Tracheostomy and laryngectomy: tubes, shared airway, and displacement

Meet the patient

A nurse calls at 3am: the day-2 tracheostomy on the ward is desaturating and the tube looks "half out." The patient is agitated, cyanosed, and no one in the room has done a tracheostomy drill before. The instinct is to shove the tube back in — and that is exactly how a false passage into the mediastinum is created.^[2]

The two questions that decide the next two minutes are the two that decide every tracheostomy emergency: does this patient still have a patent upper airway? (a tracheostomy patient usually does; a laryngectomy patient never does) and is the tract mature enough to re-pass a tube? (a fresh day-2 tract is not). Hold those two questions and the algorithm below is obvious.^[2]

References4ShowHide

1. [1]Frerk C et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults Br J Anaesth, 2015.PMID 26556848
2. [2]Cook TM et al. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia Br J Anaesth, 2011.PMID 21447488
3. [3]Apfelbaum JL et al. Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires Anesthesiology, 2013.PMID 23287706
4. [4]Khandelwal A, Kapoor I, Goyal K, et al. Pneumothorax during percutaneous tracheostomy - a brief review of literature on attributable causes and preventable strategies. Anaesthesiol Intensive Ther, 2017.PMID 28953312