Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: Tracheostomies are a common occurrence in patients' care for an intensive care unit.
Speaker: Tracheostomies are associated with complications.
Speaker: Fortunately, most of these complications are minor complications.
Speaker: However, every intensivist should be familiar with the recognition and management of potentially serious tracheostomy-associated complications.
Speaker: In today's episode of the podcast, we will discuss tracheostomy emergencies.
Speaker: Our guests are Drs.
Speaker: Laura Bontempo and Sarah Manning.
Speaker: Dr. Laura Bontempo is an emergency medicine physician.
Speaker: She's an associate professor of emergency medicine and also serves as assistant director for faculty development and resident education, the Department of Emergency Medicine at the University of Maryland Medical School.
Speaker: Dr. Sarah Manning is an emergency medicine physician.
Speaker: She's assistant professor of clinical emergency medicine in the Department of Emergency Medicine at the Indiana University School of Medicine.
Speaker: They co-authored a wonderful review on tracheostomy emergencies published in Emergency Medicine Clinics of North America, links in the show notes.
Speaker: And today, we are very honored to have them to discuss this important clinical topic.
Speaker: Laura and Sarah, welcome to Critical Matters.
Speaker: Thank you for having us.
Speaker: Thanks.
Speaker: Glad to join you.
Speaker: Before we start recording, I was just chatting that this is something that more often intensivists are doing as procedures, but still the vast majority of critical care physicians and APPs don't do tracheosteum on a regular basis, yet they encounter patients with trachs.
Speaker: at all times, and being able to recognize complications that can be very, very serious and manage them when they do occur initially is something that we believe is very important for all people at the bedside.
Speaker: So I would like to start maybe with just a general introduction of what we think of trachs and the epidemiology of these complications with the procedure, and maybe, Laura, you can take that first.
Speaker: Sure.
Speaker: Tracheostomies are fairly common.
Speaker: We do about 100,000 new trachs annually in the United States.
Speaker: And most of those patients do very well.
Speaker: There are minor complications that people handle at home that we never hear about.
Speaker: Really, it's estimated that somewhere around 40% of patients with a tracheostomy will have a complication at some point.
Speaker: I imagine the number is probably higher because as patients have trachs for longer-threatening,
Speaker: families and individuals get pretty comfortable with managing them at home.
Speaker: But about 1% will have major complications and those are the patients you have to worry about coming to your emergency department.
Speaker: And obviously, as emergency physicians, one of the the the arts of emergency physicians is to really distinguish what is not so worrisome and what is potentially life threatening.
Speaker: And I do believe that we'll talk a little bit about that, but that sometimes with tracheostomies, it can be the case where people undervalue or underestimate something that can potentially be catastrophic.
Speaker: Agreed.
Speaker: Yeah, of the serious complications, about half of them, so nationally thousands of people per year, will die from a complication from their tracheostomy.
Speaker: Now, overall, the incidence is low, so I don't want to scare people out there, but when the major complications happen, they are major.
Speaker: Excellent.
Speaker: Sarah, let me ask you about maybe some frameworks of how we can think and start categorizing these complications so that we have a frame of work to approach them.
Speaker: And one of the methods that I've seen often people talk about is grouping tracheostomy complications based on the time of peak occurrence or based on the timeline related to the tracheostomy procedure.
Speaker: Could you maybe tell us a little bit more about that?
Speaker: Yeah, sure.
Speaker: So that's one of the more common sort of classifications that you'll see in the literature is a time-based sort of grouping.
Speaker: So intraoperative complications, things that, you know,
Speaker: are common are gonna be things like hemorrhage, damage to the trachea or the surrounding structures, air embolism, rare but bad.
Speaker: And then actually Laura and I were chatting a bit earlier.
Speaker: There's also the very feared and kind of intense complication of fire in the operating suite due to your patient needs high flow oxygen and you need to cauterize things.
Speaker: pretty dramatic complications can occur intraoperatively.
Speaker: The next sort of time frame that we talk about is this sort of intermediate or early postoperative period.
Speaker: Here hemorrhage is again going to be a
Speaker: feared severe complication, decannulation, particularly worrisome in the early postoperative period because that tract is not mature, and then extratracheal air and early infectious complications are going to be important here.
Speaker: And then late postoperative periods, these are things that are, you know, weeks, months, even years afterwards are going to be things like, again, hemorrhage.
Speaker: This is one that's
Speaker: you know, can occur at any point.
Speaker: And then development of sort of anatomic complications like tracheal stenosis, fistula formation, and then again, decannulation.
Speaker: So you'll see that decannulation and hemorrhage are sort of consistent throughout the whole sort of time period.
Speaker: And then the others can vary based upon their time from their initial procedure.
Speaker: And obviously, in terms of the audience that we're targeting today, most of what we're talking about is things that occur in the early or late post-op.
Speaker: Like you mentioned, there are some very important complications associated with the procedure itself that obviously operators need to be more familiar with managing.
Speaker: Now, in terms of the types of trachs, Sarah, let me ask you, does it make a difference where you do it percutaneously or open?
Speaker: going to be subtle differences with regards to infectious complications with percutaneous and open terchiostomy approaches.
Speaker: But overall, the complication rate is fairly similar with maybe a little less complications associated with a percutaneous approach.
Speaker: Excellent.
Speaker: And another way that I've seen people set up this framework is based on severity.
Speaker: And maybe Laura, you could give us that framework, which I think is the one I probably use as we discuss each one of the complications.
Speaker: Absolutely.
Speaker: There are three major acute, potentially leading to critical life-threatening illnesses that you have to worry about with tracheostomies.
Speaker: And those are obstruction of the tracheostomy.
Speaker: They are decannulation where the tracheostomy too becomes displaced from its normal anatomic location.
Speaker: And then there's hemorrhage.
Speaker: Those are really the big three.
Speaker: When someone comes in with a tracheostomy complication, you go into that room thinking about those three first.
Speaker: And what would be more urgent complications that maybe we should be worried about, but like you said, are not first and foremost in terms of our concerns?
Speaker: I'm going to let Sarah Manning take that one because that's really her focus.
Speaker: Perfect.
Speaker: Sure, yeah.
Speaker: So urgent complications, meaning you need to take action on them, but they're not going to be immediately life-threatening within minutes to hours.
