The Vitals: The Fresh Trach of Bel Air

Let us rejoin you, our heroic intern on the critical care unit. You now are on your second ICU rotation, and this is your week to cover nights. You take your sign out from the day team, and find out that Mr. Green just underwent a tracheostomy this afternoon, and is still connected to the ventilator. The ENT team said the procedure seemed to go well, but there was quite a bit of bleeding during the procedure and afterwards. The primary team tells you that the ENT resident just saw the patient and tried to put some packing around the oozing, but it still seems to be bleeding. You are asked to follow up regarding the bleeding.

On arrival at the patient’s bedside, the nurse tells you that Mr. Green continues to have a lot of oozing from the surgical site, despite the ENT resident’s best effort to control it. The respiratory therapist tells you that the ventilator pressure alarms have been going off with high peak inspiratory pressures and he has been saturating in the high 80’s despite increasing the FiO2 to 100%. There is still blood actively coming out of the stoma.

What would your next step be?

A. PEEP! PEEP is always the answer when a patient is desatting!

B. Ask the RT if you can somehow give more than 100% FiO2? 

C. Try and pass the suction ballard through the trach.

D. Duonebs, duh! 

The correct move here would be C: trying to pass the suction ballard through the trach. If you are able to pass the ballard through the trach, then you can be reasonably sure you have a patent tracheostomy tube and are in the airway. You can then try suctioning, in case there is a clot or mucus plug obstructing the airway.  If you cannot pass it easily, the tracheostomy tube may have become dislodged somehow, or there is an obstruction within the tracheostomy tube itself. 

Let’s consider a slightly different scenario. 

Mr. Green isn’t oozing at all, however his pressure alarms are blaring, he is now saturating in the 80’s, and his neck looks really swollen. As you place your hand over his neck and shoulders, you feel crepitus. 

What could have happened?

A. Post op changes, nothing to see here.

B. Is he allergic to the tracheostomy tube? 

C. Subcutaneous emphysema in the setting of false tract ventilation.

The answer here is C: false tract ventilation. A false tract is essentially when the tracheostomy tube becomes partially dislodged and winds up anterior to the tracheal lumen instead of inside the trachea. You should be suspicious of a false tract if the ventilator is showing high pressures, there is a rapid desaturation, and you can’t pass the suction catheter more than 5-7 cm. The tracheostomy tube also may be a few cm away from the stoma and unable to be pushed in to lie flush against the neck. Another jarring physical exam finding is the rapid development of subcutaneous emphysema as the ventilator forces air into the false tract. 

The first step is to try and replace the tracheostomy tube by turning the tube upwards and then insert, after the tube is inside the trachea, turn the tube cephalad. The majority of tracheal stomas are cephalad to the cutaneous stoma, so by turning the tube upwards, you hopefully will be able to easily insert it back into the tracheal stoma. Another consideration would be using an airway adjunct (bougie, Cook Exchanger, etc.) to use as a guide for the tube to go back into the tracheal stoma, however this is a fairly advanced maneuver, and using these adjuncts has risks.  In all reality, I would be having someone call either a difficult airway team or the ENT team stat to the bedside. If the patient is acutely desaturating, removing the tube and ventilating both the stoma (use a pediatric mask) and oropharynx (adult mask) may be your best bet until you can endotracheally intubate and backup arrives.

Back to our original case. You try to pass the suction ballard through, and you are able to pass it, however, when you suction, you suck out a lot of blood. The patient continues to desaturate and now his blood pressure is rapidly falling despite the blood you are getting out. 

Which of the following should you do?

A. Panic.

B. Call your senior and prepare for an impending cardiac arrest.

C. Call the difficult airway team STAT.

D. Try and hyperinflate the cuff.

The answers are B, C, and D. An unstable patient with a fresh trach that is not working well should be considered an emergency, as they can crash within minutes. This patient is about to have a respiratory cardiac arrest, and you are unable to successfully ventilate the patient through his tracheostomy. Preparing for the impending cardiac arrest and getting yourself ready will help focus your mind (check out my previous article on using the deep breath to focus yourself). Your institution will hopefully have a difficult airway response team consisting of ENT, anesthesia, and trauma surgery. Putting this page out will bring all the experts and equipment one may need to the bedside rapidly. Hyperinflating the cuff may help to tamponade the bleeding in case there is an innominate artery bleed, and may buy you some time to establish a more permanent solution. 

I’ve written this scenario to be helpful to entry level ICU team members and to help them understand the first steps to rescuing a crashing fresh tracheostomy. We will keep pursuing this case, however now from a different perspective.

You are now the senior critical care fellow on duty overnight in the MICU. Your intern has just called you and let you know about Mr. Green, so you are running to the unit to assess the patient. Just as you get to the room, you hear the difficult airway page overhead. You quickly assess the situation, and understand that Mr. Green has a fresh tracheostomy, we are getting a lot of blood suctioned out of the trach, we cannot ventilate him, and his blood pressure is dropping. 

Taking the whole scenario into account, the most likely situation is that the bleeding has formed a clot, and this has now obstructed the airway. The tracheostomy is likely in the right place, however there may be an obstruction further down the airway. Another consideration is that there was an innominate artery bleed, and your resident has hopefully attempted to hyperinflate the cuff. The difficult airway team arrives right after you, and you all begin to discuss what the next steps are.

There are several possibilities here, all of which require a high level of coordination between the teams. In our scenario, the most helpful thing to do would be to have a bronchoscope set up for the ENT team to assess the trach. They may be able to use saline bullets to try and break up the clot and suction it through the bronchoscope. However the size of the bronchoscope that can typically fit through a tracheostomy may not be sufficient for high volume suctioning. Another thing that will likely happen concurrently is intubation from above, passing the ETT past the stoma site. This can be accomplished by having the ENT team using the bronchoscope at the tracheostomy site and either the critical care team or anesthesia team at the head of the bed intubating. Once the intubator passes the vocal cords, he/she will pause and allow the ENT team to withdraw the tracheostomy tube right to the edge of the stoma, so the whole team can visualize (with the bronchoscope) the ETT going past the stoma. Using an 8.0 ETT will allow for the use of a larger bronchoscope with a bigger working channel to hopefully break up and extract the clots. 

If your patient codes from hypoxemia before you are able to re-establish ventilation, perform ACLS as you normally would. I would have push dose epinephrine once you notice the blood pressure falling, to try and buy you a little more time for back up to arrive or for you to intubate from above. If your institution is fortunate enough to have the LUCAS device, I would recommend using that to free up more personnel and to keep the chest area as free as possible for the ENT team.

The situation where you cannot ventilate a crashing patient is universally chaotic, so really try and focus on clear communication between all teams and keeping the ambient noise down in the room. As previously discussed, if you are able to keep a clear and calm head, hopefully the rest of the team will respond to your calming energy, be able to focus on their tasks at hand, and work together effectively to try to get the best outcome possible for the patient.