Accidental displacement of tracheal tube or tracheotomy

Last Updated on by frcemuser

Approach to cause for respiratory distress in intubated patients

Think ‘DOPES’

  • Displacement of the tube
  • Obstruction of the tube
  • Patient — especially pneumothorax; also: pulmonary embolism, pulmonary oedema, collapse, bronchospasm
  • Equipment — ventilator problems
  • ‘Stacked breaths’ — a reminder about bronchospasm and ventilator settings.

Immediate assessment:

Think ‘MASH’

  • Movement of the chest during ventilation — is it absent or is movement only on one side? Is the chest hyper-expanded?
  • Arterial saturation (SaO2) and PaO2 — obtain an ABG sample
  • The skin colour of the patient (is he turning blue or pinking up?) — the SO2 monitor lags behind the true oxygen saturation of the patient
  • Hemodynamic stability

Tracheal tube displaced

The approach to Managing a patient with a tracheal tube displaced

Step 1:

  • Call for Help
  • Apply high flow oxygen
  • Check Capnography (ETCO2) if not, put it on
  • Call for Difficult airway trolley

Step 2:

Attach water circuits

Step 3:

Look

  • is ETc02 trace a normal square wave?
  • is water circuit moving with spontaneous respirations?
  • is ETc02 trace a normal square wave?

ventilate using water’s circuit

  • is ETc02 trace a normal square wave?
  • is chest moving up and down and easy to ventilate?

if no,

Step 4

Suggest with a problem with the tracheal tube

  • check tracheal tube at teeth has TT been pushed or fallen out?
  • is Tracheal tube Blocked? – pass a suction catheter
  • is patient bitting tube? – give atracurium 50mg iv
  • has cuff herniated over the end of the tracheal tube? – deflate and inflate the cuff

Step 5

if doubt/ patient deteriorating

  • Remove the tracheal tube and call for a senior anesthetist
  • ventilate with 100% oxygen using bag and facemask with Guedel airway and two hands on the mask
  • Consider LMA/i-gel/Pro seal LMA, await senior help
  • oral intubation if you have the skill

if stable
100% oxygen, wait for a senior anesthetist

Patient Factor:  if the patient has Normal ETC02 tracing/Water Circuit Moving with Spontaneous Respiration/Normal Chest wall Moving up and down – tracheal tube displacement unlikely a patient problem is most likely. Perform a focused exam and urgently seek and treat the following life-threat

  • pneumothorax (look for asymmetrical chest movement)
  • lung collapse (look for asymmetrical chest movement)
  • pulmonary edema
  • bronchospasm (chest wall movement may be minimal — look for hyperexpansion)
  • pulmonary embolus

asses breathing/circulation – follow ALS algorithm if necessary

Equipment: there may be a problem with the ventilator settings or there was an equipment failure.

  • check ventilator settings
  • trouble-shoot equipment failure

Blocked/displaced tracheostomy

The approach to Managing a patient with blocked/displaced tracheostomy

Step 1

  • Call for Help
  • Apply high flow oxygen to both the face and the tracheostomy
  • Check Capnography (ETCO2) if not, put it on
  • Call for Difficult airway trolley

Step 2

Attach water circuits

Step 3

Look

  • is ETc02 trace a normal square wave?
  • is water circuit moving with spontaneous respirations?
  • is chest moving up and down and easy to ventilate?

Try tow Careful breath with water circuit

  • is ETc02 trace a normal square wave?
  • is chest moving up and down and easy to ventilate?

Look at the neck

  • look at the neck, is it swelling or developing surgical emphysema with each breath

if no? suggest a problem with a tracheostomy

Step 4

  • is tracheostomy blocked? – pass suction catheter via tracheostomy, ensure inner tube removed
  • has cuff herniated over the end of the tracheostomy? – deflate and inflate the cuff

Step 5

if doubt/ patient deteriorating

  • Deflate tracheostomy cuff and remove the tracheostomy
  • cover tracheostomy with sterile gauze and occlusive dressing
  • ventilate with 100% oxygen using bag and facemask with Guedel airway and two hands on the mask
  • Consider LMA/i-gel/Pro seal LMA, await senior help
  • intubate if you have the skill

Patient Factors: if yes( Normal ETC02 tracing/Water Circuit Moving with Spontaneous Respiration/Normal Chest wall Moving up and down) – tracheal tube displacement unlikely a patient problem is most likely. Perform a focused exam and urgently seek and treat the following life-threat

  • pneumothorax (look for asymmetrical chest movement)
  • lung collapse (look for asymmetrical chest movement)
  • pulmonary edema
  • bronchospasm (chest wall movement may be minimal — look for hyperexpansion)
  • pulmonary embolus

asses breathing/circulation – follow ALS algorithm if necessary

Reading

Respiratory Distress in a Tracheostomy Patient

Post-intubation hypoxia


https://www.rcoa.ac.uk/system/files/CSQ-NAP4-Section3.pdf

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