. Okay, so that should really be cleaned, exchanged and this patient needs to be admitted for IV antibiotics.

Speaker 2:

This is essentially tracheitis. What is this? Take a look at this picture. What is that? Is that a trach? That looks a little bit different than a regular tracheostomy. So what is that? It is a laryngectomy tube, also known as a Larry tube. It looks a little bit different than a tracheostomy. Right Now, here's a patient who has a laryngectomy, who just walks around with no Larry tube but just a stoma exposed. All right, that's what a laryngectomy stoma might look like.

Speaker 2:

Let's look at the difference, side by side, between a tracheostomy and a laryngectomy. So first you see a normal neck, Then in the middle we have a tracheostomy and then we have a laryngectomy. Look at the tracheostomy for a moment. What you see is a stoma, so an opening going straight in to the trachea. Okay, pretty simple, right? No major anatomical changes. The trachea is there and they created a surgical connection between the trachea and the skin. This is in contrast to a laryngectomy.

Speaker 2:

Laryngectomy is a complete reconstruction of the glottis. So this is usually happening because of a head and neck cancer and what we have here is the trachea going out to the skin and then there's a blind end. It stops. It doesn't go up. Compared to the trachea where it goes up, everything's the same.

Speaker 2:

A laryngectomy does not go up, it only goes down, which means and here's the key point in a laryngectomy there is no communication between the nose and mouth and the airway. The nose and mouth does not breathe. The mouth eats, it goes down the esophagus but it does not do any respiratory function, which means you cannot manage the airway of a laryngectomy patient from above. You can only do it from the laryngectomy stoma. Okay, so that's the key point. If you're going to manage the airway in a laryngectomy patient, you have to do it through the laryngectomy stoma. If you have a laryngectomy patient, you have to do it through the laryngectomy stoma. If you have a laryngectomy tube, you can use that. If not, just like with a tracheostomy, an endotracheal tube can be placed and then you can do a scope to confirm. And as long as you're going down, it should look the same as a tracheostomy, right, it's going up where it's a blind end and significant difference. It's going up where it's a blind end and significant difference.

Speaker 2:

Let's do a question. A 12-day post-tracheostomy patient presents with massive hemorrhage from the tracheostomy site. The family reports minor bleeding from the stoma five days prior. Which of the following is the most appropriate initial management for suspected tracheo-inominate artery fistula hemorrhage? Is it immediate oral intubation and surgical consultation? Apply direct pressure by over-inflating the cuff and initiate IV fluid resuscitation? Perform a CT angiography to identify the source of bleeding or suction the tracheostomy. So we have a hemorrhage. What should we do? Put pressure on it. Anytime ever in life something's hemorrhaging and it's within some sort of distance that you can apply direct pressure. Do that first Put your finger on the thing that's bleeding or put pressure from an inflated cuff. Now, a looks a little bit tempting immediate oral intubation, but we don't need to do that in this case because we already have a tube in place with a cuff. So we're going to go for direct pressure, direct tamponade. C is also a little bit tempting, but you would never send this patient to CT because they're not stable. So only if they're stable would you consider CT angiography.

Speaker 2:

Next question A pediatric patient with a tracheostomy presents to the ED in respiratory distress. On exam, moist mucus is visible within the tracheostomy tube and minimal airflow is palpated. What is the most likely diagnosis? Is it tracheostomy tube obstruction due to mucus plugging, tracheoesophageal fistula, tracheostomy decannulation or pneumothorax? Softball question here very common. It's a mucus plug. Okay, this is probably the most common things that happens as a complication of tracheostomies. That we see is that it gets plugged up mucus and we have to suction it out. A 30-year-old female presents with a recent tracheostomy to the emergency department with sudden respiratory distress and inability to ventilate. On exam, there's decreased airflow palpated at the stoma, which is the most appropriate initial step in management. Should we administer nebulized bronchodilators?

Speaker 2:

Suction the tracheostomy tube to clear any obstruction. Remove the tracheostomy tube and attempt reinsertion, or replace the tracheostomy tube to clear any obstruction. Remove the tracheostomy tube and attempt reinsertion, or replace the tracheostomy tube with direct visualization. Okay, so the first step after giving oxygen is suction. Suction the tracheostomy tube. That alone might clear out any mucus and fix the problem. You don't want to jump too fast to removing the tracheostomy tube and inserting a new one. You can do that, it's just further down the algorithm.