Mastery of the patient assessment as well as aggressive airway management should be a vital skill set for any pre-hospital provider. Being proficient in those areas provides us with a great framework ("fallback") when everything else goes wrong. When all else fails, at bare minimum we must employ the use of the assessment to proactively anticipate changes (good or bad) and above all else, provide protection of the airway if the patient loses the ability to do so on their own.
In the spirit of airway compromise/challenges -- one airway conundrum that we infrequently come across is tracheostomy patients. TAKE A DEEP BREATH!! These low frequency encounters can bring even a seasoned provider a small amount of fear, but we don't have to overcomplicate it. Before we continue, several key concepts of the tracheostomy must be understood. A tracheostomy is usually placed for chronic mechanical ventilation, chronic poor swallowing, upper airway obstruction (such as a malignant mass), and failure to protect the airway. My grandfather had laryngeal cancer back in 2008, or my anxiety around this special population would certainly be worse. I got really familiar with his setup and unique care needs, until the cancer was in remission and the stoma was closed.
The table and images below complement one another and provide an overview of the common components you must be familiar with -- patients will usually have replacements sitting around the house. Remember the patient and family live with this device on a daily basis -- don't be afraid to leverage their own expertise. Allowing them to assist, can oddly enough calm them down on occasion which can bring the tension down for all in times of airway crisis + trach complications.
Some trach tubes may also be fenestrated -- look out for DFEN or CFEN on the neck flange. A fenestrated tracheostomy tube has a small hole or multiple holes in the shaft of the tracheostomy tube, above the cuff (if present). These small openings allow for increased airflow through the upper airway. Air can move through the upper airway even when the cuff of the tracheostomy tube is inflated. This may allow for some voicing when the cuff is inflated.
Fenestrated inner cannula
Most problems with tracheostomies are centered around (3) major issues:
Regardless of the issue at hand, best practice would dictate that we ask these questions as part of our initial assessment:
Hold "fresh/new" is the stoma? - Most complications happen in those first week after surgery. Formation of a false passage could be a big problem.
Why was the trach placed?
Any recent fevers or secretion changes? (frequency, volume, color)
Has their larynx been removed as well? If Yes, you won't be able to ventilate thru the mouth
Several methods of tracheostomy placement exist, with the majority placed surgically (not by EMS) or percutaneously. In the worst-case scenario when you cannot intubate or ventilate/oxygenate -- you may be asked, or your protocol may force you to complete the percutaneous option in the field. - We will touch more on this topic now.
Palpating the anterior neck and locating the correct landmarks is key. Below the laryngeal prominence who will find the cricothyroid membrane.
Stabilize/secure the trachea
Insert the quick Trach device or equivalent perpendicularly into the membrane
Pullback on the syringe while advancing
Loss of resistance (plunger freely moves) indicates your likely in the trachea
IMMEDIATELY change your angle to 45 degrees and proceed caudally towards the feet
Advance until the stopper meets the neck, remove stopper
Advance cannula thru the trachea
Secure and begin providing ventilation support
Tracheostomy complications can quickly become life-threatening, and knowing some basic concepts about tracheostomies can allow us to better respond to and take care of patients with these complications. As with any patient, getting an adequate history should be the first step, and in particular, knowing if the patient has had a laryngectomy can prevent the “never event” of an orotracheal intubation attempt. Before performing any interventions on a patient where there is time to set up (i.e. on a relatively stable patient), one should gather appropriate equipment such as personal protective gear, extra tubes, and suction.
October 2, 2023
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC.