Blocked Tracheostomy

Published 03/08/2022

Blocked Tracheostomy

Set-up: 

 

Lines/access: 

RIJ CVC, left radial arterial line, one peripheral cannula 

Infusions: 

Sedatives, 1L crystalloid at 80mls/hr 

Airway: 

Tracheostomy with inner tube in situ (both tracheostomy and inner tube occluded) 

Ventilator: 

V-SIMV 500/8 FiO2 0.5 Rate 16breaths/min 

Other: 

Bedside “tracheostomy box” 

Local tracheostomy algorithm laminated and hanging at bedspace but facing away from scene and not immediately apparent 

Airway & cardiac arrest trolleys 

Lung simulator capable of reducing compliance 

Clinical Setting

I:       You are the ICU registrar and are called by the nurse to assess the patient in bed 5 

S:      Nurse wants a salbutamol prescription 

B:      67M recently returned from theatre after surgical tracheostomy, fully mechanically ventilated and deeply sedated 

A:     High pressure alarms, falling saturations 

R:     Called for help 

Potential Clinical Course

  • Initially A Trachy, B SpO2 95% on FiO2 0.5, not ventilating, ETCO2 4.6kPa, reduced breath sounds, C HR 90bpm SR, BP113/67 D sedated 
  • Becomes more hypoxic and bradycardic 
  • If no intervention then cardiac collapse 
  • If appropriate management of blocked tracheostomy then patient will improve 
  • Identify blocked tracheostomy 
  • Remove tracheostomy and ventilate via bag valve mask 
  • Either stays with bag mask ventilation and calls for senior help or proceeds to intubate the patient orally.

Information for Faculty

  • Initial settings: SpO2 95% on FiO2 0.5 
    • ETCO2 4.6kPa 
    • Reduced breath sounds bilaterally 
    • HR 90bpm 
    • BP 113/67 

 

  • Progress to: SpO2 90% whilst trachy in situ (on placement first sandbag) 
    • ETCO2 6.7kPa 
    • HR 116bpm                     
    • BP 101/54  

 

  • Progress to: SpO2 86% (on placement second sandbag) 
    • ETCO2 absent 
    • HR 49bpm  
    • BP 88/42 

 

  • On removal of tracheostomy and manual ventilation: 
    • SpO2 86% then gradually up to 98% 
    • ETCO2 6.8kPa immediately on return to ventilator 
    • HR 49 then gradually up to 90bpm SR 
    • BP 88/42 then gradually up to 105/62 

Faculty Roles

 Bedside Nurse 1: 

  • You are a CNS 
  • You are looking after a 67M who is day 19 post a subarachnoid haemorrhage and coiling, who has recently returned from having a surgical tracheostomy sited 
  • Patient remains sedated and mechanically ventilated 
  • In the previous hour the patient has been fine – you do not volunteer he has just returned from his surgical tracheostomy 
  • In the past few minutes you have been struggling to ventilate the patient 
  • You are concerned he has bronchospasm as he has had asthma in the past, and ask if we could give him a nebuliser.

 

Bedside Nurse 2: 

  • You are a Staff Nurse with a few years ICU experience 
  • You are actively changing ventilator settings and listening to the patient’s chest as the candidate enters 
  • You are less convinced about bronchospasm and inform your nursing colleague that he has “quiet breath sounds”, when bronchospasm is raised you volunteer your auscultation findings.

 

HiLLO: 10 

Blocked Tracheostomy
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