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Home , Cricothyrotomy, Iron lung, Laryngectomy

Prehospital Care of the Patient with a Tracheostomy

Continuing Education:

2 hours Special Considerations (state) or Medical: Special Healthcare Needs (NREMT)

TABLE OF CONTENTS

Objectives: ...... 2 Introduction ...... 2 Is it just a tracheostomy, or is there more? ...... 4 Tracheostomy versus surgical cricothyroectomy ...... 7 Parts of the tracheostomy device ...... 10 Tracheostomy enhancements ...... 13 Quick reference chart on tracheostomy devices ...... 17 Tracheostomy emergencies...... 19 First treatment steps ...... 19 Helpful tips ...... 21 Video of outer cannula insertion ...... 22 Procedure: Sterile suctioning ...... 23 About the person with a tracheostomy ...... 25 Cardiac arrest considerations ...... 26 References ...... 28 Image credits ...... 29

Note: Commercial product names are mentioned in the education, but no financial benefit or endorsement was derived from their use. They represent commonly-known devices that may be referred by these more familiar names in the healthcare setting.

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OBJECTIVES:

The objectives for this continuing education include:

• Compare the major types of surgical airways and what to expect as normal and abnormal findings during your patient assessment.

• Explore a subset of patients with tracheostomies: Individuals with a .

• Describe the appropriate assessment of the patient with a tracheostomy for both spontaneously and mechanically-ventilated individuals.

• Examine treatment plans and procedures for respiratory emergencies involving a patient with a tracheostomy and with or without a laryngectomy.

• Discuss the appropriate procedure for tracheal suction to reduce healthcare-associated infections.

INTRODUCTION

What is a tracheostomy? A tracheostomy is a surgically-created hole () to the anterior neck, located just below the thyroid gland and usually between the second and fourth tracheal rings. Functionally, it’s similar to our prehospital surgical , but the location of the incision is different along with the intended use, as shown in the comparison table below.

Surgical Cricothyrotomy Tracheostomy

Usually used as a rapid, emergent airway. Usually a planned surgical procedure.

Used for adult patients since they usually have a wider airway and identifiable tracheal Procedure is used for all ages, including landmarks, such as the cricothyroid neonates and pediatrics. membrane. Should be avoided in young children and infants.

A temporary rescue airway. Usually a permanent functional airway.

Several vessels lie across the tracheal rings and When performed correctly, less risk of cutting can be easily cut; Usually reserved for the veins and arteries. operating room.

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A little history: Tracheostomies have been around for thousands of years. Fortunately, the procedure is kinder and gentler today compared to the earlier years.

The first known depiction of tracheostomy is from 3600 BC, which was discovered by historians on ancient Egyptian tablets. According to legend, Alexander the Great allegedly used his sword to open the airway of a soldier from a bone lodged in his throat.1,2 In the second to third century AD, Aretaeus and Galen wrote about tracheostomies that were performed by the Greek physician Asklepiades several hundred years earlier.3 Success rates were considered as questionable though.

Alexander the Great depicted as cutting the Skipping ahead to the early 20th century, tracheostomies Gordian Knot. Maybe cutting a throat for one of became much safer thanks to the work of Dr. Chevalier the earliest tracheostomies offers more truth Jackson, who is considered as a pioneer in modern than legend? laryngology and . During the U.S. epidemic in the 40s and 50s, tracheostomies and use become more common because of the paralysis that accompanied this potentially-fatal disease. This accelerated the development of modern positive-pressure that greatly improved the mortality rate and eventually replaced the “iron ”.

Today: From 1993 to 2012, over one million adults (1,352,432 to be more exact) underwent long-term tracheostomy placement, per the U.S. Agency for Healthcare and Research Quality’s Healthcare Cost and Utilization Project data.4 This number doesn’t include short-term tracheostomies, such as those created for acute or to establish an emergent airway in the hospital.

The reasons for a tracheostomy vary but may include a need for long term , poor with a high risk for aspiration, an upper airway obstruction that can’t be resolved surgically (example: a cancerous mass), and other reasons where the patient is simply unable to protect his or her airway.

While not exactly a surgical procedure sitting on everyone’s bucket list, a tracheostomy is far from handing a patient a death sentence. Many patients with a tracheostomy are able to lead independent lives at home without the need for a mechanical ventilator. In many cases, they simply need way to bypass air movement from the upper airway but otherwise have enough chest and diaphragm strength and control for spontaneous breaths.

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The benefits of a tracheostomy:4

• Improved patient comfort and less sedative use compared to long term intubation with an endotracheal tube;

• Less time spent in the hospital (reduced length of stay)

• Earlier mobility; the patient does not have to be confined to bed;

• Less risk for injury to the tracheal structures;

• Earlier oral feeding. Gastrointestinal movement in response to food is important for overall health.

It’s not without risks though… risk of complications from the tracheostomy procedure itself can be as high as 39%.5,6 In addition, the patient with a tracheostomy has lost a lot of airway protection from environmental pathogens. For example, our nosehairs help to filter contaminants from the air. So, this leaves the individual more susceptible to infectious diseases and respiratory contaminants. Air is normally humidified through our nose and downward towards the , but this is lost with a tracheostomy as well. With the drier air and structural airway change, it’s more difficult for a person with a tracheostomy to cough up mucus and clear secretions, increasing their dependency on tracheal suctioning. This may be compounded by the individual’s underlying medical condition or injury that necessitated tracheostomy placement in the first place.

The education will compare the different types of surgical airways, the devices used to maintain a tracheostomy, and how to assess and effectively treat the patient during a respiratory emergency. Most of the information applied to both the adult and pediatric patient unless otherwise indicated.

IS IT JUST A TRACHEOSTOMY, OR IS THERE MORE? LARYNGECTOMIES.

Laryngectomy: What is it? As described earlier, there’s several reasons why a person may need a tracheostomy. Depending on the cause, the individual may also need a laryngectomy as well, which essentially closes off the airway from the first tracheal rings on up.

A laryngectomy basically removes the connection from the upper airway to the trachea --- the entire is surgically removed and/or closed. The vocal folds and cords are removed along with the . The nasal passages and route directly down to the epigastrium without any access to the trachea. The airway now begins at the tracheostomy’s stoma, as shown on the next page.

