This is actually my first article about a medical topic in this new blog about critical care. My intention is to wrtite about neuro ICU care especially. As you can easily grab when yup recall the name e of the website.
I work as a fellow in critical care in a university hospital in Germany. During my last year i encountered several critical situations which made my think. Most of the time we ran deeply into trouble because we were not fully prepared or never anticipated how much s* could possibly rain on us.
One of these critical situation is when you´re in trouble because of a non-functional tracheostomy tube, especially if you did a percutaneous dilatation tracheostomy and you are within first seven days. Prof. Ellger from the department of anaesthology of my hospital and Dr. Bösel form the university of Heidelberg wrote together an SOP if you are facing this hairy situations.
The article is written in german and is linked below.
If a endotracheal tube after percutaneous dilatation tracheostomy is removed the artificial airway collapses. If the removing itself was not intented in the first place and the patient is not breathing translarygeal this can have fatal consequences. To prevent a chicken bomb or a cluster f* (hello Mr. Reid) a SOP (a standard operation procedure) makes a lot of sense.
Elective changing of a endotracheal tube after percutaneous dilatation tracheostomy within the first days should be avoided. The pretracheal softissue tends move backward in the predilation status and by this way to occlude our new airway. So Basel recommends to use a inlay for the tube. So in case of occlusion the lumen remains open after removing the inlay. The tube has to be only replaced if there is a deflating cuff or an obstruction even after removing the inlay.
In this case the patient has to be preoxygenated and the resus-equipment has ti be moved to the bedplace. Try to manual ventilate the patient.
Suction is a crucial part in this protocol. If it is possible to place a suction catheter (why not in a case of a deflating cuff) you can place a bougie or a tubus exchanger as well. So you can change the tube over the bougie and you save the day. After placing of the tracheostomy tube you have to check endtidal CO2 waveform pattern and clinical signs for correct placement.
If you are not that lucky and you cloud not place either the suction catheter nor the tubus over the bougie you have to check how long it has been since the tube has been placed.
It is crucial because if you try to change a newly placed tube by dilation tracheotomy there is a great change that the artificial airway collapses.
If you are off the hook and tracheostomy is longer then seven days in the past you can try to remove the tube und place a new one over the old tracheostomy.
If not, do laryngoscopy und place a tube. This is best done using VL. If you have visualised passing the cords, remove the tracheostomy tube and check again for correct placement.
In case of you are able to place either a endotracheal or a tracheostomy tube switch to BMV and difficult airway procedure SOP.
My daily practice changed a bit after reading this article. We have never used an inlay for our tracheostomy tubes. Leave an inlay in the first week seems to be reasonable.
If you new in the business of tracheostomy there is another very helpful article. You find the link below.
I hope this of interest for you guys out there. See you soon. Please make a comment.