TC was a co-editor on the NAP4 project in which the algorithm was included. No other external funding or competing interests declared. Previously posted on the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com.
Algorithm for management of tracheostomy emergencies on intensive care
Article first published online: 9 JAN 2013
Anaesthesia © 2013 The Association of Anaesthetists of Great Britain and Ireland
Volume 68, Issue 2, pages 217–219, February 2013
How to Cite
Kelly, F. E., Hommers, C., Jackson, R. and Cook, T. M. (2013), Algorithm for management of tracheostomy emergencies on intensive care. Anaesthesia, 68: 217–219. doi: 10.1111/anae.12140
- Issue published online: 9 JAN 2013
- Article first published online: 9 JAN 2013
We congratulate McGrath and colleagues on producing the multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies . An enormous amount of time and effort has clearly gone into producing these; bringing together so many different parties and producing a unified set of guidelines is extremely impressive. Use of these guidelines can be expected to improve significantly the safety of patients with a tracheostomy on our wards. We support the use of signs to indicate the type of tracheostomy, are currently introducing the green (potentially patent upper airway) and red (‘neck breather’) bed-head signs on our intensive care unit (ICU), and our ENT colleagues are currently introducing these guidelines, in full, on our wards.
However, whilst we feel that these guidelines will be extremely useful for ward patients, we do have some reservations about using the algorithms for tracheostomy emergencies in our ICU. Tracheostomy emergencies in ward patients are usually related to blockage of a tracheostomy: such a ward patient is unlikely to have continuous capnography monitoring, is often not oxygen dependent, is usually self-ventilating and may well have a mature stoma. Conversely, tracheostomy emergencies in patients on ICU patients usually involve displacement of a tracheostomy in a patient who would usually have continuous capnography monitoring, be oxygen and ventilator dependent and have a recently formed stoma [2-4]. For these reasons we feel that ward and ICU patients are quite different and warrant different algorithms.
Over the past two years, we have developed an algorithm to guide the management of tracheostomy emergencies on ICU (Fig. 5). As continuous capnography is now so widely recommended for patients dependent on an artificial airway that it should be routine [2-5], our algorithm emphasises the importance of capnography in making the initial diagnosis of a problem with ventilation. It is colour coded to create two pathways: the yellow boxes are designed to enable our nurses and junior trainees to initiate management, and the blue boxes target senior trainees and consultants who may arrive later and who may have additional skills. We use these algorithms regularly in multidisciplinary ‘in-situ’ simulation sessions on our ICU, and our staff report that they are easy to follow. We have had a number of displaced and partially displaced tracheostomies on our ICU over the past two years, all managed using these guidelines, with excellent outcome and no harm to the patients involved.
While we genuinely welcome McGrath et al.'s initiative, we suggest that ICU cases are likely to be different in nature and have different needs from ward cases. The importance of capnography in diagnosing the problem and the need for advanced anaesthetic skills to re-establish the airway differentiate the algorithms.
Finally, we emphasise that this algorithm is always under review, and would welcome any comments on how it might be improved. We are in the process of developing a second algorithm, to be used in patients who have had a laryngectomy (‘neck breathers’).
- 2Major complications of airway management in the UK: results of the 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2. Intensive Care and Emergency Department. British Journal of Anaesthesia 2011; 106: 632–42., , , .
- 3The use of capnography outside the operating theatre. Updated statement from the Association of Anaesthetists of Great Britain & Ireland (AAGBI). Association of Anaesthetists of Great Britain Ireland Safety statement. May 2011. http://www.aagbi.org/sites/default/files/Capnographyaagbi090711AJH%5B1%5D_1.pdf (accessed 12/11/2012).
- 4Capnography guidelines 2011. Intensive Care Society. http://www.ics.ac.uk/education/capnography_guidelines (accessed 12/11/2012)., , .
- 5European Section and Board of Anaesthesiology Recommendation for the use of Capnography. European Section and Board of Anaesthesiology UEMS Amsterdam, June 11th 2011 http://www.eba-uems.eu/resources/PDFS/EBA-UEMS-recommendation-for-use-of-Capnography.pdf (accessed 12/11/2012).