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Who gets this procedure? Most laryngectomies are performed due to cancer of the larynx. The most common cause is through years of smoking, and alcohol consumption along with smoking can increase this risk. A laryngectomy is usually reserved for those who were unsuccessfully treated with radiation and for the cancer, or for those who have very large tumors that cannot be treated with either of these therapies. However, non-cancerous tumors or abnormal growths may also necessitate this procedure.

Usually, the only way you can tell if someone has a laryngectomy versus a tracheostomy that preserved the larynx is by asking, digging through the medical history, looking for a medical ID bracelet, or if unconscious, seeing if any air passes through the nostrils. The stoma on the neck looks the same as a tracheostomy.

What the person with a laryngectomy can and can’t do: A person with a laryngectomy can still eat and drink by after healing, but there is little to no sensation of taste since the sense of smell does not work effectively without air passing through the nostrils. The individual can shower if the stoma is protected from water intrusion, but swimming or submersion of the stoma without protection (laryngectomy snorkel, for example) is obviously contraindicated.

With the removed, the normal way of speaking is also gone. However, there are electronic and physical devices that can help a person speak even after a laryngectomy, such as an or voice prosthesis.

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An electrolarynx is a medical device that facilitates speech by generating sound when held on the neck or at times intraorally. The best way to describe the sound is as monotone and almost robotic-sounding, but newer advancements are now allowing the individual to control some of the tone and inflection during speech using a pressure-sensitive button controlled with their thumb.

Individuals with a laryngectomy may want a An electrolarynx device. The one to the left is placed under more natural voice and opt for a called the mandible to create speech, while the one shown to the a tracheoesophageal puncture (TEP), which is right is inserted in the mouth (intraorally). done during the actual laryngectomy or later as a second surgery. A (interconnecting hole) is surgically-created between the trachea and esophagus and a plastic voice prosthesis is inserted. This prosthesis produces sound from esophageal vibrations created during the phase. To do this, the individual breathes in and then occludes the tracheostomy stoma with their thumb or go “hands free” with a stoma valve while exhaling. Occluding the stoma diverts air from the trachea through the voice prosthesis instead. The person creates a voice by altering the flow of air and tension within the esophagus to create vibration, which takes a lot of time to learn effectively. The prosthesis has a one-way valve to prevent food or drink from entering the trachea, but unfortunately, this small device is also prone to developing yeast and bacterial infections.

Prehospital emergencies: For EMS, the most important concern about a laryngectomy is that intubation is now impossible. There is no way to direct an endotracheal tube through the mouth to the trachea, while on the other hand, most patients with a tracheostomy (and without a laryngectomy) can be intubated emergently, if needed. Also, a BVM won’t work over the nose and mouth. You can attach a neonate mask and ventilate the stoma though.

A second concern: If the patient has a tracheoesophageal puncture with a voice prosthesis, another respiratory emergency can occur if the small plastic prosthesis dislodges from the fistula. The prosthesis is normally replaced every five months or so,7 but can also accidentally work its way out of the fistula at any time.

Speaking with a voice prosthesis post-tracheoesophageal puncture.

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The loose voice prosthesis has only three places to go:

• Coughed out of the stoma (the best situation),

• Down the esophagus (a close second),

• Or worst-case scenario, inhaled into the trachea and lodged at the carina or within a lung.

Regardless of the travel route, these patients need to have this prosthesis replaced or the fistula kept open with an appropriate catheter to prevent fistula closure, which may occur in only a few hours.7 You may find these patients with a soft 12 to 16 French catheter,8 the prosthesis’ puncture dilator, or other small, flexible, tube-like object already placed in the Voice prosthesis in place with the fistula to keep it open. If the catheter is not impeding their ventilation and plastic access tab visible, which can be or appears secured well enough, just leave it there and transport. is exiting from the upper stoma. Do not give any medications or fluid by mouth. If the patient is Image: Erman 2010 complaining of sharp chest pain immediately after the catheter insertion, it may have been accidently directed into transesophageal wall.8

Some prostheses are patient removable/insertable so he or she can clean them weekly or even more often. If these patients call EMS because of the dislodged prosthesis, it’s usually because they accidentally aspirated the device. A dilator or another prosthesis may already be in the fistula prior to EMS arrival.

TRACHEOSTOMY VERSUS SURGICAL CRICOTHYROECTOMY

A tracheostomy may be performed for the following conditions:

• Obstruction of the mouth or throat that cannot be corrected with surgery or would be unsafe to do so.

• Breathing difficulty caused by edema, physical injury, or pulmonary conditions where breathing support may need to be long term.

• Airway reconstruction following tracheal or laryngeal surgery.

• Airway protection from secretions or food because of swallowing problems.

• Airway protection after head and/or neck surgery.

• Long-term need for ventilator support. For example, individuals with amyotrophic lateral sclerosis (ALS).

A is a surgical opening made to the anterior neck and through the tracheal rings. A tracheostomy tube is inserted and used to administer positive-pressure ventilation, to provide a patent airway, and to provide access to the lower for airway clearance. There are several similarities and differences between a tracheostomy and the more familiar surgical cricothyrotomy used in the prehospital setting.

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Surgical cricothyrotomy: A surgical cricothyrotomy’s incision is made at the large space referred to as the cricothyroid membrane, which is nested between the and the crico(thyroid) cartilage. The cricothyroid membrane may also be referred to as the cricothyroid ligament.

The opening that houses the cricothyroid membrane is about 8 to 10 mm tall (vertically) in most adults, and the membrane has a glossy appearance. The cricothyroid membrane is an ideal site for a surgical airway since it does not calcify with advancing age and it also lies well above a cluster of tracheal blood vessels. It found easily in non-obese males with a prominent “Adam’s Apple”, and although more difficult, it can also be palpated in women and obese individuals. The general rule is that the cricothyroid membrane should be located about three finger breadths above the sternal notch9 (memory aid: “three to breathe”), and this may a better way to start searching for it in women and those with thicker Location for the surgical cricothyrotomy: The cricothyroid membrane. necks.

A surgical cricothyrotomy is considered as only a temporary airway fix due to its location and limited space within the cartilage junction that makes it more difficult to accommodate permanent tracheostomy devices such as a Shiley® tracheostomy tube. Instead, the long-term or permanent surgical airway of choice is a tracheostomy using a more appropriate tracheostomy tube to maintain airway patency.

