Update on management of tracheostomy

Key points•A variety of tracheostomy tubes are available and correct choice will depend on the patient.•The position of a new tracheostomy should be checked with endoscopy via the tracheostomy tube.•An emergency airway plan should be made for patients with a tracheostomy undergoing surgery.•Critical incidents are common because of a displaced tracheostomy tube when moving a patient.•Intermittent cuff leak can indicate a wrongly sized or malpositioned tracheostomy tube.Learning objectivesBy reading this article, you should be able to:•Explain the key differences between tracheostomy tubes.•Demonstrate how to check the position of a tracheostomy tube.•Describe how to manage a patient with a tracheostomy for surgery.•Plan how to manage critical incidents involving patients with a tracheostomy. •A variety of tracheostomy tubes are available and correct choice will depend on the patient.•The position of a new tracheostomy should be checked with endoscopy via the tracheostomy tube.•An emergency airway plan should be made for patients with a tracheostomy undergoing surgery.•Critical incidents are common because of a displaced tracheostomy tube when moving a patient.•Intermittent cuff leak can indicate a wrongly sized or malpositioned tracheostomy tube. By reading this article, you should be able to:•Explain the key differences between tracheostomy tubes.•Demonstrate how to check the position of a tracheostomy tube.•Describe how to manage a patient with a tracheostomy for surgery.•Plan how to manage critical incidents involving patients with a tracheostomy. More than 12,000 tracheostomies are inserted annually in the UK, and up to 20% of patients in ICU are managed with a tracheostomy.1Wilkinson K.A. Martin I.C. Freeth H. et al.On the right trach? A review of the care received by patients who underwent a tracheostomy. A report by the National Confidential Enquiry into Patient Outcome and Death.2014Google Scholar This includes both surgically and percutaneously placed tracheostomies, and both elective and emergency procedures. As a result, these complex and challenging patients are increasingly encountered in critical care units and medical and surgical wards. This article covers the selection of an appropriate tracheostomy tube, the intraoperative management of patients with a tracheostomy and the management of common critical incident scenarios. The indications for a tracheostomy are wide ranging and it is increasingly performed as a planned procedure, using both surgical and percutaneous techniques. However, there are situations where tracheostomy insertion is an urgent or emergency procedure, often because of impending airway obstruction. The optimal timing of non-urgent tracheostomy insertion in the critical care unit remains the subject of much discussion and debate, and will not be covered in this article.2Andriolo B.N. Andriolo R.B. Saconato H. Atallah Á.N. Valente O. Early versus late tracheostomy for critically ill patients.Cochrane Database Syst Rev. 2015; 12: CD007271Google Scholar, 3Huang H. Li Y. Ariani F. Chen X. Lin J. Timing of tracheostomy in critically ill patients: a meta-analysis.PLoS One. 2014; 9e92981Crossref PubMed Scopus (63) Google Scholar, 4Young D. Harrison D.A. Cuthbertson B.H. Rowan K. TracMan CollaboratorsEffect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial.JAMA. 2013; 309: 2121-2129Crossref PubMed Scopus (398) Google Scholar The main indications can be grouped into the following: the need for a) prolonged mechanical ventilation or respiratory weaning, b) provision of pulmonary toilet, c) protection of the airway, d) management of upper airway obstruction, and e) as part of a surgical procedure (Table 1).Table 1Indications for a tracheostomyProlonged mechanical ventilationThe most common indication is to facilitate weaning from respiratory support in patients with acute respiratory failure.Pulmonary toiletWhere patients are unable to clear excessive secretions (e.g. bulbar palsy or weak cough).Airway protectionWhere patients are unable to maintain an airway (e.g. assorted specific neurological condition or reduced consciousness)Part of a surgical procedureHead and neck or ENT surgery (e.g. laryngectomy)Upper airway obstructionFacial or laryngeal trauma, burns, anaphylaxis Open table in a new tab Many tracheostomy tubes are offered by different manufacturers, and it is important to know the range of tracheostomy tubes that are available locally. Key features such as internal and external diameter and length can vary significantly between manufacturers and devices. Standard tracheostomy tubes share common features, such as an inflatable cuff or neck flange. Tracheostomy tubes also have an inner cannula that can be removed for cleaning to reduce the risk of blockage or during an emergency (Fig. 1). The cuff provides a sealed airway, allowing delivery of positive pressure ventilation and protection of the lungs from oropharyngeal secretions and gastric fluid. Cuffed tubes are the most commonly used tracheostomy tube and are sized by the internal diameter (ID). However, the length and outside diameter (OD) varies between manufactures