What are the troubleshooting steps for tracheostomy patients with Belivista-related issues?

Troubleshooting Steps for Tracheostomy Patients with Airway Emergencies

The most effective approach to managing tracheostomy emergencies is to follow a systematic algorithm that prioritizes airway patency assessment, oxygen delivery, and prompt intervention with appropriate equipment readily available at the bedside. 1

Initial Assessment and Immediate Actions

1. Call for help immediately - Activate emergency response system

   • Hospital: Call the designated emergency number (displayed on bed-head sign)
   • Community: Call emergency services (999/911) 1

2. Apply high-flow oxygen

   • To both the face/upper airway AND tracheostomy tube/stoma
   • This requires two oxygen sources 1

3. Remove any attachments from the tracheostomy tube

   • Speaking valves, caps, humidification devices, or Swedish noses
   • These can become blocked with secretions 1

4. Position the patient appropriately

   • Adults: Head in "sniffing" position
   • Children under 2: More neutral position with possible rolled towel under shoulders 1

Assess Tracheostomy Patency

1. Remove inner cannula (if present)

   • Clean or replace with a new one
   • Some tubes require specific inner cannulas to connect to breathing circuits 1

2. Perform suction

   • Pass suction catheter through tracheostomy tube
   • Catheter should pass easily beyond tube tip into trachea
   • Use closed suction system whenever possible (especially for COVID-19 patients) 1
   • If resistance is met, this indicates potential blockage 1

3. Apply waveform capnography (if available)

   • Invaluable for confirming tube position and patency
   • Should be immediately available in critical care areas 1

If Tracheostomy Patent But Patient Deteriorating

1. Look, listen and feel for airflow at both the mouth/nose and tracheostomy 1
2. Consider other causes of respiratory distress:
   • Tube displacement (partial or complete)
   • Pneumothorax
   • Pulmonary edema
   • Infection 1, 2

If Tracheostomy Not Patent or Displaced

1. Attempt to pass a soft suction catheter as a guide for tube repositioning 2

2. If tube completely displaced:

   • Attempt reinsertion of the same size tube first
   • If unsuccessful, use a tube one size smaller 2
   • Use water-soluble lubricating jelly 1

3. If reinsertion fails:

   • Cover stoma with an oxygen mask
   • Maintain upper airway with chin lift/jaw thrust
   • Consider oral/nasal intubation if skilled provider available 1

4. If complete obstruction with no airflow:

   • Remove tracheostomy tube completely
   • Insert tracheal dilators or bougie if available
   • Consider emergency surgical airway if trained 1

Essential Bedside Equipment

Every tracheostomy patient should have immediate access to:

• Spare tracheostomy tubes (same size and one size smaller)
• Suction equipment with appropriate catheters
• Tracheal dilators (if locally agreed)
• Lubricating jelly
• Scissors and stitch cutter (if tube is sutured)
• Personal protective equipment
• Tracheostomy dressings and tapes 1

Emergency Equipment That Should Be Readily Available

• Basic airway equipment - oxygen masks, self-inflating bags, oral/nasal airways
• Advanced airway equipment - laryngeal mask airways, laryngoscopes with appropriate tubes
• Waveform capnography
• Fibreoptic scope
• Bougies 1

Special Considerations for COVID-19 Patients

• Minimize disconnections of the ventilator circuit

• If disconnection is necessary:

  1. Ensure adequate sedation
  2. Consider neuromuscular blockade
  3. Pause ventilator
  4. Clamp tracheostomy tube before disconnection
  5. Keep heat and moisture exchanger attached to patient 1

• Monitor cuff pressure carefully to avoid leaks

• Ensure cuff pressure is at least 5 cmH2O above peak inspiratory pressure 1

Warning Signs (Tracheostomy Red Flags)

• Airway red flags:

  • Sudden ability to talk when previously unable
  • Suction catheter not passing through tracheostomy
  • Stridor or grunting 1

• Breathing red flags:

  • Respiratory distress (accessory muscle use, increased respiratory rate)
  • Increasing oxygen requirements
  • Increasing ventilator support 1

• Tracheostomy-specific red flags:

  • Visibly displaced tube
  • Blood or blood-stained secretions
  • Increased discomfort or pain 1

Common Pitfalls to Avoid

1. Never ignore a patient complaining of breathing difficulty, even if objective signs are absent 2

2. Don't rely solely on pulse oximetry as it may not reflect ventilation problems and can give delayed indications of hypoxemia 2

3. Don't delay definitive airway management if the patient shows signs of deterioration 2

4. Avoid excessive oxygen administration without ventilatory support in patients with CO2 retention 2

5. Never attempt to force a tracheostomy tube during reinsertion as this may create a false passage 1

By following this systematic approach to tracheostomy emergencies, healthcare providers can effectively troubleshoot airway issues and improve patient outcomes.