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Tracheostomy: A tracheostomy is a long term or permanent method of preserving the airway when there is an occlusion to the upper airway. Occlusions can be caused by swelling, tumors, granular growth, or even deformity of the larynx from traumatic injury. Like a surgical cricothyrotomy, a tracheostomy is formed below the patient’s vocal cords.

The tracheostomy is positioned lower in the airway, usually between the second and fourth tracheal rings. There are several methods of creating the surgical hole ranging from forming a flap with the tracheal tissue to completely removing a window of trachea to accommodate the tracheostomy tube. The skin is manipulated to form a round stoma to ease insertion of the tracheostomy tube and provide a solid, non-tearing base for the stoma.

Most are a planned procedure performed in the controlled environment of an operating suite. As shown below, there’s room for a lot of potential complications with the proximity of nerves and blood vessels traversing alongside or even across the anterior trachea.

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PARTS OF THE TRACHEOSTOMY DEVICE

There are several types of tracheostomy devices and different ways to secure it, which are often selected with consideration towards:

• The underlying reason for the tracheostomy; • If ventilator support is needed; • Any difficulties found with swallowing; • The individual’s communication needs; • Age and mobility; • And other factors.

Tracheostomy devices and securement options should be individualized. For example, it’s generally not recommended that Velcro tracheostomy ties are used to secure the tracheostomy tube for a younger child who likes to tug. These ties can be unfastened easily, yet the child may not understand the consequences of undoing them and inadvertently removing the tracheostomy tube. Instead, tracheostomy tubes for children are usually secured with a soft cotton band that can be tied together with a knot and are more difficult to loosen.

The tracheostomy tube: Basic parts. Most tracheostomy tubes consist of four parts: An outer cannula with flange (neck plate), an inner cannula, an obturator that’s only used when exchanging out the tracheostomy tube, and tracheostomy ties. There are exceptions though, such as a tube setup with only the outer cannula and obturator (described later). The most common configuration is a dual- cannula tracheostomy, which includes the outer cannula, inner cannula, and use of the obturator when needed.

Outer cannula. The outer cannula is the largest diameter and outermost Parts of a common tracheostomy configuration: Outer cannula, tube that holds the tracheostomy’s inner cannula, and the temporary use of an obturator. stoma open. A neck plate (also called the flange) extends from both sides of the outer tube and has holes to attach cloth ties or Velcro straps around the neck.

The outer cannula remains inserted in the individual’s trachea most of the time. The only time it’s removed is to exchange it for a clean replacement as directed by the individual’s physician (usually once every few weeks or even longer) or if it is accidently removed. The outer cannula should be secured at all times with ties, straps, or held in place manually except during the quick exchange.

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Cuffed or uncuffed? The outer cannula may have an inflatable cuff or instead, be uncuffed. The pilot balloon can be inflated or deflated with a standard 10 mL Luer-lock syringe. Most long-term tracheostomy devices have a cuff filled with air, but there are exceptions, such as the softer Portex/Bivona™ cuffs that use sterile water instead.

Like an endotracheal tube or blind-insertion airway device, the inflatable cuff is used to prevent fluid from entering the airway and also helps ensure that positive pressure ventilations from a bag-valve-mask (BVM) or ventilator is effectively inflating the and not leaking past the airway. A person with a cuffed tracheostomy tube may be producing a lot of secretions that are difficult to control, needs positive pressure ventilation, and/or has a higher risk of aspiration for other reasons.

A cuffed outer cannula (left) and an uncuffed one (right). Air can slip past the tracheostomy tube in the uncuffed An uncuffed tube is usually reserved for those cannula. individuals who are spontaneously breathing without assistance, can control their secretions and have a strong swallow, and may also be using a speaking valve or other breath-driven voice device with their tracheostomy. With an uncuffed tube, some of the breath is allowed to be drawn in and exhaled into the upper airway.

Inner cannula. The inner cannula slips inside the outer cannula, is usually disposable, and it allows air to travel from the environment or oxygen source into the trachea. It’s secured or “locked” into the outer cannula by either a quarter turn twist or by using side clips you pinch with your thumb and forefinger. The inner cannula is secured to the outer cannula to prevent it from being coughed out.

If a patient has a buildup of secretions that’s blocking his tracheostomy, this is the part that is normally removed to facilitate airway suctioning and the inner cannula is then usually replaced with a new one --- most are disposable now. Some inner cannulas An inner cannula inserts into the are designed to be cleaned instead using sterile saline and sterile outer cannula and can easily be pipe cleaners that are packaged in a single-use disposable kit. removed for replacement.

If the patient is using an inner cannula, he or she can be suctioned easily without concern that the stoma itself will close up and narrow the airway. Since inner cannula is inserted into the outer cannula, there’s no risk that it could enter the stoma and end up somewhere else besides the trachea during re-insertion. For outer cannulas, that insertion risk exists since the tube could tunnel between the skin and trachea by accident and create a false track.

Disadvantage of an inner cannula? The biggest disadvantage is that the effective airway diameter is reduced by about 1 mm since it’s a tube-inside-of-a-tube design (outer and inner cannula). This is why pediatric tracheostomies may only have an outer cannula… the airway would become too narrow otherwise.

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The obturator. The obturator is a rigid, rod-like device used to help insert the outer cannula of a tracheostomy tube though the stoma. It fits inside of the outer cannula to guide the tracheostomy tube into place, much like a stylet helps shape and guide an endotracheal tube while performing with standard blades. An obturator for an outer cannula. The obturator is an *absolute-must* device when inserting a softer, more flexible outer cannula such as the silicone ones (example: Bivona™ / Portex™ tracheostomy tubes). But, even the more rigid Shiley™ (pronounced as shy-lee) tracheostomy tubes also benefit from using an obturator --- it reduces the risk of injury to the patient. Unlike an endotracheal tube stylet, the obturator has a rounded tip that extends a little past the outer cannula’s opening, so it helps to prevent tissue trauma to the patient’s airway during insertion.

Keep in mind that an obturator should never be left in the patient’s tracheostomy any longer than needed to insert and position the An obturator already inserted in the Portex™ tracheostomy tube. Notice that outer cannula. The styles differ, but the obturator is usually solid the rounded distal end of the obturator and does not allow enough breath to pass through the extends past the end of the tracheostomy tracheostomy. Leaving it in place for longer than needed causes tube to prevent injury to the airway asphyxiation. structures during cannula insertion.