and tube type (Supplementary Table S1).5Medtronic, USA. Tracheostomy product portfolio. Available from: https://www.medtronic.com/covidien/en-gb/products/tracheostomy.html (accessed 26 February 2019).Google Scholar, 6Portex, Smiths-Medical, USA. Tracheostomy Products. Available from: https://www.smiths-medical.com/products/tracheostomy (accessed 26 February 2019).Google Scholar, 7TRACOE medical GmbH, Germany. Tracoe Twist Products. Available from https://www.tracoe.com/en/products/twist/(accessed 26 February 2019).Google Scholar This has an impact on the selection of tube.8Austin Health: Tracheostomy Review and Management Service. Tracheostomy Sizing Chart. Available from http://tracheostomyteam.org/data/uploads/pdf/sizing-chart.pdf (accessed 26 February 2019).Google Scholar Significantly, the ID of the Portex Blue Line Ultra (Portex; Smiths-Medical, Minneapolis, MN, USA) is reduced once the inner cannula is inserted: a size 7 tracheostomy tube has an ID of 5.5 mm, when the inner cannula is in place. This can influence weaning from mechanical ventilation. TRACOE (TRACOE medical GmbH, Nieder-Olm, Germany) tubes must have the inner cannula inserted before they can be connected to a standard 22 mm ventilation circuit. It is important to be aware of this in an emergency situation. Specialised tubes may be more appropriate for patients with specific requirements. Extended or adjustable length tubes, are more suitable for patients with deep set tracheas caused by obesity or a neck mass (Fig. 2). These tubes are also more suitable for patients with tracheal pathology such as tracheal stenosis, to ensure the tube tip is distal to the tracheal narrowing. Patients with obesity are more likely to suffer a complication related to their tracheostomy. This is most often related to a tube that is too short or poorly chosen. It is recommended that extra-long or adjustable-length tubes should be available for all these patients.9Royal College of Anaesthetists and Difficult Airway Society4th National Audit Project: major complications of airway management in the United Kingdom. Full report and findings.March 2011Google Scholar It is important to note that not all extended length tubes can have an inner cannula inserted. Patients requiring prolonged mechanical ventilation or those who are unable to manage secretions may benefit from the use of a tube with a subglottic suction port (Fig. 1). This allows regular clearance of secretions that pool above the cuff. Pooled secretions may result in microaspiration and increase the risk of ventilator-associated pneumonia.10Muscedere J. Rewa O. McKechnie K. et al.Subglottic secretion drainage for the prevention of ventilator-associated pneumonia: a systematic review and meta-analysis.Crit Care Med. 2011; 39: 1985-1991Crossref PubMed Scopus (192) Google Scholar A novel use for this port is ‘above cuff vocalisation’, in which a retrograde flow of gas can pass above the cuff through the vocal cords to facilitate speech.11McGrath B. Lynch J. Wilson M. Nicholson L. Wallace S. Above cuff vocalisation: a novel technique for communication in the ventilator-dependent tracheostomy patient.J Intensive Care Soc. 2015; 17: 19-26Google Scholar This can aid with respiratory weaning and improve communication with the patient. Fenestrated tubes can also be used to assist speech and reduce the work of breathing. With the appropriate fenestrated inner cannula, airflow can pass through the small holes (fenestrations) and through the vocal cords (Fig. 3). An alternative can be to deflate the cuff to allow airflow around the tracheostomy tube. This allows the patient to become reaccustomed to managing their own secretions and airflow through the vocal cords to allow communication. Fenestrated tubes should not be used in patients with a newly formed tracheostomy stoma who are receiving positive pressure ventilation, because of the risk of surgical emphysema.12Fikkers B.G. van Veen J.A. Kooloos J.G. et al.Emphysema and pneumothorax after percutaneous tracheostomy: case reports and an anatomic study.Chest. 2004; 125: 1805-1814Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar Patients requiring a long-term tracheostomy tube who are breathing spontaneously, able to protect their own airway and manage their secretions, may benefit from the use of an uncuffed tracheostomy tube (Fig. 4). This can reduce the risk of tracheal damage from an uninflated cuff, aid communication and swallowing, and allow respiration via the upper airway and the tracheostomy. It can be difficult to predict which type and size of tube to select. The main factors to consider are: an appropriate ID, need for subglottic suction and need for a longer, and extended length tube. A tube with a large enough ID, so as not to increase airway resistance and work of breathing, must be factored against increased OD and length, which may not be appropriate for the size of the patient. Subglottic suction is beneficial in patients requiring prolonged mechanical ventilation, and extended-length tubes are increasingly required. After insertion of all tracheostomies, the position of the tube must be checked. If the tube is too short, the