What is the management of acute dyspnea in a patient with a tracheostomy?

Management of Acute Dyspnea in a Patient with Tracheostomy

In acute dyspnea with a tracheostomy, immediately assess tube patency with a suction catheter, remove the tube if it's blocked or displaced, and provide oxygen to both the face and stoma while preparing for emergency oxygenation through the most appropriate route. 1

Initial Assessment

1. Safety, Stimulate, Shout for help

   • Approach safely, gently stimulate the patient, and call for help 1
   • Summon specialized airway expertise (anesthesia, ENT) immediately 2

2. Assess airway patency:

   • Position the patient appropriately (consider extending neck with pillow under shoulders) 1
   • Apply high-flow oxygen to both face and stoma if available 1
   • Assess for airflow at both the mouth/nose and tracheostomy 1
   • Look for signs of respiratory distress: stridor, accessory muscle use, tracheal tug, sternal/subcostal recession 1
   • Use waveform capnography if available (can prevent >80% of airway-related deaths) 1

3. Check tracheostomy tube patency:

   • Pass a suction catheter through the tube 2
   • If catheter passes easily → continue ABCDE assessment 2
   • If catheter won't pass → deflate cuff (if present) to allow airflow around tube 2
   • If deflating cuff improves condition → continue assessment and await expert help 2
   • If deflating cuff fails to improve condition → remove tracheostomy tube 1, 2

Emergency Management Algorithm

If tube is blocked or displaced:

1. Remove the tracheostomy tube 1

   • Even if there are concerns about difficult upper airway or difficult tracheostomy, a non-functioning tube offers no benefit and has potential for harm 1
   • Exception: Only consider fibreoptic inspection of the tube while in situ if appropriate equipment and expertise are immediately available AND patient is clinically stable 1

2. Reassess both airways (mouth and stoma) 1

   • Apply oxygen to face and stoma 1
   • If patient is breathing and improving, continue ABCDE assessment

3. If patient fails to improve after tube removal:

   Primary emergency oxygenation:

   • Oxygenation can be achieved via oro-nasal route, tracheostomy stoma, or both 1
   • If using oro-nasal route, remember to occlude the tracheal stoma to maximize ventilation 1
   • If ventilating via stoma, use a small pediatric facemask or laryngeal mask airway applied to the skin 1
   • May need to occlude upper airway (close nose and mouth) if there is a large leak 1

   Secondary emergency oxygenation (if primary methods fail):

   • Consider oral intubation with a long (uncut) tube advanced beyond the stoma 1
   • Consider stoma intubation with a smaller tracheostomy tube or tracheal tube 1
   • Use fibreoptic guidance where possible to facilitate placement 1
   • In emergency situations without fibreoptic scope, blind or digitally assisted placement of a bougie may help but risks malposition 1

Special Considerations

For patients with laryngectomy:

• These patients have no upper airway in continuity with the lungs 1
• Focus on stoma management only (conventional upper airway management steps are not applicable) 1

For tracheostomy tube reinsertion:

• If reinsertion is needed, consider using a tube that is one half-size smaller than the original 1
• Use stay sutures (if present in new tracheostomy) to aid reinsertion by widening the stoma 1
• Consider using a soft suction catheter to guide placement (Seldinger technique) 1
• Limit attempts at reinsertion to three tries 1

Critical Pitfalls to Avoid

1. Avoid vigorous attempts at ventilation with a displaced tracheostomy tube - this can cause significant surgical emphysema 2

2. Do not delay removing a blocked or displaced tube when faced with a deteriorating patient 1

3. Do not make multiple blind attempts at stoma intubation - this can create false passages and worsen the situation 1

4. Do not forget to use waveform capnography when available - it's crucial for confirming correct tube placement and ventilation 1, 2

5. Do not attempt to manage alone - always call for specialized help early 1, 2

By following this structured approach to acute dyspnea in tracheostomy patients, you can effectively manage this potentially life-threatening emergency while minimizing complications.