Red flags

What should you do if you detect a red flag?

A prompt assessment of the tracheostomy and the patient should be made by someone who is competent to do so. Who this is depends on how the patient is, your role and where you work, but the person making the assessment must to be able to work out what the problem is and address it. Interventions could range from a simple reassuring assessment, a fibreoptic inspection of the tube or airways or replacement of the tracheostomy tube.

Like any assessment of the unwell patient, this should always start with ‘A for airway’. In the case of a patient with a tracheostomy, there may be two airways to consider, or with a laryngectomy, only one (in the front of the neck, not the face). Any airway problem can cause the patient to become unwell and show signs of distress. Conversely, patients with tracheostomies can become unwell with all the problems that other patients get too. It is easy to become fixated with the tracheostomy.

The ‘flags’ can be divided up into different categories.

Airway flags
Breathing flags
Specific tracheostomy flags
General flags.

Airway flags

If the patient has a cuffed tracheostomy correctly sited in the trachea, no gas should escape through the mouth. If the patient is talking to you, or audible air leaks or bubbles of saliva are seen or heard at the mouth or nose, then gas is escaping past the cuff. This may imply that the cuff is damaged or the tube tip is not correctly sited. Grunting, snoring or stridor are also signs that there is an airway problem.

Breathing flags

Listening to the patient, or observing the patient or instrumentation may show that the patient:

is not breathing (apnoea), which is detected by capnography or clinically
has difficulty in breathing (or with ventilation), which may be reported by the patient or observed clinically:
- accessory muscle use
- increased respiratory rate
- higher airway pressures
- lower tidal volumes
has hypoxia
is making whistling noises or has noisy breathing.

Specific tracheostomy flags

Careful observation may show that the patient:

has a visibly displaced tracheostomy tube (Figure 7.1); if this is an adjustable flange tube, check to see where it was last positioned
has blood or blood-stained secretions around the tube – a recently performed or changed tracheostomy bleeds a little, but if in doubt, it should be assessed
reports increased discomfort or pain
requires a great deal of air to keep the cuff inflated, which may be because:
- the cuff is damaged or has an air leak (in which case, it needs to be replaced)
- has a displaced tube and the cuff needs hyper-inflation to keep it ‘sealed’.