A 44-year-old man with a history of cardiac arrest complicated by hypoxic-ischemic encephalopathy presents to the ED in respiratory distress. He underwent tracheostomy 2 weeks ago for acute respiratory failure and was subsequently weaned to trach collar. He developed acute onset of respiratory distress at rehab this morning and now presents to the ED with acute hypoxic respiratory failure. On exam, he is hypertensive (169/88), tachycardic (HR 178), tachypneic with respirations assisted with bag-valve mask (BVM) ventilation and hypoxemic (SpO2 87%). What is your approach to the management of tracheostomy emergencies? 

It is important to use an algorithmic approach to diagnose and manage tracheostomy patients with respiratory distress. The “green" algorithm published in the Anesthesia in 2012, is a protocol derived from multidisciplinary guidelines for management of tracheostomy airway emergencies. The first step in all patients with a tracheostomy is to apply high-flow supplemental oxygen, or positive pressure ventilation via BVM if the patient has inadequate respiratory effort, to both the mouth/nose as well as the tracheostomy tube.The next step is to remove the inner cannula to assess for obstruction with inspissated secretions. A clean inner cannula must be reinserted to resume BVM respirations. It is important to understand that the inner cannula must be in place to attach a BVM to a tracheostomy tube. The next step is to pass an in-line sterile suction catheter, which is both a diagnostic and therapeutic maneuver. If the patient improves with deep suction, a mucus plug was likely present and removed. Alternatively, if the suction catheter can only be passed a few centimeters, the tracheostomy tube is either still obstructed or partially dislodged. The next step is to deflate cuff of the tracheostomy tube to reposition the tube. When a tracheostomy tube is partially displaced, the inflated cuff can obstruct the tracheal lumen impairing oxygenation and ventilation. By deflating the cuff, the trach tube can be repositioned to re-establish a patent airway. If the patient does not improve with repositioning of the trach tube, the next step is to remove the tracheostomy tube. Although there may be concerns about removing a trach tube from a patient with an obstructed upper airway, when faced with a deteriorating tracheostomy patient, a non-functioning trach tube offers no benefit and can cause significant harm. Once the tracheostomy tube is removed, emergency oxygenation via BVM of the face and the stoma should be performed. To establish a seal for mask ventilation of the stoma, a pediatric bag-valve mask or LMA can be utilized. Emergency oxygenation typically requires two airway teams to perform BVM with one team ventilating the face and the other ventilating the stoma. The final step in the green algorithm is to perform intubation, either via the orotracheal route with an endotracheal tube or via the stoma with a tracheostomy tube or small endotracheal tube (e.g. size 6).

Approximately 3 to 5 percent of tracheostomy patients have undergone laryngectomy. Laryngectomy patients are unique in that they are obligate stomal breathers and cannot be oxygenated or ventilated via the mouth or nose. In this situation, one should use the “red” algorithm which is identical to the “green” algorithm except for the final step, where a laryngectomy patient must be intubated via the stoma (using a tracheostomy tube or an ETT). Keep in mind that a mature stoma (placed > 14 days ago) can close up to 50% within 12 hours and 90% within 24 hours. Therefore, it is important to contact the surgical or interventional team that placed the tube, if a patient has been intubated orotracheally during a tracheostomy emergency, to avoid the need for subsequent revision tracheostomy. See below for a summary of “green” algorithm.

Returning to our patient, using the green algorithm, his tracheostomy tube was successfully replaced and his hypoxia resolved. During his resuscitation, the following ventilator graphics were noted. What is your diagnosis? 

Answer: Balloon rupture! 

The expiratory limb of the volume tracing shows an abrupt cutoff with return of only half the prescribed tidal volume. This is consistent with a cuff leak. 

References

McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy emergencies. Anaesthesia. 2012;67:1025-1041.