Tracheostomy care and emergencies: SAQ

This infant has a tracheostomy emergency: a child with a tracheostomy who is distressed and desaturating has a blocked or displaced tube until proven otherwise. Two features raise the stakes. A speaking valve is in place, which completely occludes the tube on expiration and can itself cause the obstruction, and the tracheostomy is only 3 days old, so the stoma tract is immature and reinsertion after any displacement carries a high risk of a false passage. ^[1]

Question 1 (10 marks)

Describe your immediate emergency management of this infant, in the correct order. ^[1]

Call for help and immediately give high-flow oxygen to both the face and the tracheostomy stoma, because you do not yet know which route is patent and covering both loses nothing. Remove the speaking valve at once, since a valve occludes the tube and is a common and instantly reversible cause of obstruction, and remove the inner cannula if the tube has one, then reassess breathing. ^[2]

Pass a suction catheter down the tube to test patency and clear secretions. If the catheter passes, the tube is patent, so suction, ventilate, and reassess. If the catheter will not pass, the tube is blocked or displaced, so deflate the cuff if present and remove the tracheostomy tube, because a tube that cannot be cleared only occupies the airway. ^[1]

After the tube is removed, reassess breathing and oxygenate. Because this infant has a normal upper airway, cover the stoma and give oxygen or bag-mask ventilation via the face in the usual way, or alternatively deliver oxygen or ventilation directly to the stoma with a small mask or supraglottic airway. Only once the infant is oxygenated should a controlled attempt at re-cannulation be made. ^[1]