Airway & Tracheostomy Management

Key Points
1. Always give oxygen in highest concentration possible.
2. Use simple methods for airway control first.
3. Seek anaesthetics critical care help if you think reached limits of competency.
4. Common complications of tracheostomy include displacement, blockage, haemorrhage.
- Surgeons must be aware of and able to deal with these complications.

Airway Management

Assess and recognise.
- dyspnoea / apnoea
- accessory muscle use
- central cyanosis
- sweating and tachycardia
- decreased LOC

Apply High Flow O2 via Hudson with reservoir bag.
- do not concern yourself with suppressing resp drive if they need O2
Sats monitoring.

Airway support
- chin lift; jaw thrust
- guedel (sized angle mandible to mouth; insert upside down & rotate)
- suction
- laryngeal mask
- ET tube
- surgical airway

Tracheostomy

Indications:
- weaning from mechanical ventilation
- bronchial toilet (excess secretions)
- Protect airway (e.g. following CVA)
- Maintain airway (upper airway obstruction)

Types
- cuffed / non-cuffed; (cuffed allow ventilation but not speech).
- Single lumen vs inner cannula (Inner cannula removed for cleaning; safer long term).
- Fixed vs adjustable flange (flange overcomes short term problems like swollen neck; not appropriate long term)
- Fenestrated vs non-fenestrated (allow patients to talk with tubes in; not when ventilated).

Size
- most adults can accommodate outer diameter 10mm F, 11mm M
- maximal size --> reduced work of breathing
- but if too big, can cause pressure necrosis.

Ward Management of Tracheostomy

Humidification and regular suction
- lack of basic toilet leads to blockage
Apply CCrISP algorithm when facing tracheostomy problems
Determine when procedure performed and what type of type
- do NOT change within 3 days of placement; ideally not within 10d perc
Single lumen tubes should be avoided on wards
Only skilled staff should manipulate them.

What are the complications?

1. Blockage or displacement.
- breath through nose / mouth
- give oxygen via face; if bag-mask, may need someone to occlude the stoma to stop air leak
- maintain airway until help arrives.
- if blocked, suction catheter
- if inner cannula, remove and change
- if cannot breath spontaneously, obtain airway by other means.

2. Haemorrhage
- erosion of vessels around site.
- apply pressure
- infiltrate dilute adrenaline (1:80,000) to obvious bleeders.
- if no obvious, generally infiltrate edges
- check coags and correct.
- can try pressure to root of neck or at sternal notch, increase cuff volume without bursting.
- get an ENT / head-neck surgeon.

Removal
Remove as soon as need passed
Safe if coughing, expectorating, phonating and protecting airway with cuff deflated.
Best to do in morning when rested and staff around.
1. Ensure equipment available.
2. Monitor
3. Ensure supplemental O2 via tracheostomy mask
4. Explain
5. Deflate cuff and suction.
6. Remove.
7. Dress and occlude stoma.
8. Supplemental facial oxygen.
9. Observe closely.