Speaker: They're going to be things like a tracheoesophageal fistula, tracheal stenosis, infection around the trach site or the trachea, pneumonias as well, and then cutaneous fistula formation.
Speaker: So let's dive into these in more detail.
Speaker: And maybe, Laura, we'll start with the life emergent or life-threatening complications that you mentioned.
Speaker: We talked about decannulation, obstruction, and hemorrhage.
Speaker: And maybe we can start with trichostomy decannulation first.
Speaker: How would you recognize it, manage it?
Speaker: What are the pearls that you could give our listeners in terms of recognizing and managing this potentially deadly complication?
Speaker: Tracheostomy decannulation can occur at any time, and the easiest way to recognize it is when someone comes into the emergency department and the trach is in their hand as opposed to in their neck.
Speaker: That's pretty much a giveaway right there that something's gone wrong.
Speaker: When that happens, you have to get that tracheostomy to back in place as quickly as possible.
Speaker: It is actually time-sensitive because although you're not going to watch the tracheostomy close in front of your eyes, actually the tracheostomy
Speaker: Diameter of the stoma can actually get smaller over the course of hours, making it difficult to get the same tracheostomy size back in.
Speaker: So if a tracheostomy is completely displaced, it is a time-sensitive condition.
Speaker: That patient should not wait in the waiting room, even though they might not be in any respiratory distress, especially if it's a mature tract.
Speaker: And I think that... You do need to get something back in right away.
Speaker: And even with cleaning the tracheostomy that the patient brought, you can replace the same tracheostomy back in place.
Speaker: So if you're at some place, say a low resource center, maybe someplace where you can't get your hands on tracheostomies quickly, you can use a tracheostomy the patient brought in with them.
Speaker: You just want to give it a quick clean first.
Speaker: Excellent.
Speaker: And I think another important aspect of the cannulation, right, is that when they come to the ED, like you mentioned in the case that you shared, it is more likely than not, not always, that they've probably...
Speaker: had some time for that tract to mature.
Speaker: Now, in the hospital setting, in the ICU, a lot of times people might have a decannulation hours the day after or immediately post the procedure.
Speaker: And could you tell us a little bit about, you talked about time sensitive in terms of the stoma closing, but there's also a very time sensitive issue in knowing when the trach was done related to maturity.
Speaker: Could you talk a little bit more about that?
Speaker: Yes, absolutely.
Speaker: And that is a very, very important part because that differentiates how you're going to approach putting that trach back in.
Speaker: Thankfully, a tracheostomy tract is considered mature after just seven days.
Speaker: So they do mature quickly, which is a very nice thing.
Speaker: Within those first seven days, patients likely haven't left the hospital, and there are retention sutures in place to try and have an extra layer of protection.
Speaker: So if the tracheostomy falls out, the connection between the trachea and the skin of the patient is still maintained.
Speaker: Because the concern is the track isn't mature, the tissue hasn't had time to heal, create that track, and
Speaker: The tracheostomy falls out, and now you have a hole in the skin and a hole in the trachea, but they're not necessarily aligned with one another.
Speaker: And trying to thread that needle, thread the tracheostomy through the skin, tracheostomy 2, rather, through the skin and into the trachea itself, should not be done blindly.
Speaker: So if someone's tracheostomy has been displaced and the trache has been in there for seven days or fewer,
Speaker: Do not go blind.
Speaker: You need fiber optic guidance on this one.
Speaker: You definitely need to see where you're going because the risk of creating a false track and putting the tracheostomy tube into the subcutaneous tissue of the neck is very high.
Speaker: It's just not worth doing.
Speaker: So you need to have direct visualization.
Speaker: You would load your tracheostomy tube onto a fiber optic scope, insert that fiber optic scope through the tracheostomy stoma,
Speaker: look, make sure you see tracheal rings or find the tracheal rings.
Speaker: When you know that you're inside the trachea, then you use that scope as a bridge and simply insert your tracheostomy over your scope.
Speaker: And now you know you're in the trachea.
Speaker: Thankfully, that's only in the first seven days and retention sutures are in place to try and minimize the risk of the trachea falling away from the skin.
Speaker: One of the aspects that I often see in emergent situations, whether it be in the emergency department or in the ICU, is that sometimes as we perseverate on a task, we kind of lose our broad focus of other options and better options.
Speaker: And we kind of become very narrow minded.
Speaker: And that can be dangerous for patients.
Speaker: If you have any doubt, what should you do?
Speaker: Well, a tracheostomy patient should still have a patent connection between their oropharynx, nasopharynx, and their trachea.
Speaker: So if you are becoming task-focused and perhaps don't have a fiber optic scope or can't find the tracheal rings, whatever it may be, you can attempt to intubate that patient through the mouth.
Speaker: Now, why that patient got a tracheostomy will certainly have a factor on the ease or difficulty of you being able to do an
Speaker: oral endotracheal intubation.
Speaker: If a patient got a tracheostomy because they have bad COPD and need ventilatory support, then their intubation shouldn't be any different from anybody else's.
Speaker: But if someone got a tracheostomy because they have a head and neck tumor, well, then that's going to make for a potentially a difficult oral intubation.
Speaker: But with a tracheostomy, not with a laryngectomy, but with a tracheostomy, there still is a connection between the oropharynx and the trachea
Speaker: and you can attempt intubation from above through the mouth while you're working on fixing the tracheostomy displacement.
Speaker: And I think that's a super important point, especially for our ICU colleagues, because the reality is that in your world, Laura, you can come, you'll have people who had all sorts of crazy ENT procedures who come in with their trachs right in their hand, and that is a problem.
Speaker: But in the ICU world, with some very, very small exceptions, the vast majority are people who probably were stuck on the ventilator, having a hard time weaning, and they had a trach as part of their progression of care.
Speaker: So likelihood of upper airway issues is...
Speaker: It's probably lower, but it's something that I often forget.
Speaker: People get very excited or focused on trying to fix the trach, but you always, like you said, have something you can do is protect the airway, get that airway, and then call for more help to figure out what the next step is.
Speaker: Yes, and an important thing to remember is that you can oxygenate, right?
Speaker: So while you're working on the trach, put a non-rebreather on the patient's nose and mouth.
