1. Laryngectomy & Tracheostomy Emergency Management & Patient Perspective
Amy Kerr, SLT
Mr Taran Tatla, ENT Consultant
Wednesday 17th July 2013

2. Altered Airway Huge impact on people’s lives
Discoordinated care can result in dangerous, potentially fatal situations
Practices variable
Awareness & knowledge can be lacking
Catastrophic events
Opportunity to do better

3. Artificial Airway Incidents
Majority due to airway loss:
Displaced trache
Tube occlusion (partial or complete)
Airway obstruction / stenosis
Potential factors:
Lack of staff education
Confusion with anatomy
Lack of equipment / resources

4. What is the purpose of an Artificial Airway?
Provide adequate ventilation and oxygenation
Maintain a patent airway
Eliminate airway obstruction
Reduce the potential for aspiration
Provide access for secretion clearance

5. Normal anatomy

6. Tracheostomy

7. Laryngectomy

8. Total Laryngectomy Removal of larynx
Separation of trachea from oesophagus
Permanent stoma

9. Contributing factors to an emergency
Over production of sputum
Coughing
Irritation of trachea
Undue movement of the tracheostomy tube
Multiple suctioning attempts
Dry, hardened secretions
Sputum plug blocking airway or tracheostomy tube
Cuff integrity compromised
Aspiration of stomach contents
Dysphagia

10. National Patient Safety Agency
Approached by the National Association of Laryngectomy Clubs – due to concerns re: emergency care
171 surveys returned

11. National Patient Safety
26/171 patients required ambulance assistance and felt that staff didn’t have the right equipment available.
30/171 patients required emergency treatment in hospital and felt that the hospital staff did not know how to manage their specific needs.
The main concerns for both were lack of:
Tracheostomy masks for delivering oxygen
Suction units for clearing stoma
Tracheal forceps to remove plugs
A patient wrote of his experience in A+E with chest pains. “The nurse was going to give oxygen. I told the nurse I was a neck breather and she then said put the mask on him and we’ll force the air down”

12. Emergency Management Ventilation Suctioning Aspiration Loss of airway
Cardiopulmonary resuscitation

13. Ventilating Tracheostomy vs Laryngectomy patients
Via the stoma* / tracheostomy ^
Trache patients – inflate cuff to form seal
Laryngectomy – insert a trache/endotracheal tube into stoma and inflate cuff
*never via the mouth for a laryngectomy
^must not forget standard oral airway manoeuvres in an emergency with an obstructed tracheostomy

14. Suctioning Tracheostomy: Laryngectomy :
ensure non-fenestrated inner cannula and suction via the tracheostomy
Laryngectomy :
suction via the stoma, no need to place tracheostomy tube.

15. Aspiration – Tracheostomy
Reduce risk by changing to a cuffed tube and inflating cuff, change to a non-fenestrated inner cannula
NB: inflating cuff will help reduce aspiration of secretions but not completely eliminate
Request SLT assessment
If chronic consider use of medication to reduce secretions

16. Aspiration - Laryngectomy
If no Surgical Voice Restoration (SVR), very low risk unless recent Head & Neck Surgery

17. Total Laryngectomy - SVR
If patient has SVR then ensure;
The voice prosthesis is in place – if dislodged and you are able to see the tract – place catheter
Is the voice prosthesis leaking? If it is leaking continue NBM and request SLT assessment 17

18. Loss of airway Tracheostomy:
Suction – if unable to pass catheter remove inner cannula – remove secretions
If still unable to pass catheter patient may require a trache change
Consider positioning of trache, type of trache
Remember standard oral airway manoeuvres

19. Loss of Airway Laryngectomy:
Place tracheostomy / endotracheal tube via stoma
Laryngectomy tube (monitor stoma size)
Suction as required
Humidification:
Regular nebulisers
Humidified oxygen
Ensure adequate hydration to thin & loosen secretions
Speaking valves (e.g. Passy-Muir) NOT for use with laryngectomy patients!

20. Cardiopulmonary Resuscitation
Tracheostomy:
Inflate cuff (if tube not blocked or displaced)
Bag ventilate via tracheostomy tube connector (catheter mount)
If the tracheostomy tube is removed due to blockage/ displacement & unable to be replaced:
If the upper airway is patent, cover the stoma (swabs/ hand) and ventilate via the upper airway (e.g. Bag-valve-mask)
If the upper airway is not patent, ventilate via a paediatric mask or laryngeal mask airway (LMA) applied to the stoma
Compression to breath ratio 30:2

21. Cardiopulmonary Resuscitation
Laryngectomy:
Bag via stoma using a paediatric mask or LMA
Insert a trache / endotracheal tube and inflate cuff to form seal
Compression to breath ratio 30:2

22. UK National Tracheostomy Safety Project NTSP www.tracheostomy.org.uk
Excellent online resources and emergency guidelines
started as a group of 4 Intensive Care Doctors working in Manchester who wanted to improve the management of patients with tracheostomies, and formed a multi-disciplinary working party to develop these resources.

23. Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA
Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia Jun 26. doi: /j , with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd."

24. Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA
Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia Jun 26. doi: /j , with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd."

25. Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA
Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia Jun 26. doi: /j , with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd."

26. Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA
Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia Jun 26. doi: /j , with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd."

28. I was at a recent ENT conference and the speaker showed a similar slide to this one. I would consider myself quite experienced with the care of laryngectomy and tracheostomy patients and this just served to highlight the importance of reading case notes and / or obtaining an accurate, detailed handover.
To try to work out whether the person in each photo has a trache stoma or a permanent lary stoma, is nigh on impossible.
Communication – difficult, with extra care and attention needed