
Contents
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Introduction Introduction
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Section 1—Treatment of Complications During Tracheostomy Insertion Section 1—Treatment of Complications During Tracheostomy Insertion
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A. How to Reduce the Risk of Airway Fire A. How to Reduce the Risk of Airway Fire
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Step by Step Step by Step
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1. Communicate early with the surgeons if cautery will be used, and instruct them to inform you prior to usage. 1. Communicate early with the surgeons if cautery will be used, and instruct them to inform you prior to usage.
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2. If patient is unable to tolerate lower FiO2 levels, request that the surgical team avoid using cautery. 2. If patient is unable to tolerate lower FiO2 levels, request that the surgical team avoid using cautery.
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B. How to Prevent Cuff Damage During Tracheostomy Insertion B. How to Prevent Cuff Damage During Tracheostomy Insertion
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Step by Step Step by Step
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1. Ensure proper anesthetic depth and paralysis prior to manipulation to ensure there is no involuntary displacement and to optimize glottic view. 1. Ensure proper anesthetic depth and paralysis prior to manipulation to ensure there is no involuntary displacement and to optimize glottic view.
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2. Retract the ETT prior to tracheostomy insertion. 2. Retract the ETT prior to tracheostomy insertion.
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C. Management of Cuff Damage or Loss of ETT Cuff Pressure and Tidal Volume C. Management of Cuff Damage or Loss of ETT Cuff Pressure and Tidal Volume
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Step by Step Step by Step
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1. Immediately alert the surgeons to stop the procedure. 1. Immediately alert the surgeons to stop the procedure.
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2. If the cuff is ruptured, exchange the ETT. 2. If the cuff is ruptured, exchange the ETT.
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3. If unable to replace the ETT, ensure adequate ventilation via bag-mask or place a supraglottic airway (SGA). 3. If unable to replace the ETT, ensure adequate ventilation via bag-mask or place a supraglottic airway (SGA).
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4. After replacement, pull back the ETT via laryngoscopy until the cuff is at the glottis. 4. After replacement, pull back the ETT via laryngoscopy until the cuff is at the glottis.
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D. Management of the Inability to Ventilate After Tracheostomy Insertion D. Management of the Inability to Ventilate After Tracheostomy Insertion
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Step by Step Step by Step
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1. Immediately alert the surgical team that you are unable to ventilate. 1. Immediately alert the surgical team that you are unable to ventilate.
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2. Check for malposition of the tracheostomy. 2. Check for malposition of the tracheostomy.
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3. Advance the preexisting ETT from its retracted position. 3. Advance the preexisting ETT from its retracted position.
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4. If still unable to ventilate after advancing the ETT, perform bronchoscopy. 4. If still unable to ventilate after advancing the ETT, perform bronchoscopy.
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5. Once ventilation is reestablished, reattempt tracheostomy placement. 5. Once ventilation is reestablished, reattempt tracheostomy placement.
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E. Management of Sudden Increase in Airway Pressure with Cardiovascular Collapse E. Management of Sudden Increase in Airway Pressure with Cardiovascular Collapse
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Step by Step Step by Step
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1. Initiate cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS), if indicated. 1. Initiate cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS), if indicated.
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2. Ensure proper positioning of the ETT and rule out pneumothorax. 2. Ensure proper positioning of the ETT and rule out pneumothorax.
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3. Perform needle thoracostomy (see Chapter 13 on tension pneumothorax for more details). 3. Perform needle thoracostomy (see Chapter 13 on tension pneumothorax for more details).
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F. Management of Bleeding During Dissection for Tracheostomy Placement F. Management of Bleeding During Dissection for Tracheostomy Placement
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Step by Step Step by Step
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1. Maintain communication with surgeon and monitor surgical field for bleeding. 1. Maintain communication with surgeon and monitor surgical field for bleeding.
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2. Maintain ventilation and hemodynamics. 2. Maintain ventilation and hemodynamics.