Speaker: Give yourself as much time as you can before hypoxia occurs if you're having difficulty with the trach.
Speaker: Excellent.
Speaker: Is there anything else that you would want to mention on decannulation?
Speaker: Absolutely, yes.
Speaker: So we talked about the obvious thing.
Speaker: You're decannulated if someone comes in the trach's in their hands, but the more subtle part is when the tip of the tracheostomy has come out of the trachea, so a false passage has occurred.
Speaker: So someone may come in with a trach that's
Speaker: partially in place, maybe sticking out a little farther than it should be.
Speaker: Um, maybe someone's on a home, a home vent, or maybe someone's just having some respiratory distress, the trach's in place, but they're not breathing well because the trach tip isn't in the tracheostomy.
Speaker: So those things can be more subtle.
Speaker: If someone is trying to be bagged to say someone's in the hospital, they're having a bagged assisted, Ambu bag assisted ventilation and their neck starts to blow up, you start to get discrepidance and, and, uh,
Speaker: and the neck starts to look different because there's sub-q air, the tracheostomy is not in the right spot.
Speaker: So there's the very not subtle presentation of trach completely out and there's the subtle trachs in, but the patient's having some respiratory distress.
Speaker: I can't bag the patient.
Speaker: The vent keeps alarming.
Speaker: There's subcutaneous air of the neck.
Speaker: Those are also tracheostomy displacements.
Speaker: Are there any tricks related to the type of tracheostomy or parts of the tracheostomy or changing to a different type of tracheostomy that are worth having in our bag of tricks for decannulations?
Speaker: Well, you always want to have a smaller one.
Speaker: If you can have a smaller one around, because again, if that trach's been out for any number of hours, it's very possible that you will not be able to put the same one back in.
Speaker: But if you don't have access to a range of tracheostomy sizes, grab an endotracheal tube.
Speaker: You can put an endotracheal tube in.
Speaker: That will work.
Speaker: It's quite a valid temporizing measure until you can get the equipment that you actually need.
Speaker: And in terms of endotracheal tubes and tracheostomy, so usually, and I don't know how standardized this is, but my understanding is that usually the size of the trach is the diameter of the lumen.
Speaker: Does that compare favorably or the same with endotracheal tubes?
Speaker: That's a good question, and unfortunately, it's a complicated answer because it partially depends on the brand of the tracheostomy tube.
Speaker: You would think that a 6-0 endotracheal tube would be a 6-0 tracheostomy tube.
Speaker: It's not, unfortunately, and there's no quick and easy answer for that.
Speaker: It's
Speaker: Endotracheal tubes are measured by inner diameter, tracheostomy tubes are measured by outer diameter.
Speaker: So that might not seem like a big difference, but that millimeter, millimeter and a half can make a difference.
Speaker: So the answer is you have to look at it.
Speaker: You have to know what brand your hospital or clinic or wherever you work stocks for tracheostomies and take a moment to figure out the difference between the numbering of the tracheostomy brand that you have and the numbering of a standard endotracheal tube.
Speaker: Fair.
Speaker: And in general, is there like a go-to ET tube?
Speaker: I guess you're talking about size, so you probably wouldn't go with an eight-size ET tube usually, right, if you're going to put it through the trachostoma?
Speaker: Right, usually a six.
Speaker: A six would be where you would start for an adult.
Speaker: For an adult, you usually start a six.
Speaker: And then, you know, go down or go up, depending on what fits.
Speaker: You don't want to – the tracheostomy, it's not a power maneuver.
Speaker: You shouldn't be putting a lot of force into putting that tracheostomy in place.
Speaker: If you hit resistance, downsize.
Speaker: Perfect.
Speaker: So one of the findings that you were mentioning when there's a false lumen or the trach has decannulated and it's in the wrong position is difficult bagging and other findings that can also be seen with an obstruction, right?
Speaker: So obviously here you can kind of have a little bit of overlap.
Speaker: But let's talk a little bit about tracheostomy obstructions.
Speaker: Sure.
Speaker: Those are very common because patients, you know, tracheostomies require care.
Speaker: And if patients and or caregivers are not vigilant in the care of the tracheostomy, it's very easy for secretions to accumulate in the tracheostomy tube.
Speaker: And then they become dried and they form what's called a tracheostomy cast within the tube.
Speaker: And then you simply have a clogged pipe.
Speaker: It's really just as mechanical as a clogged pipe.
Speaker: the lumen gets smaller and smaller.
Speaker: Patients have a more difficult time breathing, and then they eventually have some respiratory distress.
Speaker: So what's the first thing that you do when you suspect somebody has an obstruction?
Speaker: Take out the tracheostomy if it's more than seven days old.
Speaker: And if it were less than seven days old, Laura?
Speaker: Yeah.
Speaker: That's a tough one.
Speaker: again, you might want to look for alternate ways to help your patient breathe better, such as using the oropharynx, applying oxygen, maybe BiPAP, whatever it is, using the nose and mouth as an entrance.
Speaker: Because taking out a tracheostomy that's fewer than seven days old, it's a risk that you won't be able to get it back in.
Speaker: And I think that often people get flustered and forget kind of the ABCs.
Speaker: But one of the things that I know that commonly people will do is they try to suction, they find resistance.
Speaker: But one of the first things that RT will usually do is deflate the cuff, right?
Speaker: And can you explain a little bit more about that?
Speaker: Sure, of course.
Speaker: If your tracheostomy lumen is obstructed, then you need to use the area around the tracheostomy.
Speaker: Well, that is presumably filled by a balloon.
Speaker: So now the area around the tracheostomy is occluded with a balloon, and the area within the cannula of the tracheostomy is occluded with whatever it may be, a mucus plug, tracheal cast, whatever it is, and there's going to be no flow.
Speaker: So deflating the balloon, although it might seem...
Speaker: wrong.
Speaker: It's sort of, it doesn't seem like a go-to maneuver to deflate the balloon to have someone breathe better.
Speaker: You're simply eliminating the obstruction around the tracheostomy tube so that there is access to the lower portion of the trachea for airflow.
Speaker: Excellent.
Speaker: And then same as with the decannulation, obviously, if you're still struggling, especially if it's a new trach in the ICU, that might be a common situation.