tip may impinge onto the posterior tracheal wall or sit in the subcutaneous tissue. The cuff may also herniate up into the superior larynx and sit within the vocal cords. This can cause reduced pulmonary compliance, persistent cuff leaks or tracheal damage. Tubes that are too short are the main cause of tube displacement or accidental decannulation. Meanwhile, tubes that are too long may sit too close to the carina, risking endobronchial tube placement. Capnography, although essential to confirm that the tube is in the trachea, does not ensure appropriate tube position. The use of endoscopy allows a more detailed assessment. The endoscope can be passed via the tracheostomy tube, to assess tube tip position in relation to the carina and within tracheal lumen, ensuring it is not abutting the tracheal wall. Endoscopic views from above, via the larynx, can assess that the whole cuff has passed through the anterior tracheal wall, and the tube and cuff are positioned appropriately within the trachea. This can be performed via a partially withdrawn tracheal tube if part of the surgical tracheostomy procedure. The patient's neck should always be placed in the neutral position during endoscopy, as this is the natural position the tracheostomy sits within the trachea. Cuff pressure should be checked to confirm no leak exists at normal inflation pressures (20–30 cmH2O). If higher pressures are required, this may suggest a malpositioned or herniated cuff within the trachea. Neither of the techniques described above can, in isolation, confirm appropriate tube position within the larynx.13McGrath B.A. Lynch K. Templeton R. et al.Assessment of scoring systems to describe the position of tracheostomy tubes within the airway — the lunar study.Br J Anaesth. 2017; 118: 132-138Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar By using a combination of endoscopy (both tracheal and laryngeal views), capnography and cuff pressure, it is possible to provide an accurate estimation that the tube is in the correct position and an appropriate size for the patient. The tube position should always be assessed and documented, including the tube tip to carina distance, so future checks of tube position can be performed.1Wilkinson K.A. Martin I.C. Freeth H. et al.On the right trach? A review of the care received by patients who underwent a tracheostomy. A report by the National Confidential Enquiry into Patient Outcome and Death.2014Google Scholar Endoscopy via the oropharynx may not need to be performed routinely, but can provide valuable information if there is any doubt about tube position. If the tube does not sit in the correct position, it should be changed for a different size or extended-length tube and the position rechecked. About 30% of new tracheostomies are inserted surgically, most commonly as a planned procedure during surgery or for a critical care patient unsuitable for percutaneous insertion. Both of these groups of patients can have an increased incidence of difficult airway. The NCEPOD (National Confidential Enquiry into Patient Outcome and Death) On the Right Trach study suggested that nearly 20% of patients required additional difficult airway equipment, and more than 6% had at least one failed attempt at intubation.1Wilkinson K.A. Martin I.C. Freeth H. et al.On the right trach? A review of the care received by patients who underwent a tracheostomy. A report by the National Confidential Enquiry into Patient Outcome and Death.2014Google Scholar There are also situations in which an emergency surgical tracheostomy is required, most commonly because of failure of the primary airway or upper airway obstruction. If available, high-flow nasal oxygen therapy should be utilised in order to slow time to desaturation where intubation or face-mask ventilation is difficult or not possible. As this can result in a Fio2 of close to 1.0, there is a risk of airway fire if the surgeon uses diathermy during the procedure. The tracheal window should be made with a scalpel to reduce this risk. Patients undergoing extensive head and neck surgery, such as oral cancer resection or a laryngectomy, may need a tracheostomy as part of their operation. For surgery in the mouth or on the lower neck, it provides an unobstructed operating field during the procedure, and a secure route for ventilation after surgery. The latter is particularly important because swelling and oedema are often worse in the immediate period after surgery, risking airway obstruction. Patients with previously normal airway anatomy can become very challenging to reintubate in an emergency. These tracheostomies are usually performed at the beginning of the operation, after induction of anaesthesia and oral intubation. Sometimes a laryngectomy tube (Fig. 5) is used instead of a tracheostomy tube for intraoperative ventilation of the lungs. The former can be sutured in place and sits flush to the skin, allowing the ventilation circuit and heat and moisture exchange (HME) device to be kept away from the operating area. When the operation is finished, the laryngectomy tube is exchanged for a tracheostomy tube and the appropriate position checks are