What is the management for post tracheostomy subcutaneous emphysema?

Management of Post-Tracheostomy Subcutaneous Emphysema

Immediate removal of the tracheostomy tube is essential when subcutaneous emphysema develops following tracheostomy, as continued attempts at ventilation through a displaced tube can worsen the condition and lead to significant complications. 1

Initial Assessment

• Assess both the upper airway and tracheostomy stoma for patency by looking, listening, and feeling for airflow 1
• Apply high-flow oxygen to both the face and tracheostomy stoma if available 1
• Use waveform capnography when available to confirm airway patency 1
• Pass a suction catheter through the tracheostomy tube to:
  • Establish if the airway is patent along its length
  • Perform therapeutic suction if needed 1
• Avoid using stiff introducers or bougies as these can create false passages if the tube is partially displaced 1

Management Algorithm

If the tracheostomy tube appears patent:

1. If suction catheter passes easily into the trachea:

   • Continue ABCDE assessment
   • Ensure cuff is inflated if ventilation is required 1

2. If suction catheter will not pass:

   • Deflate the cuff (if present) to allow airflow past a partially displaced tube 1
   • Reassess both airways to determine if they are now patent
   • If cuff deflation improves the clinical condition, continue ABCDE assessment and await experienced assistance 1

If subcutaneous emphysema is present or worsening:

1. Remove the tracheostomy tube immediately 1

   • Even with concerns about difficult airways, a non-functioning tracheostomy offers no benefit and has considerable potential for harm 1

2. After tube removal:

   • Reassess both airways (mouth and stoma)
   • Apply oxygen to both face and stoma 1
   • If the patient is breathing and improving, continue ABCDE assessment 1

3. Emergency oxygenation options:

   • Via oro-nasal route (remember to occlude the tracheal stoma) 1
   • Via tracheostomy stoma using a pediatric facemask or laryngeal mask airway applied to the skin 1
   • May need to occlude the upper airway by closing nose and mouth if there is a large leak 1

Advanced Airway Management

• If the patient fails to improve after removing the tracheostomy tube:

  • Oral intubation may be possible using a long (uncut) tube advanced beyond the stoma 1
  • Alternatively, attempt intubation of the tracheostomy stoma with a smaller tracheostomy tube or tracheal tube 1
  • When possible, use a fiberoptic scope to facilitate placement 1

• For patients with known difficult airways:

  • Consider fiberoptic inspection of the tube while it remains in situ, but only if:
    • Appropriate equipment and expertise are immediately available
    • The patient is clinically stable 1
  • This should not delay tube removal in a deteriorating patient 1

Prevention of Worsening Emphysema

• Avoid vigorous attempts at ventilation via a potentially displaced tracheostomy tube 1
• Only use gentle hand ventilation after confirming tube patency with a suction catheter 1
• Reduce ventilator pressures and consider bronchodilators to decrease airway pressure if mechanical ventilation is required 2
• Check if fenestration of tracheostomy tube is extraluminal or consider changing to non-fenestrating cannulas 2

Complications to Monitor

• Bilateral pneumothorax can develop alongside subcutaneous emphysema 3
• Posterior tracheal wall tears may require bypassing the laceration to allow secondary healing 4
• Extensive subcutaneous emphysema can extend hospital stay and increase morbidity 5, 2

By following this algorithm, clinicians can effectively manage post-tracheostomy subcutaneous emphysema while minimizing the risk of further complications.