Speaker: You always have the option to secure the airway from above, and that should be your go-to response as you get more help.
Speaker: Mm-hmm.
Speaker: Yes.
Speaker: And grabbing a fiber optic if you have one, because the fiber optic is being able to look and make sure you see tracheal rings and refeed your tracheostomy tube over it is also a go-to maneuver.
Speaker: Excellent.
Speaker: So we talked about detannulation, we talked about obstruction, and the third big potential life-ending complication is hemorrhage.
Speaker: Can we talk a little bit about hemorrhage, Laura?
Speaker: Absolutely.
Speaker: So hopefully...
Speaker: you'll never see it.
Speaker: That's the idea that you'll never see a massive tracheal hemorrhage.
Speaker: But I really enjoy talking about this because this is one of those low incidence, high acuity events that there's no time to, there's simply no time to look up what to do.
Speaker: And if you know what to do, there's a potential, small, but potential, you can save a life here.
Speaker: And if you don't know how to take immediate action on this patient's
Speaker: The fact is the patient's going to die if there's a major hemorrhage because the mortality from a tracheoanominant artery fistula hemorrhage is 95 plus percent at baseline.
Speaker: Some studies have 100 percent mortality, but there are a handful of things that you need to know to do that could potentially get your patient in that single digit survival rate.
Speaker: And as you mentioned, I've been in practice for several years.
Speaker: I have a lot of gray hair, but I have not seen, fortunately, one of these.
Speaker: But I hear all sorts of stories of patients who died or very dramatic instances of somebody sitting on the patient's chest with their fingers stuck into the trach and rolling the patient to the OR, right?
Speaker: All sorts of things.
Speaker: But in terms of bleeding, minor bleeding is common from patients, especially critically ill patients that have
Speaker: many reasons to have cardiopathy but that's not what we're talking about here we're talking about the the big one really is um when when you have an arterial bleed that like you mentioned if not taking care of immediately will kill the patient and how do we recognize that
Speaker: Well, yeah, I do want to pause there for a moment because the major bleeds, sure, they're obvious.
Speaker: You know what's happening.
Speaker: But the minor bleeds can tell you that a major bleed is coming.
Speaker: So in addition to sort of knowing what to do,
Speaker: One take-home point that Sarah and I always try and drive home whenever we talk about this to audiences is that any tracheostomy bleeding, you must identify the source.
Speaker: If it stopped, if it was minor, if the patient wants to go home, whatever it is, you have an obligation to definitively identify the source of that bleeding.
Speaker: Because if that was a sentinel bleed that stopped, your patient will die on the second bleed.
Speaker: That's the fact.
Speaker: If you get, if you're lucky enough to get it with a patient's lucky enough to get a warning shot, have a sentinel bleed that then spontaneously resolved, you still have to take it very, very seriously.
Speaker: So even that minor bleeding, you have to make sure you identify the source.
Speaker: And that's, I guess, an excellent point and a very important pearl for our audience.
Speaker: If you can immediately identify it with the operator, the surgeon, okay, this is what it was, and you feel comfortable, great.
Speaker: But what would you do?
Speaker: Like, what's a step further if you're really not sure in terms of diagnostics?
Speaker: CTA of the head and neck.
Speaker: You can look for a CTA of the head and neck to look for any vascular disruption.
Speaker: You can do a direct visualization with endoscopy and see if you can see the source of the bleeding.
Speaker: You can use your eyes and maybe the source of the bleeding is actually a skin source.
Speaker: But one way or another, you have to definitively identify the source.
Speaker: So eyes, eyes directly, eyes through a bronchoscope, fine, or a CTA or some combination thereof.
Speaker: And specifically to try to identify an enominate artery fistula or bleeding source, the CTA probably is the best just because of the location, right?
Speaker: Yeah, CTA or classic angiography, one or the other, as long as you're looking at the vessels.
Speaker: Okay, excellent.
Speaker: And they can be very subtle.
Speaker: When you look at a CTA with a trachea enominate artery fistula, you see this tiny little connection and you think, ah, that's nothing.
Speaker: But no, that's the thing that will kill your patient.
Speaker: So you have to also make sure you tell your radiologist what you're looking for.
Speaker: Excellent.
Speaker: So the first very important point with managing hemorrhages to recognize that even what seems to be a trivial bleed can be a sentinel event for something that can be life, life threatening.
Speaker: What should we do if all hell breaks loose and somebody starts bleeding from an enominate artery?
Speaker: Yeah.
Speaker: Well, the first thing you do is you check to see if the tracheostomy tube has a cuff.
Speaker: And the tracheostomy tube has a cuff that's a very good, that's given the situation, that's a good spot to be.
Speaker: You want to slowly over inflate that balloon.
Speaker: You want the average balloon, not average, the standard balloon rather holds 10 cc's of air.
Speaker: that balloon can actually hold up to 50 CCs of air.
Speaker: Now you want to inflate with steadily and gradually.
Speaker: You don't want, certainly don't want to pop the balloon, but those balloons will expand.
Speaker: And if you ever have the opportunity to even grab an endotracheal tube and slowly inflate the balloon up to 50 CCs, you will see the shape of the balloon changes.
Speaker: Not only does the diameter get wider, but the shape changes as well.
Speaker: And that can tamponade.
Speaker: If you are slowly inflating that balloon and you have hemostasis achieved, there's no need to put additional air in.
Speaker: No, stop.
Speaker: But you can put in up to 50 cc's.
Speaker: And 85% of the time, that will work to either stop or control the bleeding to a point where you can get the patient to the, mobilize the patient to the operating room.
Speaker: Is this always a surgical treatment or is there any role for IR here?
Speaker: It's one or the other, whatever you can get to fastest, really whatever's going to stop the bleeding.
Speaker: If you can mobilize IR faster than surgery, then they're both legitimate options.
Speaker: And also depends on your institution and what your operators feel comfortable doing.
Speaker: But like you said, this is one of those that really time is of the essence and there is no definitive treatment at the bedside.
Speaker: All we're doing is temporizing with a hope that we can get them to a definitive treatment.
Speaker: Now, if the balloon fails, what are your other options?
Speaker: Well, let's back up one second.
Speaker: If there is no balloon.