Tracheostomy ties. Whether the patient has a dual cannula tracheostomy tube (inner and outer cannula) or a single (just the outer cannula), most tracheostomy tubes are secured to the individual with cotton twill ties, padded fabric straps, beaded chain, or commercial Velcro straps that wrap around the back of the neck.

When replacing an outer cannula secured with cotton twill ties, one person should hold the cannula in place to prevent it from accidentally dislodging. Another person cuts the soiled, old ties since they’re normally secured with a knot. New ties are threaded from one end of the cannula flange, back around the posterior neck, and secured with a knot on the other end of the flange. The ties or Velcro straps should not be too loose where the outer cannula can dislodge with coughing or movement. But, they shouldn’t be tight enough to cause pain or skin breakdown either. The general consensus is that you should be able to slip one finger under the tie or strap comfortably;10 this is tight enough.

Not all tracheostomy tubes have ties or Velcro straps though. Individuals with a permanent tracheostomy or laryngectomy and with no perceived need for assisted ventilation may have a only a “button” that maintains the stoma opening (shown on next page). It appears discreet and nearly flush with the skin. These type of airway devices usually do not have a tube entering and curving down into the trachea. Instead, the device is

Page 12 of 29 secured to the anterior tracheal wall, which reduces the amount of airway restriction from the tube and potential irritation from the tube itself.

The tracheostomy button may be set up as a dual cannula tube with cannula cap sitting inside of the outer tube. This inner cannula (the cannula cap) can be easily removed for cleaning or replacement.

During or other need for assisted ventilation, you’ll find that the button will not fit your standard BVM port. In this case, attach a neonatal mask to A tracheostomy or a pediatric or adult BVM laryngectomy button. Keep in mind that this does not (depending on tidal volume have a 15mm connector, so if needs of patient) and place the you need to ventilate, use a mask over the stoma/button. neonatal mask on the BVM and apply directly over the Ventilate for chest rise only. stoma.

If the patient has a laryngectomy, the upper airway is surgically closed. If instead the patient has a patent upper airway, you’ll need someone to to occlude the nares (pinch them closed like a kid jumping into a pool) and keep the mouth closed to prevent ventilated air from escaping while giving a breath. Otherwise, your ventilations will take the path of least resistance: the upper airway.

TRACHEOSTOMY ENHANCEMENTS

Most tracheostomy devices are just a tube within a tube that’s secured to the patient with twill or Velcro tracheostomy ties.

In the past, tracheostomy tubes used to be manufactered entirely with stainless steel or even silver. Today, softer silicone and polyvinyl chloride (plastic) tubes are the most common ones worn for short and long term use. They are lighter in weight, less expensive to replace, usually more comfortable for the individual, and can be disposible, reducing the risk for bacterial or fungal colonization.

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When assessing your patient with a tracheostomy, you may find him receiving titrated oxygen by a ventilator, with a humidfied oxygen collar placed over the tracheostomy, or even spontaneously breathing without any supplemental oxygen. In some cases, you may find a cap-like device covering the tracheostomy hole but not occluding it completely. One example is shown to the right, and this is a Passy-Muir® speaking valve. There are different manufacturers and styles available, but most of the commonly-used ones are recognizable as a speech valve by the four, six, or eight spoked-wheel A Passy-Muir® speaking valve. This one appearance on the outside of the device. Some have a port to allow oxygen offers a snap-on supplemental oxygen tubing for low-flow needs, while others are very lightweight and low profile. port.

A few words about those speaking valves. Most speaking valves work by allowing a thin flap of flexible plastic (the valve itself) to bend open during . Air can enter the tracheostomy tube easily with only a little bit of resistance. However, when the individual exhales, the valve is closed --- air is forced towards the upper airway and through the vocal folds to produce speech. Before the advent of these valves, the individual with a tracheostomy would simply occlude the stoma with his thumb while exhaling and produce speech. A valve helps decrease the risk of infection from whatever pathogens are residing on his thumb and also makes speech a hands- free process. Understandably, this valve cannot be used for those with a laryngoectomy since their upper airway is completely closed.

This valve does add some resistance to the airway, so should be one of the first devices removed when trying to improve the patient’s ventilation during an emergent situation. But during normal day-to-day life, this resistance has benefits, even for those patients who cannot speak. It add positive pressure to the airway (PEEP) to help prevent atelectasis (alveolar collapse) and improve oxygenation. It may also improve swallowing and decrease the risk for aspiration. These are some of the reasons you could find a speaking valve A Passy-Muir® speaking valve (PMV 2001) shown in-line with the ventilator circuit. The attached in-line to a ventilator circuit. tracheostomy’s outer cannula cuff must be deflated to prevent barotrauma and suffocation.

If someone has a speaking valve in place, their tracheostomy cannula should either be an uncuffed style or the cuff must be completely deflated during use. Vocal cords

If you think back to the way the valve works, it prevents air from leaving the tracheostomy tube during exhalation. But, if the tracheostomy cuff is Speaking valve Deflated cuff inflated, this blocks the upper airway route as well. The patient will not be able to exhale and will quickly suffocate.

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Fenestrated cannulas. Speaking of speech, another alternative to a speaking valve is a fenetrated outer (or a fenestrated outer with a matching fenestrated inner) tracheostomy cannula. These devices look like ordinary cuffed tracheostomy cannulas except they have one or more additional holes along the shaft to allow exhaled breath to escape.

When using the fenetrated cannula for speech, the individual inhales and exhales normally, but the hole allows air to escape into the upper airway and pass through the vocal cords to produce speech. Like a speaking valve or the thumb technique, the stoma needs to be closed for speech to prevent air from leaving the tracheostomy tube instead. A cap or plug is usually used, but when it’s applied, the cuff also needs to be deflated to allow air to escape. Keep in mind that the cuff is located below the fenestrations, so applying a cap to the end of the tube and inflating the cuff greatly reduces the amount of air from leaving. It only has the small fenestration.

A matter of choice. A person may not want the effects of a fenestrated cannula all of the time. For example, if the individual is producing a lot of secretions (such as during sleep) or needs mechanical ventilation, a cuffed tube without the free-flow of air into the upper airway is preferred. In this case, the fenestrated inner cannula can be removed, a regular inner cannula (non- fenetrated) can be inserted in its place, and this effectively blocks the fenetration(s) in the outer cannula. Any plugs, caps, or speaking valves are removed. With the outer cannula’s cuff inflated, the tracheostomy now functions just like a non-fenestrated one.

