Guidelines for Tracheostomy and Laryngectomy Emergencies
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Anaesthesia 2012, 67, 1025–1041 doi:10.1111/j.1365-2044.2012.07217.x Guidelines Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies B. A. McGrath,1 L. Bates,2* D. Atkinson3 and J. A. Moore3 1 Consultant in Anaesthesia and Intensive Care Medicine, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK 2 Specialist Registrar in Anaesthesia and Intensive Care Medicine, North Western Deanery, Manchester, UK 3 Consultant in Anaesthesia and Intensive Care Medicine, Central Manchester NHS Foundation Trust, Manchester, UK Summary Adult tracheostomy and laryngectomy airway emergencies are uncommon, but do lead to significant morbidity and mortality. The National Tracheostomy Safety Project incorporates key stakeholder groups with multi-disciplinary expertise in airway management. , the Intensive Care Society, the Royal College of Anaesthetists, ENT UK, the British Association of Oral and Maxillofacial Surgeons, the College of Emergency Medicine, the Resuscitation Council (UK) the Royal College of Nursing, the Royal College of Speech and Language Therapists, the Association of Chartered Physiotherapists in Respiratory Care and the National Patient Safety Agency. Resources and emergency algorithms were developed by consensus, taking into account existing guidelines, evidence and experiences. The stakeholder groups reviewed draft emergency algorithms and feedback was also received from open peer review. The final algorithms describe a universal approach to managing such emergencies and are designed to be followed by first responders. The project aims to improve the management of tracheostomy and laryngectomy critical incidents. ................................................................................................................................................................ Correspondence to: B. A. McGrath Email: brendan.mcgrath@nhs.net On behalf of the Difficult Airway Society, the Intensive Care Society, the Royal College of Anaesthetists, ENT UK, the British Association of Oral and Maxillofacial Surgeons, the College of Emergency Medicine, Resuscitation Council (UK) the Royal College of Nursing, the Royal College of Speech and Language Therapists, the Association of Chartered Physiotherapists in Respiratory Care and with input from the National Patient Safety Agency. *Present position: Consultant in Anaesthesia and Intensive Care Medicine, Royal Bolton Hospital NHS Foundation Trust, Bolton, UK. Accepted: 1 May 2012 Tracheostomies can be temporary or permanent and ment of upper airway obstruction, airway protection, to performed using an open surgical technique, or percu- facilitate weaning from mechanical ventilation, to allow taneously. Over 5700 surgical tracheostomies were long-term ventilation and to provide assistance in performed in adults in England during 2009 ⁄ 10, along removing respiratory tract secretions [2]. Around 570 with an estimated 5000–8000 percutaneous tracheosto- laryngectomies were performed in England during mies in critical care [1]. Tracheostomies are performed 2009 ⁄ 10 [1], the majority for carcinoma of the larynx, for a variety of clinical indications including manage- resulting in permanent alteration of the airway; the Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland 1025 Anaesthesia 2012, 67, 1025–1041 McGrath et al. | Tracheostomy management guidelines upper airway is not, and cannot be, connected to the were urgently required, similar in structure to previous trachea. Collectively, these patient groups can be DAS algorithms and Resuscitation Council (UK) guide- referred to as ‘neck breathers’, but confusion can arise lines [28]. These tracheostomy and laryngectomy emer- if carers do not understand the differences between the gency guidelines were developed following wide procedures and the resultant anatomy. Complications consultation with key national bodies involved in following tracheostomy can be immediate, short-term or tracheostomy care, incorporating feedback from their long-term. Immediate complications include haemor- members and utilising case reports in the literature. The rhage and loss of the airway, with short-term compli- purpose of this article is to present the guidelines and cations including blockage or complete or partial their rationale. tracheostomy tube displacement. Long-term complica- tions include tracheomalacia, tracheal stenosis or prob- Methods: guideline development lems relating to the stoma itself [3–6]. A variety of The authors were tasked at their local hospitals to take artificial airway devices can be inserted into tracheos- the lead in developing guidelines for the management of tomy or laryngectomy stomas and these may become