Speaker: Or there is no balloon.
Speaker: That's the tricky part.
Speaker: So here's where it really takes some grit.
Speaker: You have a patient who's having a massive hemorrhage from their airway.
Speaker: There's no balloon.
Speaker: And what am I going to ask you to do?
Speaker: I'm going to ask you to take out the tracheostomy.
Speaker: right seems counterintuitive to everything we've been taught uh in medicine but you want to use a bougie or a tube changer something so that you don't lose uh your lumen take that tracheostomy out and replace it with a tracheostomy tube with a balloon or an endotracheal tube with a balloon and then try and inflate that and then try and inflate that over inflate the balloon if that fails
Speaker: If that fails, then there is one truly heroic maneuver.
Speaker: And you talked about people with their hands in the neck on, on, on the bed, something called an Utley maneuver.
Speaker: You're going to take again, a counterintuitive, but you're going to take that airway out and you're going to reach your finger in and, um,
Speaker: You can visualize this.
Speaker: You're standing in front of the patient.
Speaker: You're taking your index finger, putting it into the tracheostomy, and the enominant artery is actually in front of the trachea.
Speaker: It's between the trachea and the sternum, essentially.
Speaker: So you're going to put your thumb on the sternum on the exterior of the patient, your index finger inside the trachea of the patient, and squeeze the two of them together with the goal of compressing the enominant artery between your finger that is now in the patient's airway
Speaker: and your thumb, which is external to the patient's sternum.
Speaker: It is heroic, and if you do that, and if you gain control of the hemorrhage, then you are not doing anything else at all until that patient gets to IR or the operating room.
Speaker: You simply, you can't let go.
Speaker: Well, quite dramatic and heroic, as you mentioned, but I think it's one of those things that we all hope we never have to do.
Speaker: But like you said, if we encounter these, understanding what are the steps that we need to do as we get help can save that patient's life.
Speaker: Is there any risk factors in particular or a timeframe when these bleeds would be most likely?
Speaker: Yes, in the first, about 75% of trachea nominate fistulas will bleed in the first month after a tracheostomy goes in.
Speaker: So just long enough for the patient to be discharged from the hospital and come back to the emergency department.
Speaker: So that's the really high stress.
Speaker: They can happen at any time.
Speaker: There are case reports of them happening several years out from a trachea being placed, but the majority will happen in the first four weeks.
Speaker: And I do want to have one small caveat here is that as we talked about, while you're trying to control the bleeding, there's also the airway to worry about.
Speaker: And you can, again, try and secure that airway through the mouth.
Speaker: So to keep the patient ventilated while you're trying to deal with the hemorrhage of the trachea, it's complicated.
Speaker: Absolutely.
Speaker: And this sounds like really, I mean, it's going to be a true disaster.
Speaker: And I have fortunately not seen it, but I can only imagine.
Speaker: But it's one of those things that even though it's not as likely, knowing a couple of steps can make a huge difference and being calm at that point.
Speaker: So really appreciate you sharing that with us.
Speaker: So we talked about the cannulation, obstruction and hemorrhage, which are the things that really
Speaker: can kill your patient quickly and that we have to pay attention to where they come to the ED or in the ICU.
Speaker: But there's also other complications, maybe more urgent or called urgent that can occur.
Speaker: And I think it's important for all our clinicians to be aware of.
Speaker: And Sarah, we want to talk about those a little bit more.
Speaker: Yeah, sure.
Speaker: Yeah, so there's a collection of sort of these semi-urgent, urgent complications.
Speaker: Many of these are going to be a little bit later in presentation.
Speaker: Common ones, tracheoesophageal fistula, stenosis of the trachea, and cutaneous fistula.
Speaker: And then infection of either the actual surgical site or pneumonia are going to be super common.
Speaker: So in terms of a facheosephagial fistula, tell us a little bit more about when to suspect it, what are we looking for, what's the treatment, how do we diagnose it?
Speaker: Yeah, sure.
Speaker: So the presentation is commonly just a persistent air leak.
Speaker: You can also notice abdominal distension, particularly if your patient's on some higher pressures, because you're going to be pushing air through this defect into the digestive tract.
Speaker: You also, if it's a smaller defect, you know, sort of
Speaker: recurrent aspiration and complications sort of in that sphere is going to be your giveaway.
Speaker: The reason that this happens is typically as a pressure injury.
Speaker: So prolonged pressure, particularly on the posterior wall of the trachea, is going to
Speaker: lead to this fistula formation.
Speaker: There's a lot of risk factors associated with that.
Speaker: Most of that is going to be things that are having deleterious effects on either wound healing or sort of perfusion.
Speaker: So things that you're going to see a lot, you know, sepsis, anemia, hypotension, poor nutritional status, hypoxia, and then other comorbidities like type 1 diabetes, prolonged steroid use,
Speaker: So a lot of things that sort of go hand in hand with prolonged intubation are going to be risk factors for fistula formation.
Speaker: In terms of... Go ahead.
Speaker: Sorry.
Speaker: No, just sort of thinking in an anatomic kind of sphere as well.
Speaker: You know, the fact that it's sort of a pressure-related injury is also going to contribute to where these occur.
Speaker: Typically, this is going to be distal to the stoma itself and more associated with the level of the balloon of the device.
Speaker: And they can get actually pretty large.
Speaker: You know, they can be upwards of four or five centimeters.
Speaker: And in terms of managing these, obviously, the most important thing is going to be to recognize or at least even suspect it and order the right appropriate diagnostic testing.
Speaker: But in terms of managing, is this something that needs to be managed acutely or something that you just have enough time to, okay, call ENT or look at this with a little bit more time?
Speaker: You've got a little bit of time.
Speaker: There are definitely things that you can do sort of in the immediate setting, and it's really more like a damage control and avoidance of risk.
Speaker: So the bigger risks here is going to be contamination of the airway.
Speaker: And so suctioning the trachea and discontinuing anything oral is going to be beneficial.
Speaker: If you can decompress the stomach, say if they have a gastric tube,
Speaker: that you can use to drain stomach contents is going to be helpful.
Speaker: However, if they have an NG tube, you want to kind of reduce the risk of additional pressure application there.
Speaker: So if they have an NG tube, it's a good idea to remove that.
