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We congratulate McGrath and colleagues on producing the multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies [1]. 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.

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Figure 5. Tracheostomy displacement algorithm for patients on ICU.

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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’).

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