Emergency Management of Failed Tracheostomy - An Update

Introduction:

Tracheostomy is an invasive procedure in which a surgical opening (hole) is made in the windpipe (trachea) in front of the neck to insert a tube (intubation) in it to secure an airway. The inserted tube facilitates oxygen delivery and ventilation either temporarily or permanently. More than 100,000 tracheostomy procedures are done in the United States every year. These are done for medical emergencies in which there is upper airway blockage or situations in which intubation is not feasible. In addition, tracheostomies are also done for patients who require prolonged intubation, have surgically removed part of the airway due to cancer, or have an advanced disease affecting the nerves and muscles of the airway. However, in some cases, a tracheostomy can fail or lead to severe complications that require emergency management.

What Is a Tracheostomy?

A tracheostomy procedure involves creating an opening at the front of the neck to insert a tube into the trachea (the windpipe) to help the patient breathe. The tube is then connected to an oxygen supply or a ventilator (a machine that helps breathing). In addition, the tube inserted into the windpipe is also used to remove the secretions and fluid build-up in the windpipe and the throat. The goals of tracheostomy include the following:

1. Oxygen delivery to the lungs as the patient is unable to breathe normally (due to an injury, accident, or weak airway muscles).

2. Assist the patient in breathing if their throat (upper airway) is blocked due to a tumor, swelling, or foreign body lodged in it.

3. To prevent fluid or food from being aspirated into the lungs for patients who find coughing difficult.

A tracheostomy is usually planned and carried out in the hospital. However, in case of emergencies, it is done outside the hospital (at the scene of the accident).

When Is a Tracheostomy Done?

A tracheostomy is done in the following scenarios:

1. When the need for prolonged mechanical ventilation is expected (such as in acute respiratory failure).

2. Upper airway obstruction.

3. Difficult airway (when less invasive techniques such as endotracheal intubation are not successful).

4. Failure to wean from mechanical ventilation.

5. Traumatic brain injury.

6. Infections that block the airway (such as epiglottitis, Ludwig’s angina, etc.)

7. Foreign body obstruction of the airway.

8. Edema (build-up of fluid) or inflammation of the airway.

9. Neoplasm or tumor mass obstructing the airway.

10. For airway protection.

11. Neuromuscular diseases (affecting the muscles of the airway and lungs).

12. Inability to manage secretions in the airway.

How Is a Tracheostomy Performed?

If the tracheostomy is planned, it is done under general anesthesia. In case of emergency, a local anesthetic is used to prevent pain during the procedure. A skilled doctor or surgeon performs the procedure and makes a hole in the patient's throat (using a needle or scalpel). After which, a tube is inserted into the windpipe through the surgical hole. Surgical tapes or stitches hold the tube inserted in place. Then a dressing is placed around the opening in the neck. The tube may be connected to the ventilator if the patient requires assistance in breathing.

How Is Early Tracheostomy Failure Managed?

Tracheostomy is a safe procedure to keep the patient oxygenated and ventilated. However, it may fail and lead to some complications at times. The failure and complications that arise due to tracheostomy depend on the patient's general condition (age, disease), the reason the tracheostomy is performed, and the skill of the doctor performing the procedure. The early complications (leading to tracheostomy failure) that can occur during the procedure or shortly after include:

1. Difficulty Inserting the Tracheostomy Tube - The doctor can find it difficult to insert the tube into the windpipe through the surgical hole. This affects oxygen supply and ventilation. In such a scenario, the doctor will try to reinsert the tracheostomy tube after altering the patient's position or using additional interventions to help secure the airway.

2. Wrong Positioning of the Tube - There is a possibility that while establishing the surgical airway, the tube insertion is not into the trachea but into the surrounding structures (such as paratracheal insertion). In such cases, the air does not reach the lungs, and the procedure fails. The tube needs to be removed and reinserted into the windpipe in order to supply oxygen to the lungs.

3. Bleeding - Minor bleeding can occur from the trachea or the surgical hole itself during tracheostomy. These are common and improve within a few days. However, if the bleeding is severe, it may require a blood transfusion and an alternative ventilation method.

4. Lung Collapse - At times, during or shortly after the procedure, air may get collected around the lungs, which causes them to collapse (pneumothorax). Mild pneumothorax resolves spontaneously without treatment. However, if it is significant, the patient might require surgery to implant a tube into the chest (to drain the air around the lungs).

5. Accidental Injury - During the procedure, the nerves near the throat and windpipe may get accidentally injured. The nerves in the area usually supply to the larynx (voice box) or the esophagus (food tube from the mouth to the stomach). As a result of damage to these nerves, the patient might have problems with speaking or swallowing. These accidental injuries can be avoided by carefully identifying the structures of the tracheostomy.

6. Infection - There is a possibility of infection to the windpipe or the surrounding tissues and structures after the tracheostomy procedure. Antibiotics are usually used to treat such infections.

7. Tracheostomy Tube Falls Out - If the tube falls out, the doctor ensures ventilation with a new tube reinserted or an alternative ventilation method.

How Are the Late Complications of Tracheostomy Managed?

Some complications can occur several days or weeks (even months) after the tracheostomy. These include:

1. Failure to Heal - The tracheostomy wound fails to heal properly at times and may start bleeding. In such scenarios, the tube is removed temporarily, and surgery is performed to control the bleeding.

2. Blocked Tracheostomy Tube - There is a possibility that the tracheostomy tube gets blocked (gradually or suddenly) with secretions or fluids. Such blockages can be prevented by regularly cleaning the tube and suctioning the fluids.

3. Collapsed Trachea - The windpipe (trachea) can collapse if tracheal walls are weak and are not able to support the trachea. This happens when the tube is not fitted correctly. A collapsed windpipe is managed by further surgery.

4. Narrowed Trachea - Accidental injury to the throat and the structures surrounding the trachea can result in scars and airway narrowing. Such patients experience breathing difficulties. The narrowed trachea is managed by the surgical widening of the airways and implanting a stent (a small tube to hold the airways open).

Conclusion:

Tracheostomy is a procedure in which a surgical hole is made in front of the neck to insert a tube into the windpipe. These are usually performed during emergencies or planned for certain patients requiring prolonged intubation. Though tracheostomy is a safe procedure, it can fail due to early and late complications that can arise during and after the procedure. Efficient management of failed tracheostomy ensures adequate oxygenation and ventilation for the patients, thus saving lives.