Speaker: And then just sort of elevating the patient's head of bed to a bit higher, 45 degrees or so, is going to help reduce
Speaker: kind of avoid further contamination as well.
Speaker: And then if they've got an obvious suppurative complication like pneumonia, hopefully you're going to be treating that as well.
Speaker: But the long-term management is in the sphere more of ENT.
Speaker: There's a lot of things they can do minimally invasively all the way up to surgical correction.
Speaker: Excellent.
Speaker: I think like we said, it's more important for emergency physicians and intensivists to recognize and to think about it so that we can avoid further damage and get the right next steps.
Speaker: We're talking about fistulas.
Speaker: There's also cutaneous fistulas that can occur with trachs.
Speaker: Any comments on that, Sarah?
Speaker: Yeah, cutaneous fistulas, they're a little bit different for a couple of reasons.
Speaker: So this is more sort of after decannulation.
Speaker: So, you know, your patient no longer requires their tracheostomy, and so they are decannulated.
Speaker: And ideally, what's going to happen is that that stoma is going to gradually close over the course of several weeks, and most of them are going to close completely in about six weeks.
Speaker: However, you can have sort of that persistent epithelialization of that stoma and just failure to close.
Speaker: They usually give it up to about six months, and if it's still persistent after that point, you sort of diagnose this cutaneous fistula.
Speaker: And really the big thing,
Speaker: sort of issue is the fact that you've got this direct, you know, sort of connection to deep structures of, you know, the trachea and the lungs.
Speaker: And so difficulty maintaining secretions and risk factors for infection are sort of the big issues here.
Speaker: And then obviously you're not going to be able to go swimming.
Speaker: Submersion intolerance is the term that we use there.
Speaker: And just issues with phonation and things like that.
Speaker: So in a more acute setting, I just want to ask you a quick practical question.
Speaker: If you had an obstruction or decannulation emergently and you took out the trachea and intubated them orally, you obviously have a fistula now, right?
Speaker: I mean, or you have a stoma.
Speaker: Maybe it's not fistula is not the right word.
Speaker: What's the best way to cover that?
Speaker: So, so you've, you've orally intubated.
Speaker: Okay.
Speaker: So you can apply just a moistened gauze.
Speaker: This is something to think about, particularly if you are trying to bag your patient, you want to occlude that, that opening as well.
Speaker: So you're going to just, just a moistened gauze to try to be sort of occlude that opening.
Speaker: And I think just an important reminder, right?
Speaker: I mean, in the frenzy of the emergency, maybe you forget about that.
Speaker: But if you're trying to back ventilate or intubate from above, right, you probably have removed the trach, you probably should occlude that and make sure that that stoma is secured.
Speaker: Yeah.
Speaker: Yeah.
Speaker: And then it seems obvious, but again, these can be high stress scenarios.
Speaker: Just make sure that when you do orally intubate your patient that you advance the endotracheal tube to a sufficient depth that the balloon is well below your stoma.
Speaker: Perfect.
Speaker: So the last two complications that I wanted to touch on, and then we can wrap things together, was the tracheal stenosis.
Speaker: If you could give us some comments on that, that obviously is more of a long-term complication, but something that we should all be aware.
Speaker: And it's also in patients who have a history of tracheostomy, that might be a problem.
Speaker: Yeah, tracheal stenosis is pretty common.
Speaker: So more common after prolonged intubation or tracheostomy, particularly with balloon devices.
Speaker: What's going to happen is that there's going to be...
Speaker: granulation tissue and fibrosis that form sort of within the lumen of the trachea.
Speaker: And the sort of beneficial or sort of fortunate thing, I guess, is the more apt term, is that most tracheal stenosis doesn't really cause a lot of symptoms.
Speaker: And it really isn't until 50% or more of the lumen is obstructed that patients really start to notice difficulty clearing secretions, persistent cough, dyspnea,
Speaker: and things like that.
Speaker: Things like dyspnea at rest and stridor, the stenosis has to be very dramatic.
Speaker: You're talking about a lumen, like a tracheal diameter of five millimeters or less that is going to be present before you start to develop those symptoms.
Speaker: So the stenosis is going to be pretty profound if your patient has stridor or dyspnea at rest.
Speaker: One thing that patients may notice that may be sort of the canary in the coal mine is their tube exchanges become progressively difficult.
Speaker: And they may notice a little bit more bleeding with tube changes, and that can be the sign that something is developing.
Speaker: Excellent.
Speaker: So really, it'd be more of patients who have prolonged tracheostomies or managing them maybe even outside of the acute setting, but probably something that in the acute setting, the ICU would be less likely to be a problem.
Speaker: Yeah, the area where it's going to cause a more kind of urgent or emergent issue is when you have underlying tracheal stenosis that maybe on a normal day your patient is able to tolerate without issue, but then they have something else.
Speaker: Maybe they develop tracheitis or pneumonia and difficulty managing those secretions, managing the edema of that acute illness becomes compounded with their tracheal stenosis, and all of a sudden it's a big deal.
Speaker: Perfect.
Speaker: And the last urgent complication that obviously is commonly seen in the ICU with any procedure that's invasive is infection.
Speaker: Could you give us some thoughts on recognizing and managing infection, especially not overdoing it and giving people antibiotics when they don't need it, I presume?
Speaker: Yeah, we are all sort of trying to be better stewards of our antibiotics.
Speaker: But the presence of a tracheostomy is a risk factor for patients.
Speaker: It's this sort of permanent connection between the outside world and the aerodigestive tract.
Speaker: And so, and these are two very sort of microbial rich environments that provide a sort of perfect milieu for bacterial overgrowth.
Speaker: So the cornerstone of infection sort of care with these is just going to be really strict wound care.
Speaker: And this is true in immediate post-operative setting and just the general maintenance of a tracheostomy device is going to be strict hygiene with regards to your care.
Speaker: Okay.
Speaker: Most infections are going to occur sort of postoperative, like that early postoperative period, a little bit more commonly with an open tracheostomy.
Speaker: Most of these are going to be minor.
Speaker: And a lot of times even just sort of that wound care is going to be enough if you start to develop symptoms.