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3. Perform anterior neck ultrasound. 3. Perform anterior neck ultrasound.
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4. Ensure the patient is not coagulopathic. 4. Ensure the patient is not coagulopathic.
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5. Perform bronchoscopy after bleeding is controlled. 5. Perform bronchoscopy after bleeding is controlled.
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Section 2—Complications in Patients with a Preexisting Tracheostomy Section 2—Complications in Patients with a Preexisting Tracheostomy
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G. Identifying Whether the Patient Has a Tracheostomy or a Laryngectomy Stoma G. Identifying Whether the Patient Has a Tracheostomy or a Laryngectomy Stoma
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Step by Step Step by Step
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1. Determine if the patient has a laryngectomy stoma or a tracheostomy. 1. Determine if the patient has a laryngectomy stoma or a tracheostomy.
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2. If a tracheostomy is present, identify the tracheostomy type. 2. If a tracheostomy is present, identify the tracheostomy type.
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3. Confirm that the inner cannula can connect to the anesthesia circuit and maintain positive pressure ventilation (PPV). 3. Confirm that the inner cannula can connect to the anesthesia circuit and maintain positive pressure ventilation (PPV).
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H. Management of the Inability to Ventilate via an Existing Tracheostomy H. Management of the Inability to Ventilate via an Existing Tracheostomy
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Step by Step Step by Step
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1. Inform the surgeons to halt the current operation and avoid further positive pressure breaths. 1. Inform the surgeons to halt the current operation and avoid further positive pressure breaths.
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2. Deflate the tracheal tube cuff (if present) and remove the inner cannula to assess for obstruction. 2. Deflate the tracheal tube cuff (if present) and remove the inner cannula to assess for obstruction.
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3. Provide oxygenation via the upper airway while occluding the tracheostomy tube. 3. Provide oxygenation via the upper airway while occluding the tracheostomy tube.
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4. Once ventilation is reestablished, insert a suction catheter through the tracheostomy to assess for tube occlusion. 4. Once ventilation is reestablished, insert a suction catheter through the tracheostomy to assess for tube occlusion.
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I. Management of Accidental Decannulation of Preexisting Tracheostomy I. Management of Accidental Decannulation of Preexisting Tracheostomy
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Step by Step Step by Step
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1. Inform surgeons and halt the operation. 1. Inform surgeons and halt the operation.
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2. Provide oxygenation via the upper airway. 2. Provide oxygenation via the upper airway.
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3. If the tracheostomy is older than 7 days, reinsert the tracheostomy blindly with or without the use of a guidance tool (e.g., obturator or bougie). 3. If the tracheostomy is older than 7 days, reinsert the tracheostomy blindly with or without the use of a guidance tool (e.g., obturator or bougie).
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4. If unable to ventilate from above or reinsert tracheostomy, insert SGA or attempt laryngoscopy. 4. If unable to ventilate from above or reinsert tracheostomy, insert SGA or attempt laryngoscopy.
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Other Management Considerations Other Management Considerations
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Further Reading Further Reading
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References References
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7 C7Tracheostomy Complications
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Published:September 2023
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Abstract
Tracheostomy is a surgically created airway midline through the neck and into the proximal trachea. This procedure is utilized in patients with prolonged mechanical ventilation and in patients with anticipated difficult airway access. Although the procedure is relatively low risk in regards to cardiovascular status, it can have severe airway complications. When complications occur, they are mostly related to loss of the airway. The approach can be done open or percutaneously, or a combination of both. Both approaches can be done at the bedside, depending on local practices and surgical aptitude. If done in the operating room, then it is commonly performed via an open approach. The choice of approach is usually related to patient body habitus, vascular anatomy, airway anatomy, positioning, or risk of bleeding. The two most dangerous complications are bleeding and loss of the airway. Before a tracheostomy is attempted, there should be adequate advanced airway equipment and practitioners present trained in securing difficult airways. Quick recognition of the causes is essential to prevent life-threatening complications.
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