{"id":2275,"date":"2018-07-25T11:24:44","date_gmt":"2018-07-25T15:24:44","guid":{"rendered":"http:\/\/first10em.com\/?p=2275"},"modified":"2018-10-11T21:49:49","modified_gmt":"2018-10-12T01:49:49","slug":"tracheostomy","status":"publish","type":"post","link":"https:\/\/first10em.com\/tracheostomy\/","title":{"rendered":"\ufeffRespiratory distress in the patient with a tracheostomy (update)"},"content":{"rendered":"

This is an update of a previous version of this post<\/a>. I am reposting to coincide with the release of a new textbook that I am pretty excited about. The textbook is the Resuscitation Crisis Manual<\/a>. It provides very succinct action scripts for the major emergencies that we see. It is exactly the textbook that I always wanted in residency, but didn’t exist. The absence of this kind of resource was exactly the reason that I started First10EM. (Perhaps, in the future, Scott can just keep me up to date on his projects. If I had just waited a couple years, I could have had the textbook without feeling like I had to write it by myself.)\u00a0I wrote the “Tracheostomy Emergencies” chapter of the book – hence the decision to repost this topic. (I guess I should note that I don’t get anything for writing that chapter, so I don’t have any financial conflicts of interest – just intellectual biases.)<\/p>\n

If you want to hear more about the book, check out this EMCrit podcast<\/a>.<\/p>\n

Case<\/b><\/h2>\n

A 45 year old man, well known to your department because of a prior anoxic brain injury and multiple complications including a permanent tracheostomy, is brought in by ambulance from home in respiratory distress. You know from prior conversations with the family that the patient is to receive full, aggressive medical management. He is using every accessory muscle that you can see, his respiratory rate is 55, and his oxygen saturation is 87% on room air…<\/p>\n

<\/p>\n

My approach<\/b><\/h2>\n

\"Frist10EMCall for help.<\/strong> You will want RT present. You may also want ENT and someone who can operate a fiberoptic scope (if that isn\u2019t you).<\/p>\n

Ensure all your difficult airway equipment is out and ready.1,2<\/sup><\/p>\n

\"Frist10EMApply oxygen to both the patient’s face and the tracheostomy site. (If there has been a laryngectomy, there will be no connection between the upper airway and the trachea, but if you are not sure, put oxygen on the face.) The priority is oxygenation and not necessarily definitively securing the airway.1<\/sup><\/p>\n

Assess for breathing (air movement) by looking, listening, and feeling at both the mouth and the tracheostomy. Waveform capnography should be applied if available.1,2<\/sup><\/p>\n

Aside from your normal differential diagnosis of respiratory distress, the tracheostomy adds three important considerations: tube obstruction, tube displacement, and equipment problems.<\/p>\n

Key question: Is<\/strong> the tracheostomy patent and appropriately placed?\"Frist10EM
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