Speaker: If erythema and cellulitic change that's extending more than, you know, oftentimes we'll talk about like four or six centimeters away, then you're really starting to apply your antibiotics at that point.
Speaker: And then it can get really bad, though.
Speaker: So things like osteomyelitis, even neck fascia have been observed after tracheostomy placement.
Speaker: Is there any value in prophylactic antibiotics or that's not something that's recommended?
Speaker: It's a little bit controversial.
Speaker: My sort of the current thing that I'm seeing the most is that probably not sort of outside of, you know, sort of intraoperative kind of stuff.
Speaker: Not really.
Speaker: And it shouldn't be carried on sort of in that early postoperative period.
Speaker: Excellent.
Speaker: Well, I think that we definitely covered a broad spectrum of emergent life fetting to urgent complications.
Speaker: I want to be respectful of everybody's time, so I would like to put things together.
Speaker: Sergio, can I just jump in with that?
Speaker: One thing, because I realized when we were talking about the obstruction, there's so much to talk about.
Speaker: But one point, which I really do want to make sure we cover in this podcast, is that when someone has a double cannula tracheostomy, which most adults do, most children do not because it adds that extra effect.
Speaker: width of the tracheostomy, but most adults do, is that if there's an obstruction, simply taking out that inner cannula and leaving the outer cannula in place will relieve most of the obstructions.
Speaker: And it's a very simple maneuver.
Speaker: So I know we have to think about both the simple and the complicated.
Speaker: I want to make sure we put that simple in there.
Speaker: If someone has an inner cannula,
Speaker: And that's where the blockage is going to be.
Speaker: Just take that out.
Speaker: The patient will still h ave a patent airway because the outer canyon will still be in place.
Speaker: And you will make your patient feel much better very, very quickly.
Speaker: Excellent.
Speaker: And I think that's a very important point, Laura.
Speaker: What I was going to say, those who know me know that I like things in threes and kind of three lessons that I definitely learned today in not any particular order.
Speaker: But number one is you absolutely must know when that trait was placed.
Speaker: And that's a big, big, important piece of information.
Speaker: And seven days is kind of a magical day, right?
Speaker: I mean, below seven days is a different approach than more than seven days.
Speaker: And that relates to
Speaker: Pursuing maturity of that of that track that tracheal tract number two is that for every one of these emergencies, especially the ones that are life-threatening there are simple steps that you can apply in terms of ABCs right and and
Speaker: An example is what you exactly shared right now.
Speaker: If there's an obstruction, somebody has an inner cannula, remove that, right?
Speaker: And that by itself might be if somebody's having difficulty breathing and they have an inflated cuff, deflate the cuff, and that might help them and give you some time.
Speaker: So there's always simple steps.
Speaker: the trait came out, place it back in that we can follow.
Speaker: And number three, which is really something that I think we can't emphasize also enough is that you always have the option and should always have a plan to intubate from above when things are not going well.
Speaker: And that can save the patient, but also buy you some time.
Speaker: Laura, is there anything else you want to add in terms of your personal approach to these emergencies?
Speaker: We've covered a lot of territory and I think you just summed it up very nicely.
Speaker: I'd say for the obstruction, if it's over seven days old, just put it back in, use endotracheal tube.
Speaker: If you don't have a tracheostomy, I'm sorry for the decannulation that is, if it's greater than seven days old, simply put it back in and use endotracheal tube.
Speaker: If you don't have a tracheostomy tube for an obstruction, remove that inner cannula.
Speaker: And if that doesn't work, take out the tracheostomy.
Speaker: If it's more than seven days old and for the bleeding,
Speaker: make sure you truly identify the source of the bleeding before you decide it's a minor event.
Speaker: Excellent.
Speaker: Sarah, anything from your standpoint?
Speaker: No, I think we've said it a couple of times, but I think it's such a mental hurdle to get over that it bears repeating.
Speaker: I think probably one of, if not the most important sentence in the entire article is, although removing an artificial airway may seem counterintuitive in a distressed patient, a non-functioning tracheostomy offers no benefit to the patient.
Speaker: So it's just another impediment to getting the job done.
Speaker: I think Dr. Manning wrote that line.
Speaker: It's excellent.
Speaker: And I think it also, I would say that not only it doesn't offer any benefits, but I think it's a distraction for the team because it's giving people the wrong focus, right?
Speaker: Yeah.
Speaker: Yeah.
Speaker: So that's a great place to stop our trach discussion.
Speaker: And what I would like to do is we usually close the podcast with some questions unrelated to the clinical topic.
Speaker: Would that be okay?
Speaker: Sure.
Speaker: want to tap into the wisdom of our guest.
Speaker: So I'll start with Laura and we'll do each question for both of you.
Speaker: So the first question relates to books that have influenced you the most or books that you have gifted often to others.
Speaker: Yeah, that's quite a deep question there.
Speaker: I've read a lot of books over the years and each have different influences on me.
Speaker: I have to say, although this may be an answer that, I don't know, perhaps several people give the book, Who Moved My Cheese?
Speaker: It's a short book.
Speaker: It's an easy read and it really has a lot of
Speaker: profound messages delivered in a pretty straightforward way.
Speaker: And I often find myself, I have that one, you know, standing up propped open on my, my bookshelf and I haven't reread it recently, but it's just there as a reminder that it, that it delivers some good messages.
Speaker: Perfect.
Speaker: What about yourself, Sarah?
Speaker: Oh, I'm in the definitely multiple, multiple books camp.
Speaker: I found that I,
Speaker: I've learned sort of different lessons from a couple of books that I've gone back to a couple of times.
Speaker: But if I'm going to pick one book that influenced me the most, it's going to be a little bit of a maybe out there pick.
Speaker: And it's the first book I ever loved.
Speaker: And it was actually Where the Red Fern Grows.
Speaker: And because I'm sitting in my parents' garage,
Speaker: It's my younger brother's old bedroom.
Speaker: We're on a little family vacay.
Speaker: It's going to be where the red fern grows.
Speaker: I remember reading it in third grade with Jeannie George, my third grade teacher.
Speaker: And it was the first book that ever made me realize that books could make you feel things, like could have an emotional connection with a book.
Speaker: And so it has been a book that I have owned for almost my entire life now.
Speaker: Excellent.