A fenetrated cannula can also be used for those who are being weaned off of a tracheostomy. A cap/plug can be attached to the end of the uncuffed cannula to force air to enter and exit the upper airway, but easily removed if needed to improve ventilation.

Disadvantage: Since the extra holes offer more plastic edges to contact tracheal lining, it can cause irritation and trauma to this tissue. In response to this irritant, the body deposits additional tissue at the site and forms a granuloma.11,12 A granuloma is a reactive tissue formation (like a blister or callous) that developes into a ball-like shape and will continue to grow as irritation continues, sometimes right into the outer cannula’s fenestration (hole). This not only blocks the air hole, but can cause painful bleeding when the cannula is removed. Granulomas can be very vascular with small vessels throughout the mass.

A tracheal granuloma visualized with . Image: Watters KF, 2017

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Caps and plugs. A trachestomy may be capped off as a final phase towards decannulation (intentional and planned removal of the tracheostomy) if the individual can breathe through their upper airway. Remember that a cap fully-occludes the airway; it doesn’t take a rocket scientist to figure out what happens if a cap is applied to a patient with a laryngecomy or an inflated cuff.

Caps and plugs that completely occlude the airway are red in color. Like a stop sign, red = stop. In this case, air flow stops. On the other hand, a speaking valve can be transparent, purple, white, or even other colors, but never red.

Cuff inflation. Just like an endotracheal tube cuff, the tracheostomy cuff should not be overinflated or underinflated. Tracheal capillary perfusion pressure is normally 25 to 35 mmHg.11 To avoid exceeding that pressure against the tracheal tissues and causing necrosis of the area under the cuff, it’s generally accepted that 30 11 cmH2O is the maximum amount of pressure that should be applied to the cuff. However, most EMS services do not have a manometer on hand to measure this pressure at the pilot balloon.

If the pressure is too low, secretions can seep under the cuff and enter the lower airway. If the pressure is too high, tracheal wall tissue damage will occur. One technique that offers an appropriate pressure requires only a stethoscope. Keep in mind this will not work with laryngoectomy patients since their upper airway is closed off.

The Minimal Leak (or even no-leak) Technique: When you need to inflate a deflated tracheostomy cuff, attach an air or sterile water filled Luer-lock syringe to the pilot balloon. Remember that the type of cuff dictates whether you use air or water. Place the stethoscope head to one side of the patient’s trachea and above the stoma and listen for breath or ventilatory sounds (if on a vent or assisted with a BVM). This is your starting point where air is passing by the cuff freely.

Begin to slowly push air or fluid into the pilot balloon while listening at the same location. At some point, the respiratory sounds will decrease and then stop. This indicates that little to no air is leaking past the cuff, and:

• Spontanously-breathing patients: Withdrawl just a little so just a very slight amount of leak is present. Auscultating above the stoma and to one side • Ventilated or BVM, or patient has plenty of secretions: of the trachea. Don’t withdraw that bit of air or fluid like you would for spontaneous breathers. Instead, you’ll want that complete seal to prevent aspiration.

Confirm that the pressure does not feel too firm or very soft at the pilot balloon before disconnecting the syringe. What you feel in the firmness of the balloon is the same pressure across the cuff. Advise the receiving hospital that the cuff was inflated by this method and not verified with a manometer.

Important: The cuff does NOT secure the tracheostomy tube in place… the tracheostomy ties are what keeps the cannula in place. Don’t overinflate the cuff to try and “secure” the tube in the airway. Think of how easily an endotracheal tube dislodges even when inflated and with a pair of vocal cords trying to resist it’s movement. It’s not the cuff that secures the tube in the endotracheal or tracheostomy airway.

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QUICK REFERENCE CHART ON TRACHEOSTOMY DEVICES

Clear as mud yet? To add to the confusion, there’s several ways to combine or alter a tracheostomy’s function by using different cannulas or caps. The chart below offers a quick review of the different basic devices:

Device: What it looks like: Description: Cannula materials:

Metal is long lasting and may be less susceptible to hosting bacterial Metal colonies.11 It’s an earlier material for (stainless steel or silver) tracheostomy tubes, and has now been mostly replaced by plastic/silicone tubes.

The most common tracheostomy material. It’s lightweight, inexpensive compared to metal, and may be more Plastic comfortable since the plastic softens a bit (PVC, polyurethane, or silicone) with body heat. There are clean-and- reuse varieties as well as disposable ones. Silicone is the softest material.

Cannula types:

The outer cannula has an inflatable cuff that may be filled with air or sterile water, depending on the type. The Outer cannula - Cuffed cuffed outer cannulas are usually used for those individuals who need positive pressure ventilation (ventilator) or have an increased risk for aspiration.

An uncuffed outer cannula is usually reserved for pediatrics and those Outer cannula - Uncuffed individuals who can better control their airway. It’s usually not used for those who need positive pressure ventilation.

The inner cannula slips into and locks inside of the outer cannula. It’s an optional device. While it reduces the effective airway diameter a little bit, it Inner cannula makes it easier to keep the airway clean. You can quickly resolve breathing difficulties by removing it, such as those

caused by mucus plugs or excessive secretions.

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Cannula specializations:

A fenestrated cannula can have a single hole configuration or multiple holes. Fenestrated Multiple holes may help reduce the risk of large granuloma formations. (single)

A fenestrated cannula can be used to enable speech or as part of a weaning program to help acclimate the individual

to using his upper airway again.

To work as a fenestrated cannula, both Fenestrated the outer and inner cannulas must have (multiple) matching holes. The fenestrated inner cannula must be replaced with a smooth (no holes) one if ventilating the patient.

Obturators:

The obturator is used as a temporary insertion device for the outer cannula. Metal cannulas The rounded tip extends past the outer cannula to help guide it into the trachea smoothly without causing injury. Once the outer cannula has been inserted, the

obturator must be removed immediately Plastic/silicone cannulas since it blocks air movement in the tube.

