Guideline development

Draft guidelines were developed, tested and refined locally before being re-submitted to the UK stakeholder organisations. Extensive use was made of real-life critical incidents that were recreated using high-fidelity simulation and different management strategies were attempted with different staff members and local airway experts. Near-final guidelines were subject to open peer review for a period of 6 months via the NTSP and UK stakeholder organisation websites. During this period, the resources were accessed over 28 000 times and the emergency algorithms downloaded nearly 9000 times, with worldwide feedback received. Generally, feedback was positive and supportive of the project aims, with many comments adapted to be included in the final version of the guidelines with the contributors’ permission.

First, it was clear from initial analyses that distinct bedside information and algorithms were required for patients with a potentially patent upper airway and those with a laryngectomy. This led to the development of the bedhead signs, allowing essential information to be clearly displayed and immediately available to responders in an emergency. This allows the responder to know immediately whether the patient has any special considerations for managing the upper airway or the tracheostomy stoma. Bedside information can also summarise key details regarding the nature and date of the tracheostomy, the method of stoma formation and the function of any ‘stay sutures’.

Second, it was recognised that separate algorithms were needed for patients with a potentially patent upper airway and those with a laryngectomy. However, it was also apparent that there would be similarities between the algorithms, with the management of laryngectomy patients following the same steps as for tracheostomy patients, but without the upper airway elements.

It was clear to us that a number of principles should underpin the guidelines that we developed. The two key priorities were supported by our critical incident reviews: oxygenation of the patient takes priority (not necessarily securing the airway immediately and definitively, unless required for oxygenation) and the best assistance should be sought early. Ideally, this assistance would include other members of the multi-disciplinary team who are trained and competent to deal with tracheostomy emergencies. Emergencies should be managed in adequately equipped clinical environments.

Rather than taking a problem-specific approach, we developed a generic algorithm that would cover the vast majority of common and easily reversible clinical situations that arise, while accepting that a number of special circumstances do exist (e.g. the critically ill ventilated patient in the ICU, or the patient who has undergone a complex tracheal reconstruction). Even in these complicated scenarios, key airway management principles can still be followed. This approach also allows training to be standardised.

We have divided the competencies and training required between those of the primary and secondary responders. The primary responder (typically a nurse, junior doctor or allied health professional) needs to be guided to detect airway problems, to assess tracheostomy and airway patency and to provide basic emergency oxygenation. The secondary responder (typically an anaesthetist, intensivist, head and neck surgeon or specialist practitioner) will have skills in conventional airway management and will also be guided to use skills in managing the tracheostomy or stoma. These skills would typically include oro-nasal intubation techniques (including difficult intubations), the ability to use a fibreoptic scope to assess or replace tracheostomy tubes and the ability to perform and manage an emergency surgical airway or tracheostomy. Our emergency algorithms are thus divided into sections to reflect the differing skills of the responders.

The algorithms are applicable for any urgent or emergency situation that develops in a patient with a tracheostomy or laryngectomy.

Interactive algorithms with video links to each of the key steps are available from the website www.tracheostomy.org.uk. There are details of each of the key steps in the algorithm explained in the e-learning resources associated with this manual.

Patent upper airway: the ‘Green algorithm’

This algorithm is paired with the green bedhead sign and assumes a potentially patent upper airway, meaning that it is anatomically possible for the upper airway to connect to the trachea and thus theoretically allow ventilation by this route. This is in contrast to the situation with a laryngectomy. The following section should be viewed in conjunction with the green algorithm. It is important to remember that the original reason for the tracheostomy may have been a difficult, or even impossible, upper airway.

