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Introduction

Tracheostomy

  • A stoma is created through the neck to the trachea to form an airway below the larynx. The larynx remains intact.
  • Tracheostomy patients can breathe through their stoma and potentially their mouth / nose to some extent.
  • A tracheostomy tube +/- inner tube may be present.

Laryngectomy

Patients with a laryngectomy cannot be oxygenated, ventilated or intubated via the mouth.

  • A stoma is created through the neck to the trachea to form an airway, however the larynx is completely removed. The trachea is only connected to the neck and stoma. Airflow from the mouth and nose into the trachea is impossible.
  • Usually, a tube will not be in situ. Other devices such as laryngeal buttons, heat-moisture exchangers (HME) or tracheo-oesophageal puncture (‘TOP’) speaking valves may be present.
Clinical Presentation

Patients with tracheostomy or laryngectomy who are showing signs of:

  • Change in level of consciousness
  • Increased work of breathing
  • Oxygen desaturation
  • Cyanosis
  • Nil or reduced air flow out of the tracheostomy tube
  • Decreased, nil or gurgling breath sounds
  • Unusual vocal, upper or lower airway sounds such as stridor, wheeze or louder than usual crying which indicates exhaled air is passing through the upper airway rather than the tracheostomy tube
  • High inspiratory airway pressure (or low tidal volume if the patient is mechanically ventilated)
  • Unable to pass the suction catheter or inner cannula     
Exclusion Criteria
Exclusion Criteria
Risk Assessment
  • The default route of oxygenation and ventilation in all patients should be the stoma.
  • It may be hard to establish whether the patient has a laryngectomy or tracheostomy. Where uncertain, providing oxygen via both routes is advocated.
  • Patients and carers will frequently be familiar with the management of tracheostomy / laryngectomy emergencies. Consider their advice and follow any action plans that may be present.
  • Discuss with the caregiver about reattaching any external devices (e.g. Swedish nose, speaking valve) that were removed prior to starting the procedure; these may stay disconnected in case the patient requires suctioning during ambulance transport.
Management

Suction

Oxygenation

  • Oxygen via the stoma is the priority as it is appropriate for both laryngectomy and tracheostomy patients.
  • If two sources of oxygen are available, a second mask should be added to the patient’s face as some tracheostomy patients may benefit from oxygenation via a partially patent upper airway, especially if their tracheostomy is totally blocked.

Apnoeic / cardiac arrest

  • Ventilation / intubation should be attempted via the stoma.
  • When ventilating through the stoma, assess for significant air leak through the mouth. If this is present the upper airway may be patent to some extent. BVM ventilation via the stoma is unlikely to be successful. Paramedics should attempt to cover the stoma with an occlusive dressing to achieve an airtight seal and manage the patient via the upper airway.
  • Ensure monitoring with ETCO2 for all ventilation
Primary Care
Intermediate Care (EMT / Level 2)
  • As per Primary Care guidelines
Advanced Care (AP)
    Critical & Extended Care (CCP, PSO)
      Additional Information

      Patients who are critically ill or have comorbidities are more at risk and complications become more likely the longer the tube is kept in situ. Complications that can occur with a tracheostomy include:

      • Partial or complete airway obstruction due to blockage
      • Tracheostomy tube dislodgement or tracheostomy in a false passage
      • Tracheal damage or erosion
      • Tracheal stenosis
      • Formation of stomal or tracheal granulation tissue
      • Persistent cuff leak
      • Faulty oxygen source or ventilation device
      • Ineffective humidification
      • Infection
      • Aspiration

      References
      References
      Key Terms & Links

      Normal airway

      Normal airway

      Tracheostomy

      Tracheostomy

      Laryngectomy

      Laryngectomy

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      Clinical Services

      Responsible Manager
      Head of Clinical Services

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