performed. Patients with an existing tracheostomy may also present for surgery. Before surgery, it is important to confirm what tracheostomy tube the patient has in place. This includes size, distance from the carina and presence of an inner cannula. The indication for the tracheostomy should be identified and whether the patient has a patent upper airway. A backup ventilation strategy should be decided upon, in case the tube becomes dislodged or obstructed. Anaesthesia can be induced using either an i.v. or inhalation technique. During surgery, the management is the same as for other patients, including monitoring, analgesia and ventilation strategies. After the operation, the patient has a protected airway and does not require extubation. They can be transferred to the recovery area for ongoing care once spontaneous breathing has been re-established. Whether or not the patient requires later admission to critical care should be dependent on the nature of surgery, the patient's condition and local practices. Worldwide, it is estimated that up to 30% of patients with a temporary or permanent tracheostomy may have a significant complication relating to their tracheostomy.14McGrath B.A. Wilkinson K. The NCEPOD study: on the right trach? Lessons for the anaesthetist.Br J Anaesth. 2015; 115: 155-158Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Tracheostomy complications are often described as early, short- or long-term (Table 2).Table 2Complications of a tracheostomyEarlyShort-termLong-termHaemorrhageBlockageTracheomalaciaAspirationTube displacementTracheal stenosisPneumothoraxPneumothoraxTracheocutaneous fistulaFailure of procedureSurgical emphysemaDecannulation problemsInfectionDelayed haemorrhageTracheal necrosisTracheo-arterial fistula Open table in a new tab Anaesthetists and critical care doctors, as ‘airway experts’, are often called to emergencies involving a tracheostomy, and it is essential that they are familiar with the management of these situations. The Royal College of Anaesthetists 4th National Audit Project showed that most tracheostomy-related critical incidents are related to displacement of the tracheostomy tube, especially on movement or in patients who are obese.9Royal College of Anaesthetists and Difficult Airway Society4th National Audit Project: major complications of airway management in the United Kingdom. Full report and findings.March 2011Google Scholar After this, the National Tracheostomy Safety Project was developed to create expert guidelines for the management of tracheostomy and laryngectomy-related emergencies. These guidelines are now widely used and describe a generic algorithm to manage most common and easily reversible critical situations. Separate colour-coded algorithms are provided for patients with a potential patent upper airway (Fig. 6) and those with a laryngectomy. The guidelines aid the early detection of a blocked or displaced tube and describe initial and advanced airway interventions. They are designed to be easy to follow, especially for doctors less experienced in managing a patient with a tracheostomy.15McGrath B.A. Bates L. Atkinson D. Moore J.A. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies.Anaesthesia. 2012; 67: 1025-1041Crossref PubMed Scopus (136) Google Scholar The key principles of the algorithm are:1.Waveform capnography has a prominent role at an early stage in emergency management.2.Oxygenation of the patient is prioritised.3.Trials of ventilation via a potentially displaced tracheostomy tube to assess patency are avoided.4.Suction is only attempted after removing a potentially blocked inner tube.5.Oxygen is applied to both potential airways.6.Simple methods to oxygenate and ventilate via the stoma are described.7.A blocked or displaced tracheostomy tube is removed as soon as this is established and not as a ‘last resort’ A separate algorithm is available for patients with a laryngectomy. The principles and goals remain the same, but without the conventional upper airway steps. Patients with a laryngectomy do not always have a tracheostomy tube in situ, but may have other devices inserted into their airway. Bedside signs should also be displayed next to every patient with a tracheostomy. This allows important information regarding the patient and their tracheostomy to be shared quickly. There should be additional equipment beside their bed, including the following: spare tubes and inner cannulae (especially one size smaller), suction equipment, stitch cutters and an emergency bell. More specialist equipment such as a fibreoptic scope and advanced airway equipment should be available nearby. Bleeding from or around the tracheostomy site can be potentially life-threatening, and it is important to establish the origin of the bleeding. In all situations any anticoagulants or clotting abnormalities should be reversed or treated, the airway assessed for obstruction and expert surgical help sought. Bleeding from the tracheostomy may be from aberrant vessels around the stoma damaged during insertion of the tracheostomy. It can also be from a trachea-innominate artery fistula, although this is rare.16Singh N. Fung A. Cole E. Innominate