Emergency Tracheostomy Management – the ‘Green’ Algorithm

The steps involved in the emergency assessment and management of the tracheostomy patient (who may have a patent upper airway), follow the Green algorithm, as set out by the NTSP.³

The algorithm is freely available from the NTSP online resources, produced for use in clinical areas likely to encounter tracheostomy emergencies, and can be found here.

The NTSP in collaboration with The Health Foundation has also created videos outlining the emergency assessment of patients with tracheostomies, following the Green pathway, which can be found here.

Initial management

1. Call for expert airway help

2. Assess airway patency and signs of life

• Use a look, listen and feel approach, while performing basic airway opening manoeuvres. Feel for airflow from the mouth and tracheostomy.
• If the patient is breathing spontaneously provide high flow oxygen to the mouth and tracheostomy
• If the patient is not breathing spontaneously or is only making occasional gasps, with no pulse, start CPR.

Oxygen can be provided via the mouth (by face-mask) and via the tracheostomy (by either a Waters circuit or bag-valve-mask applied directly to the tube, or by using a paediatric face-mask).

There is potential for harm if attempts are made to ventilate through a blocked or displaced tracheostomy. If a false passage is present, air will be forced into the soft tissues causing severe surgical emphysema. This may make further airway interventions and ventilation more difficult.

Waveform capnography aids airway assessment and allows monitoring of ventilation and cardiac output. The 4^th National Audit Project report from the Royal College of Anaesthetists and the Difficult Airway Society (NAP4) identified a potential for delayed diagnosis of displaced tracheostomy tubes through omission of capnography.⁸ They recommend that this be used at the earliest opportunity in tracheostomy emergencies and ventilated patients.

Assessing the tracheostomy

At each stage, if an intervention is successful, maintain oxygenation and move on to perform an ABCDE assessment. If unsuccessful, proceed to the next step of the algorithm.

Pass a suction catheter

• Remove all external adjuncts including speaking valves, humidifiers and inner tubes.
• Attempt to pass a suction catheter beyond the end of the tracheostomy tube. If the catheter passes beyond the tip of the tube, the tube can be considered patent.
• Suction below and through the tube to remove any secretions causing partial obstruction

Deflate the cuff

• If it is not possible to pass a suction catheter, deflate the tube cuff (if one is present)
• Reassess airway patency using a look, listen and feel approach at the mouth and tracheostomy and look at waveform capnography.
• If deflating the cuff stabilises or improves the patients condition, it indicates that there is some airflow around the tube within the airway, and that the tracheostomy tube is obstructed or displaced.

Remove the tracheostomy tube

• Reassess using a look, listen and feel approach at the mouth and tracheostomy stoma, and using waveform capnography
• The NTSP advises against blind attempts at reinsertion of a tracheostomy tube before day seven, especially if the tracheostomy was performed percutaneously. There is an increased risk of creating a false passage, due to elastic recoil of the tissues covering the original opening.^1,3

Primary emergency oxygenation

If the patient is deteriorating or not breathing, there are now two options:

• Oxygenate and ventilate using standard oral airway techniques i.e. oral airway adjuncts, bag-valve-mask, supraglottic airway devices. Be sure to gently occlude the tracheostomy stoma simultaneously to prevent gross air leak. This can be done with gauze.
• Oxygenate and ventilate via the tracheostomy stoma. This can be achieved using a bag-valve-mask with a paediatric face-mask or by placing a laryngeal mask over the stoma.

Secondary emergency oxygenation

If the above techniques are not effective at oxygenating the patient, secondary airway techniques should be used. There are several important factors that may determine the chosen method, including the age of the stoma, the skillset of the team and the equipment and adjuncts available.

• Attempt oral intubation
  • Plan for a difficult airway, as this may have the original reason for tracheostomy.
  • Use an uncut tube as the extra length may allow the tube to pass below the stoma.
• Attempt intubation of the stoma        
  • Size 6.0 cuffed endotracheal tube
  • Smaller sized tracheostomy tube
  • Fibreoptic intubation. This could include using an Aintree catheter mounted upon a fibreoptic bronchoscope

Learning bite

• Use waveform capnography as an adjunct to assess airway patency and ventilation.
• Be cautious using positive pressure ventilation through a tracheostomy until the patency of the tube has been established.