Specialized adjuncts:

A speaking valve fits on the end of the exposed tracheostomy cannula and allows the individual to speak. When he inhales, the valve opens and lets air pass into the trachea. When he exhales, the Speaking valve valve shuts closed and forces air into the upper airway, past the vocal cords. The cannula must be uncuffed or the cuff deflated, otherwise, the individual cannot exhale.

A red cap or plug occludes the tracheostomy port completly. This is usually used for those who are in the final stages of tracheostomy weaning and are preparing to breathe through their upper Cap or plug airway entirely. It can be quickly detached in case of mucus buildup that can’t be coughed up or if the individual needs positive pressure ventilation during an emergency.

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TRACHEOSTOMY EMERGENCIES

Since many patients with a tracheostomy or laryngectomy may be unable to speak (not a candidate for a speaking valve, etc.), let their signs guide you in the respiratory assessment.

Difficulty breathing is usually characterized with one or more of the following:

• Altered mental status, restless, and/or increased combativeness;

• Pale or cyanotic skin color (a late sign);

• Tachycardia (may be masked by beta-blocker or calcium channel medications);

• Tachypnea (increased respiratory rate);

• Labored attempts at breathing or alarms sounding off on a ventilator;

• Low ; high readings;

• Grunting, snoring, gurgling, or stridor;

• Accessory muscle use;

• Decreased or abnormal breath sounds on auscultation of the lungs.

One of the most common causes of respiratory decline or failure is a mucus plug, where excess secretions have built up in the tracheostomy cannula and effectively reduced the airway diameter. It doesn’t take much built-up A mucus plug in the distal cannula. mucus to cause a major restriction in airflow. Life-threatening for a tracheostomy.

FIRST TREATMENT STEPS

The first treatment steps depend on the type of respiratory complaint you’re dealing with. Is it an emergent airway with a patient unable to breathe? Or is it a reactive airway such as a COPD patient in need of a beta-agonist medication (example: albuterol)? Or, are you caring for a febrile patient with suspected pneumonia or even sepsis from an airway infection?

Restricted airway --- Patient appears to be unable to breathe or be ventilated effectively?

As with any emergent airway, oxygenation and ventilation are the priority. The first question that should come to mind is: What kind of tracheostomy am I dealing with? The flowsheet that follows offers a rapid assessment of the device sitting in the stoma and immediate first steps.

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Managing an Emergent Tracheostomy Airway

Laryngectomy? All ventilation attempts Does the patient have a laryngectomy? will have to be made to the stoma. If so, remember that any upper Consider using a neonate mask on a airway ventilation will be ineffective. BVM or LMA/i-Gel over the stoma to form a good seal.

Apply supplemental oxygen to the stoma.

Sometimes someone gets their caps Is there a cap, plug, or speaking valve in place? and valves confused, or they will If yes, remove it. If this doesn’t take care inflate the cuff with a speaking valve in of the problem, proceed to the next step. place. All can prevent the patient from exhaling, so just remove the device.

Mucus plugs are the #1 cause of airway Is this a dual cannula tracheostomy? obstruction. Just removing the clogged If yes, remove the inner cannula. If this does not fix the inner cannula may fix the problem problem or there’s only one cannula, try the next step. completely. The outer cannula maintains the stoma opening.

Even single cannula patients get mucus Suction the airway using sterile technique. plugs. Use sterile suction to clear the airway. The procedure is described on the next page.

Still unable to ventilate the stoma or If the airway is still occluded, deflate upper airway (non-laryngectomy patients)? the cuff. The cannula may not be Consider deflating the tracheostomy cuff (if sitting in the stoma correctly and the a cuffed cannula) and re-attempt ventilation. cuff is causing an obstruction.

Still unable to ventilate? If the outer cannula is sitting in a false track or is damaged, it needs to be May need to consider removing the outer cannula and removed and replaced. Use an replacing it using an obturator or gently inserting a obturator to help guide it in. Or, insert cuffed endotracheal (ET) tube into the stoma --- only a sterile, lubricated endotracheal tube insert a few inches into the trachea if using an ET tube. in its place and inflate the cuff.

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HELPFUL TIPS

Cuffed dual-cannula tracheostomy and need to ventilate? Removing the inner cannula fixes most of the respiratory problems faced by a patient with a tracheostomy. The cannula may be crusted with secretions and needs to be cleaned or replaced with a new one, and this might take a few minutes. Don’t let your patient decline… he or she should be oxygenated and/or ventilated while awaiting the inner cannula’s replacement.

If the patient has a dual-cannula tracheostomy tube, you’ll find that the outer cannula will probably not fit the 15mm connection on your BVM directly. You will either need to reinsert a clean inner cannula, use a neonatal mask or an LMA/i-Gel over the stoma, or see if the facility has a flexible silicone adapter designed to connect the BVM to the outer cannula. Inner cannulas should have the 15mm connection and are designed for use with standard ventilator tubing or a BVM.

Also, check that the cuff’s pilot balloon feels inflated upon palpation. Ventilating with a deflated cuff reduces the amount of air that reaches the lungs.

Uncuffed outer cannulas and the need to ventilate? If the patient needs positive pressure ventilation at the stoma and does NOT have a laryngectomy, be sure to occlude the nares and mouth to prevent ventilations from escaping through the oro/nasopharynx.

Does the patient have a fenestrated cannula? If ventilating the stoma, you’ll need to replace the inner fenestrated cannula with a non-fenestrated (smooth) one so it functions like a standard tracheostomy tube. The standard inner cannula will block the holes in the outer cannula.

Replacing the outer cannula? If you need to help replace the outer cannula, keep the tube portion of the cannula sterile if at all possible. Remember that both the inner and outer cannula tubes can introduce harmful pathogens directly into the respiratory tract.

Align the patient’s head and neck in an exaggerated sniffing position to ease insertion. Oxygenate. Insert an appropriate obturator into the outer cannula and lubricate the cannula’s exterior with a sterile, water- soluble gel. Introduce the cannula into the stoma and direct it into the airway following the natural curvature. The patient may cough or “buck” during insertion… it’s not an entirely comfortable process. Inserting the outer cannula into the stoma.

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When inserted correctly, the cannula flange should rest against the neck. Remove the obturator and check for breath sounds, using capnography during ventilation to confirm placement. Make sure the cannula did not form a false track or was only partially- inserted, as illustrated to the right.