artery hemorrhage following tracheostomy.Otolaryngol Head Neck Surg. 2007; 136: S68-S72Crossref PubMed Scopus (13) Google Scholar If the patient is stable, it may be possible to perform endoscopy via the tracheostomy to help establish the cause of bleeding. Suction should be used and localised bleeding can be treated with external compression, surgical clips or cauterisation. A piece of gauze soaked with adrenaline or tranexamic acid can be packed around the bleeding site. Bleeding deep within the stoma may not resolve with this procedure, in which case hyperinflating the tracheostomy tube cuff may tamponade the bleeding vessel temporarily. The cuff should be inflated with air slowly to prevent cuff rupture; usually 35–50 ml is sufficient, depending on the size of the tube.17Bradley P.J. Bleeding around a tracheostomy wound: what to consider and what to do?.J Laryngol Otol. 2009; 123: 952-956Crossref PubMed Scopus (27) Google Scholar An uncuffed tube should be replaced with a cuffed tracheostomy tube or tracheal tube and the cuff inflated. Once the bleeding has been controlled the patient should undergo urgent surgical exploration and repair. Occasionally granulation tissue can form at the tip of a long-term tracheostomy and can bleed. This can be treated with excision or cauterisation via a bronchoscope. It is also important to remember that haemoptysis may be confused for bleeding related to the tracheostomy tube. Surgical emphysema is a recognised complication of both surgical and percutaneous tracheostomy insertion. Risk factors include a tight closure of the stoma site around the tracheostomy tube, use of packing materials around the stoma site or tracheal injury during insertion. Displacement of the tracheostomy tube into the pretracheal tissue can cause significant surgical emphysema, especially if the patient is mechanically ventilated. The risk is increased, by the use of too short or fenestrated tubes that may have openings within the pretracheal tissue.18Mostert M.J. Stuart H. Subcutaneous emphysema caused by a fenestrated tracheostomy tube.Anaesthesia. 2001; 56: 191Crossref PubMed Scopus (1) Google Scholar It is important that forceful mechanical ventilation is not attempted if there is concern that a tracheostomy tube is potentially displaced; this can result in extensive surgical emphysema, making front of neck access very difficult. Management of surgical emphysema is usually conservative, with treatment of the underlying cause. Malpositioned tracheostomy tubes should be exchanged for an appropriately sized one and non-fenestrated inner cannulas sited. If a patient develops surgical emphysema, they should be assessed for a pneumothorax as it can often occur simultaneously. Most initial tracheostomy tubes that are inserted will have an inflatable cuff. Cuffed tubes are usually for short-term use, until a patient is weaned from a ventilator and can manage their own secretions. Occasionally, a cuffed tube is required long-term in patients with chronic conditions, such as reduced consciousness or neuromuscular conditions affecting the pharynx. The cuff requires regular checks to ensure it is at an appropriate pressure of between 20 and 30 cmH2O.19Seegobin R.D. van Hasselt G.L. Endotracheal cuff pressure and tracheal mucosal blood flow: endoscopic study of effects of four large volume cuffs.Br Med J (Clin Res Ed. 1984; 288: 965-968Crossref PubMed Scopus (438) Google Scholar Pressures that are too high increase the risk of tracheal stenosis, tracheomalacia and tracheal fistulas. Too low pressures cause air leaks and allow microaspiration of secretions from above the cuff. Occasionally, cuff leaks around a tracheostomy can be intermittent. Potential causes include: an underinflated cuff, a defective or damaged cuff, or high ventilation pressures that exceed the cuff pressure. Tubes that are too small for the trachea often require high cuff pressures to create a seal. Importantly, a cuff leak can indicate a partially displaced tube causing the cuff to herniate into the upper larynx. Checking the cuff pressure is an important part of a tracheostomy tube position check. Persistent cuff leaks despite normal pressures and without an obvious cause may benefit from endoscopic inspection of the tube position as previously described. The tracheostomy tube may need to be repositioned or advanced. A tube that is too small or short should be exchanged for a larger or extended-length tube. This may not be possible in patients requiring high levels of ventilatory support and should be balanced against the risks of a partially displaced tube.20National Tracheostomy Safety Project. Cuff management. Available from: http://www.tracheostomy.org.uk/storage/files/Cuff%20management.pdf (accessed 26 February 2019).Google Scholar Patients with tracheostomies are increasingly seen in critical care units and ward environments. These can often be complex patients to manage, and anaesthetists are regularly asked to provide an expert opinion on their care, especially during emergency situations. It is important that all anaesthetists and critical care doctors are familiar with these patients and their management.