Speaker: Well, and I love that obviously one of the reasons why we ask this is because people go in different directions.
Speaker: But I think exactly what you both said, right, is that there are books that within their simplicity have a universal wisdom that you can apply again and again.
Speaker: But also the idea is, I mean, a lot of times I like to gift books because most of the people that I give gifts to or that I interact with are very privileged to have a lot of things going in their life.
Speaker: And
Speaker: I feel that if I give them a book that they connect with, that's a gift that they carry forever.
Speaker: So definitely, it's interesting that this is the first book that you recall creating that connection.
Speaker: So that's just perfect.
Speaker: And I will put links to all these in the show notes.
Speaker: So the next question goes to Laura.
Speaker: What do you believe to be true in medicine or in life that most other people don't believe or at least don't act as they believe it?
Speaker: I'm going to stick with the medicine portion of that.
Speaker: And a truth that I believe that I know to be a truth is even if you as a doctor are having a really bad day, your patient's most likely having a worse day.
Speaker: So always keep that perspective there.
Speaker: that yes, you may be tired, you may not have eaten, whatever it may be, you're still not the patient in the hospital or in the emergency department who's concerned that they have something really bad going on or perhaps actually do have something really bad going on.
Speaker: So always realize as the clinician, you are there to give empathy to your patient, even if you're having a tough time that day.
Speaker: Yeah, and I think it's always a very important reminder, right,
Speaker: We complain sometimes of having a bad shift or a bad day, but we get to go home.
Speaker: A lot of our patients either don't ever make it back or have to be admitted or in the ICU especially are very sick and their families are there still struggling.
Speaker: So I think it's a very, very valuable reminder.
Speaker: And I think that that definitely falls in the category of people not behaving like they believe it.
Speaker: Although if we talked in an environment like this, most people would agree.
Speaker: But it's something that I think often we all or a lot of people forget at the bedside.
Speaker: So it's a great point.
Speaker: Thanks, Laura.
Speaker: Sarah, what about yourself?
Speaker: What is something that you believe to be true in medicine or life that most other people don't believe or don't behave like they believe?
Speaker: I think it's an intersection of medicine and life.
Speaker: I think that our...
Speaker: sort of public discourse has become really just confrontational and kind of mean.
Speaker: And I think that the truth in medicine is that I think most people show up to work and they try their best every day.
Speaker: And sometimes when things aren't going easily and aren't sort of falling in the way you think they should,
Speaker: it's easy to start sort of blaming those around you.
Speaker: But I really do think that everyone shows up to the hospital every day and they try their best.
Speaker: And I think that's absolutely true.
Speaker: And we should obviously give them that benefit, right?
Speaker: And really assume that everybody's there trying to do the best they can.
Speaker: And nobody goes to work thinking, I want to have a crappy day, right?
Speaker: Yeah, I haven't yet.
Speaker: Yeah.
Speaker: Excellent.
Speaker: So to finish, I just wanted to get from each one of you something that you want to share with our audience, something you want every intensivist to know.
Speaker: It could be a quote, fact, even about what we talked today, but just kind of a closing thought.
Speaker: And we'll go with Laura first.
Speaker: I kind of feel like I should give Sarah a first shot at this because I have a feeling from the emergency medicine perspective, we might have similar thoughts on this one.
Speaker: So I'm going to let her go first on this one so I don't steal any thunder that she might have.
Speaker: Sarah, you're up.
Speaker: So, yeah, so I was thinking about this, and I think that I'm a pretty visual person, and I think of sort of our role and sort of information gathering.
Speaker: In the ED, I often feel like a siphon, like I'm starting the siphon, because I feel like once –
Speaker: we get this sort of initial bolus of information.
Speaker: We then know all the other questions we need to ask.
Speaker: And so, and it sucks, literally sucks because we are the siphon.
Speaker: So having to, you know, maybe give us a little...
Speaker: a little break because we're having to suck every ounce of information from often incomplete and variably hopeful informants for especially those critically ill patients.
Speaker: We've all called the nursing home only to find that no nurse on staff was ever taking care of the patient ever.
Speaker: And they're not even sure that they're a resident of their facility.
Speaker: So, yeah.
Speaker: So give us a break on the sometimes not knowing all of those details because we're trying to pull the siphon.
Speaker: And once the information's flowing, we can get a little bit more.
Speaker: But we're in that first stage.
Speaker: Yep.
Speaker: And I think it connects to what you were saying, right?
Speaker: It's really having that empathy, not only for our patients, but also for our colleagues in terms that we don't always –
Speaker: Stand in their shoes and understand what else is going on.
Speaker: And the stories that we usually make to explain whatever we think is a shortcoming are usually the wrong stories, right?
Speaker: So have that empathy for everybody.
Speaker: I think it's a very important point.
Speaker: Laura?
Speaker: Laura?
Speaker: I'm so glad I let Sarah go first because I had a feeling we'd be circling around the same topic material there.
Speaker: And indeed, indeed, we we were.
Speaker: So my my thought is similar, is that in the emergency department with a critical care patient, our job is to treat the patient while we're figuring out what's wrong with the patient.
Speaker: So we we do that.
Speaker: And when all the labs are back and all the data is back and the history has been gathered, the picture really comes in.
Speaker: And that's hopefully what we hand off to the intensivist, at least to the best of our ability.
Speaker: But while we're gathering the data and treating the patient at the same time, it's not as finessed as the care in the ICU, in the emergency department.
Speaker: We acknowledge that.
Speaker: And we just like our colleagues to know that we are building the airplane while we're flying it.
Speaker: I think that's a perfect place to stop.
Speaker: And I want to thank both of you for sharing your time and your expertise on such an important topic.
Speaker: I think very important also the relationship between the ICU and the emergency department, right?
Speaker: And most of our patients come from the ED.
Speaker: And I think getting to work together and building that bridge is something that can only benefit our patients, but also makes our practice much more enjoyable.
Speaker: So again,
Speaker: Thank you for being on the podcast.
Speaker: I hope to talk to you guys again soon.
Speaker: And hopefully I'll meet you in person in a conference in the near future.
Speaker: Well, thank you for having us.
Speaker: Yeah, I appreciate it.
Speaker: That would be great.
Speaker: It's been a lot of fun.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