The outer cannula needs to be secured with tracheostomy ties or straps before anyone releases the tube. One strong cough can dislodge it if the ties are not secured in place. One finger should be able to slide between the tie and the neck. Partial insertion (left) where the cuff is not aligned properly, and for the right-side image, the cannula forms a “false track” between the skin and trachea, missing the airway completely.

VIDEO OF OUTER CANNULA INSERTION

Reinsertion of a dislodged outer cannula while on scene may be the only way to maintain effective ventilation/respiration. Waveform capnography and pulse oximetry should be obtained and recorded after the procedure to confirm correct placement of the tube into the trachea.

A four-minute video of an outer cannula removal/replacement (produced by the Medical College of Georgia/Georgia Regents University) is available online at: https://youtu.be/LrAMAwBfbcI. The individual was very anxious/nervous about the procedure, and the cuffless tracheostomy tube was well-overdue for a replacement. However, the remained calm and explained the process to the patient and his family to help ease his fears. If the outer cannula was cuffed instead, remember to completely deflate the cuff with a syringe first before removing the cannula.

Their procedure left some room for improvement, so there’s two additional learning points to gain from this video:

• Remember to avoid contacting the cannula’s tube --- the part that’s inserted into the trachea. Just pick it up using the outer flange and external port to avoid airway contamination.

• It took a while before the obturator was removed from the outer cannula. This should be done sooner to allow the patient to breathe. No air can enter the tracheostomy tube when the obturator is in place.

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PROCEDURE: STERILE SUCTIONING

Although we were taught sterile tracheal suctioning during EMT-Intermediate/Advanced or class, a review of the procedure helps to ensure the best outcome for our tracheostomy patient and reduce the risk of healthcare-associated infections.

Equipment:

• You’ll need an appropriately-sized sterile suction catheter. These catheters are made of a soft plastic and usually have a thumb hole to control suction. A chart of approximate suction catheter sizes is provided below, which in this case is based on the patient’s age. While there’s a calculation that more accurately predicts the size based on the tracheostomy tube diameter, this is the most convenient method for EMS and applies to endotracheal tubes as well:

Approximate size of Patient’s age: the suction catheter:

Newborn 6 Fr

Up to 3 years old 8 Fr

5 to 16 years old 10 Fr

Adult female 12 Fr

Adult male 14 Fr

• Sterile gloves; • Sterile water or sterile saline; • Suction source with tubing and canister; • 4x4 gauze, because this gets messy.

Steps for the procedure:

1. Explain what you will do for the patient. This can be uncomfortable and they appreciate being forewarned.

2. If the patient is using supplemental oxygen, maintain this source whenever possible to keep him oxygenated.

3. Find an area to work (small table, countertop) next to the patient that is cleared off --- prevents accidental contamination.

A pristine uncluttered ambulance countertop? Unheard of. But at least shove most of the stuff away.

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4. Personal protective equipment (PPE) --- it’s recommended that you wear a disposable gown, eye protection, and gloves as misdirected secretions will happen.

5. There are different sterile suction kits on the ambulance and also in the nursing facilities. Some kits contain everything from the sterile water to sterile table drapes, A barebones sterile suction kit: Sterile while others only offer the sterile suction catheter. catheter, gloves, and disposable container. Remember back to your education: Keep what needs to remain sterile: Sterile. If water is not included in the kit, ask your partner to pour sterile water or saline into a container and attach the suction tubing to the unit. Let him work the “dirty side” while you don on sterile gloves and are the only one handling the sterile items that enter the trachea.

Open sterile packages by pulling the lid or cover away from you, not towards you and your “dirty” uniform. Place sterile items on a sterile drape only, and drop them at least an inch away from the drape’s edge. Closer to the center, the better. Always know where your hands are; if you have to do this procedure by yourself, designate one hand as sterile and the other as dirty. Keep it that way.

6. With the suction hooked up and running at a lower suction setting (50 to 100 mmHg) and sterile water/saline poured (thank you, partner), ask your partner or other healthcare provider to unhook the patient’s ventilator tubing (if present) or remove any caps or speaking valves from the external port. If you are alone, use your designated “dirty hand” only to remove these devices.

7. Use your designated dirty hand to manipulate the thumb suction hole to activate and deactivate the suction, while the other sterile hand is the only one that maneuvers the suction catheter into the patient’s tracheostomy.

8. Insert the suction catheter into the water to confirm it’ll draw fluid, then release the suction using the thumb hole. Insert the end of the empty suction catheter into the tracheostomy tube. Do not activate the suction just yet.

9. After inserting the catheter about four to five inches (adult, less for children), you’ll either feel some resistance or the patient will begin to cough. Immediately back the catheter up a bit to prevent further irritation.

10. Now begin suctioning by occluding the thumb hole with your designed dirty hand. With your sterile hand still on the suction catheter, twirl and begin drawing the catheter back out, suctioning during the entire time. As you reach the end of the catheter, control it so it does not pop out and fling secretions.

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11. The suctioning attempt should not exceed 10 seconds per round. It should only take two or three rounds of sterile suctions to clear most tracheostomy patient’s airways.

12. If you’re having difficulty suctioning out thick secretions, a small squirt of sterile saline can help moisten and loosen them. Keep the patient oxygenated between suction attempts to prevent desaturation.

13. Use gauze to wipe the patient’s skin and external port of any secretions. Dispose of PPE properly.

ABOUT THE PERSON WITH A TRACHEOSTOMY

Sometimes it’s easy to focus on the tracheostomy and neglect the fact that there’s a person tied to it. Or, there’s the stigma that this change in lifestyle was entirely their fault. While many tracheostomies are necessary as a result of secondary to tobacco use, there are other indications such as laryngeal cancer from other causes, non-cancerous tumor growths, neuromuscular disorders such as amyotrophic lateral sclerosis (ALS) or myasthenia gravis (MS), high level spinal cord injury, or severe, acute infections/toxin exposures. A lot of that can’t be prevented.

A tracheostomy can become a permanent part of an individual’s life or just a temporary fix. A person can live independently with only a small affect on their quality of life, or could be bedbound and living in a skilled nursing facility. Tracheostomies are placed in the newly born and also those nearing the end of life.

When assessing your patient, be open to their recommendations for care and treatment. Like a mother who cares for a chronically-ill child, your patient will know what works best for them based on their past experience.