Help and equipment

The first step is to call for help. Who is called will depend on the patient, the responder and the location. The bedhead sign should display local details specific to this patient of who to call and how to avoid delays. The details of the bedhead signs should be agreed and completed when the patient is first admitted or transferred to the clinical area, not when an emergency occurs. If out-of-hours specialist or clinical cover is not immediately available, appropriate arrangements must be in place to ensure that assessments and emergency responses can be delivered. Clinical areas caring for patients with tracheostomies should be staffed and equipped to do so. This includes the provision of routine and emergency airway equipment. Most equipment should be at the bedside. Additional equipment and fibreoptic scopes should be available at all sites (including wards) where patients with a tracheostomy are cared for. Fibreoptic scopes are used either to enable inspection of the tube position, to assist in the replacement of the tube or to enable management of the upper airway. Specialist areas such as critical care will need a difficult intubation trolley, waveform capnography and a fibreoptic scope to be immediately available.

Assessment of breathing

Following the principles of basic life support, the first clinical steps attempt to open the airway and look for evidence of breathing. Tracheostomy patients will usually have two airways (the native upper airway and the tracheostomy) and clinical assessment takes place by looking, listening and feeling at the face and tracheostomy tube or stoma for 10 s, following basic upper airway opening manoeuvres. Videos of this can be seen here.²

A Mapleson C anaesthetic breathing system (commonly referred to as a ‘Waters circuit’, Figure 8.1) can be used attached to a facemask placed over the face or tracheostomy stoma, or directly to the tracheostomy tube. The collapsible bag can offer visual clues to confirm the presence of respiration if the bag is seen to move. This circuit also enables ventilation, but must be used only by those who are competent to do so, as harm may occur if the expiratory valve is left closed. Videos detailing this assessment may be viewed here.³

Figure 8.1 (a) A Mapleson C (‘Waters circuit’) anaesthetic breathing system. (b) Waveform capnography is invaluable when managing airways.

Waveform capnography is invaluable when managing airways and should be used at the beginning of the assessment. If the patient is breathing spontaneously, apply high-flow oxygen to the face and tracheostomy. This will require two oxygen supplies, which may necessitate the use of the oxygen cylinder on the resuscitation trolley. Pulse oximetry can add valuable information as to the success of interventions and to the urgency of subsequent interventions.

If the patient is not breathing (apnoea or occasional gasps) or there are no signs of life, then a pulse check must occur and cardiopulmonary resuscitation commenced as per international guidelines. The remaining details of these algorithms deal with managing the airway – a critical component of any ALS teaching. A primary tracheostomy problem (e.g. tracheostomy tube blockage) may have led to the cardio-respiratory arrest in the first instance.

Assessment of tracheostomy patency

Simple, easily reversible problems have caused significant morbidity and mortality to tracheostomy patients. These have included the inappropriate use of obstructing (decannulation) caps or obturators attached to the tracheostomy tubes, incorrectly used speaking valves (with an inflated, cuffed tube) and humidifying devices (e.g. Swedish noses) blocked with secretions. Because of this, any device attached to a tracheostomy tube must be removed in an emergency.

Inner tubes used with tracheostomies can significantly reduce the risk of tube occlusion, provided they are cared for and used appropriately. If a tracheostomy tube becomes blocked, simply removing the inner tube may resolve the obstruction. However, it must be remembered that inner tubes vary significantly in their design, with some requiring replacing after cleaning, to allow connection to breathing circuits. It is essential to know what equipment is used in your clinical areas, as unfamiliarity with equipment may lead to morbidity and mortality.

Passing a suction catheter via the tracheostomy will establish whether the tube is patent and also allow therapeutic suction to be performed (Figure 8.2). The suction catheter needs to pass easily beyond the tracheostomy tube tip and into the trachea. The depth of insertion will depend on the length of the tube in situ. Gum-elastic bougies or similar introducers should be avoided at this stage, because these stiffer devices are more likely to create a false passage if the tracheal tube tip is partially displaced. The soft suction catheters will not advance sufficiently into the pre-tracheal tissues and are less likely to cause further problems if used to assess patency (Figure 8.3).

Figure 8.2 Suctioning via the tracheostomy.