tracheostomy ⁄ laryngectomy emergencies. Initial algo- blocked or displaced, leading to significant patient harm. rithms were tested in simulated scenarios and clinical The likelihood and nature of such harm depends on the environments, and then further refined using multi- incident location (e.g. critical care unit, operating disciplinary feedback over a period of three years. theatre, ward, community) [4, 7–13], which reflects the Following trials of the resources in this local setting, it underlying condition of the patient and the nursing and was recognised that, if suitably adapted, this approach medical infrastructure available for both routine and might fulfil the needs identified by several organisations emergency care [14]. referred to above. Hence, a proposal was submitted to In the UK, the Difficult Airway Society (DAS) the DAS Committee and this work was formally guidelines for the management of difficult intubation launched as a DAS-sponsored guideline development [15] have become widely established in UK anaesthetic project at the DAS Annual Scientific Meeting in practice and are applicable to related fields, such as Cheltenham in November 2010. critical care. Similar systematically developed recom- As the project initiators and DAS recognised the mendations have been produced in other countries [16– wider implications of this work, a multi-disciplinary, 20]. National guidelines have not been available for the multi-site Working Party was established consisting of management of tracheostomy-related emergencies; how- representatives of key organisations with a stated ever, some local solutions have been developed piece- interest in airway management, namely: DAS, the meal, a situation that is similar to that of general airway Intensive Care Society (ICS), ENT UK and the British emergencies before publication of the DAS algorithms. Association of Oral and Maxillofacial Surgeons (BA- Before such guidance, emergencies were commonly OMS). managed by relying on individually acquired skills and A literature review was conducted of available experience or lessons learned from previous errors [21, scientific publications up to 2011 using databases 22]. The spotlight has recently fallen again on airway (Medline, Embase, PubMed) and search engines (Google management in the UK following the widely publicised Scholar) and officially recognised websites (DAS, Society National Audit Project (NAP4) report examining major of Airway Management, American Society of Anesthe- complications of airway management [7, 8]. siologists, European Society of Anaesthesiology). English Following a cluster of serious untoward incidents language and English abstract publications were involving hospitalised ‘neck breathers’ in the North searched using keywords and filters, using relevant West of England, similar critical incidents reported to words and phrases, such as ‘tracheostomy’, ‘surgical the UK National Patient Safety Agency (NPSA) were airway’, ‘surgical access’, ‘laryngectomy’, etc. A large examined and recurrent themes were identified [9, 10], number of papers, abstracts, case reports, opinion-based evident in similar publications [4, 5, 11, 12, 23–27]. It articles and websites were retrieved, but no large was clear that simple, clear and authoritative guidelines randomised controlled trials were found. Furthermore, 1026 Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland McGrath et al. | Tracheostomy management guidelines Anaesthesia 2012, 67, 1025–1041 the publications themselves lacked a clear coherent candidates. The RCoA allowed use of its in-house structure and instead examined the topic from very programmers to develop and update our teaching specific viewpoints. Thus, expert opinion in the form of resources and those for the related e-Learning for editorials, book chapters and comments were also taken Healthcare modules. The website is designed, main- into consideration to generate these guidelines, using the tained and privately hosted by one of the authors (BAM) available publications only as reference points. with the majority of resources developed collaboratively Draft guidelines were tested and refined locally between all authors and members of the e-Learning for before being re-submitted to the stakeholder organisa- Healthcare team, with input from members of the tions. Guidelines were published on the project’s website Working Party. The smartphone applications have been (http://www.tracheostomy.org.uk), with links from the developed by the authors, with associated costs met from other organisations along with an invitation for member course fees. peer review, for a period of six months. During this period, the resources were accessed > 28 000 times and Results: the guidelines the emergency algorithms downloaded