Most independently-living people with a tracheostomy will clean and suction their tracheostomy devices and airway at least twice a day. Humidified and heated oxygen or air directed towards the tracheostomy helps decrease the risk of mucus plugs and respiratory problems from dried secretions. Those who need more frequent tracheostomy care are usually on a every four to eight hour schedule of cleaning and suctioning.

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If your patient’s tracheostomy cuff needs to remain inflated, this is a sign that secretions cannot be controlled well by the individual and/or they need positive pressure ventilatory support.

Many who live independently or with minimal assistance and have a tracheostomy use an uncuffed outer cannula or keep their cuffed one deflated most of the time. This allows them to eat by mouth and produce an less- impeded swallow, cough, and speech. They can clean or change out their inner cannula daily or more often as directed by their physician. Many are able to self-suction, and may prefer to do that versus allowing a paramedic to take over. Don’t take offense --- it’s an uncomfortable process and they may prefer to control their degree of discomfort.

Tracheostomy bibs may be used to help hide the cannula while out shopping or to prevent dirt and other contaminants from entering the airway. There’s even devices available that allow a person with a tracheostomy to enjoy activities we take for granted, like swimming.

CARDIAC ARREST CONSIDERATIONS

If the patient is in cardiac arrest, have a high degree of suspicion that it may be respiratory-related unless you find evidence otherwise. While the American Heart Association’s C-A-B approach (circulation-airway-breathing) to CPR still applies, this is not the patient you want to passively oxygenate for six minutes before securing the airway. Start chest compressions and defibrillate as needed, but make the airway and breathing a high priority as well. Unless the patient has a laryngectomy, oral intubation is possible if you are unable to ventilate the stoma. When performing oral intubation, be sure to remove the outer cannula first.

If the best option for the patient is to intubate the stoma instead, use a smaller cuffed endotracheal tube than you would expect for oral intubation. For example, use a 5.5 or 6.0 endotracheal tube for adults or a size that fits into the stoma easily without additional trauma. Advance the tube to where the cuff is only 2 cm past the stoma.13

Obviously, don’t use a tube tamer or other commercial securing device Using an LMA (above) to form a seal for BVM ventilation over the as this will occlude blood flow from stoma. An endotracheal tube the major neck vessels. Instead, a (right) inserted in the stoma and transparent occlusive dressing secured with a transparent occlusive dressing.

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(Tegaderm™, for example) would be ideal.

Keep in mind that when you’re providing BLS ventilations at the upper airway, you’ll need to occlude the stoma to prevent air from escaping by that route.

It may be difficult to detect carotid artery pulse in the neck of some laryngectomees because of post-radiation fibrosis that developed after their cancer treatment.14 Some patients may not have a radial artery pulse in one of their arms if tissues from that arm were used for a free flap to reconstruct the upper esophagus.14

Look for surgical scars on the extremities and if they exist, consider avoiding those limbs for a pulse check. Use a femoral pulse or use the Doppler to help with pulse detection, if needed. Preparing to remove skin and vessels for a lateral arm flap in a patient who needed reconstruction of the lateral . Legend: BOT, base of tongue; GOT, glossotonsillar sulcus; PH, pharynx including tonsillar fossa and pillars; R, radial artery. Radial pulses may no longer be palpable on this extremity, so look for surgical scars before declaring pulselessness.

Questions? Please contact a member of the training staff.

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REFERENCES

1 Pierson DJ. Tracheostomy from A to Z: historical context and current challenges. Respir Care 2005;50(4):473–475.

2 Trubuhovich RV. Primary Sources and the Tracheostomy Legend about Alexander the Great. J Anest History 2018; 4(1):38.

3 McClelland RM. Tracheostomy: its management and alternatives. Proc R Soc Med 1972;65(4):401–404

4 Mehta AB, Syeda SN, Bajpayee L, et al. Trends in Tracheostomy for Mechanically Ventilated Patients in the , 1993-2012. Am J Respir Crit Care Med. 2015 Aug 15;192(4):446-54. doi: 10.1164/rccm.201502-0239OC.

5 Terragni PP, Antonelli M, Fumagalli R, et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA 2010;303:1483–1489.

6 Young D, Harrison DA, Cuthbertson BH, et al. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA 2013;309:2121–2129.

7 Karatayl SK, Özgürsoy O, Yüksel C, et al. Life-Threatening Respiratory Distress in a Total Laryngectomy Patient: Aspirated Voice Prosthesis or Lung Tumor? Turk Arch Otorhinolaryngol 2016; 54: 131-133.

8 Emergency Procedures for Tracheoesophageal Puncture After Total Laryngectomy. Nova Scotia Hearing and Speech Centres. Available at http://www.nshsc.nshealth.ca/sites/default/files/For%20website%20EMERGENCY%20PROCEDURES%20F OR%20TRACHEOESOPHAGEAL%20PUNCTURE.pdf. Accessed December 24, 2018.

9 Levitan J. A Primer on the Surgical Airway. Emergency Physicians Monthly. Available at http://epmonthly.com/article/a-primer-on-the-surgical-airway/. Accessed December 26, 2018.

10 Watters KF. Tracheostomy in Infants and Children. Resp Care 2017;62(6)799-825.

11 Hess DR, Altobelli NP. Tracheostomy Tubes. Resp Care 2014;59(6):956-973.

12 Siddharth P, Mazzarella L. Granuloma associated with fenestrated tracheostomy tubes. Am J Surg 1985;150(2):279-280.

13 Long B Koyfman A. Managing the Tracheostomy Patient. Emergency Physicians Monthly (November 2016). Web site: http://epmonthly.com/article/managing-tracheostomy-patient/. Accessed December 30, 2018.

14 Brook I. Rescue Breathing for Laryngectomees and other Neck Breathers (2015). Atos Medical AB. Available at https://www.atosmedical.com/wp-content/uploads/2015/10/rescue-breathing.pdf. Accessed December 31, 2018.

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IMAGE CREDITS

Erman AB, Deschler DG. Voice Rehabilitation after Laryngectomy. Clin 2010;2(3):231-236.

Discharge Instructions: Tracheostomy or Stoma Care. Mount Nittany Health. Available at https://www.mountnittany.org/articles/healthsheets/2910. Accessed December 28, 2018.

Watters KF. Tracheostomy in Infants and Children. Resp Care 2017;62(6)799-825.

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