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Case of the Quarter: The Terrible Trach
Editor's Note: EMS World’s "Case of the Quarter" feature is developed by Texas’ Montgomery County Hospital District EMS to share lessons learned from real-life calls and their outcomes. Click here for the MCHD Paramedic Podcast discussing this case.
Staffed by around 300 paramedics and supported by 12 regional first-responder organizations, Montgomery County Hospital District (MCHD) EMS is a publicly funded 9-1-1 provider for Montgomery County, Texas, covering 1100 square miles just north of Houston. MCHD answers more than 90,000 calls a year. This article follows an MCHD crew responding to a call for shortness of breath and cough in a patient with a tracheostomy tube.
Introduction
Handling complications relating to tracheostomies can be anxiety-provoking for all emergency providers. It’s imperative to understand the parts of a tracheostomy and have an algorithm prepared to evaluate and treat these patients.
Why Is EMS Called
Calls made to emergency services related to tracheostomies commonly include complications such as difficulty breathing, ventilator alarms, fever/infection, increased suction requirements, and, possibly the most concerning, bleeding from the trach. The most frequent cause of respiratory distress in a patient with a tracheostomy is due to obstruction, which may be secondary to mucus plugs, blood clots, or tube displacement.1
Don’t forget that patients with tracheostomy can have other causes for their respiratory difficulties separately or in addition to a tracheostomy complication.
Differential Diagnosis
Tracheostomy obstruction/displacement, pneumonia, pulmonary embolism, foreign body obstruction, heart failure, pneumothorax, and COPD exacerbation.
Why Do Patients Have Tracheostomies?
The indications for tracheostomy placement in adults can be grouped into several categories: to relieve a mechanical airway obstruction (from angioedema, facial trauma, or malignancies), to allow for long-term ventilation, and to manage secretions.1 Tracheotomies can be performed in an open surgical or percutaneous manner with the tracheostomy tubes placed between the second and third tracheal rings (Figure 1). Most tracheostomy stomas are considered matured after 7 days, meaning that the tract is well healed. The age of the stoma, therefore, is an important detail in the patient’s history, as blind reinsertion of a trach tube less than 7 days from surgery increases the risk of creating a false tract.2
The Parts
There is distinct terminology related to tracheostomy tube specifics that are variable depending on patient needs. For example, tubes can be either cuffed or uncuffed, which is comparable to the way that cuffs work on endotracheal tubes. Most tracheostomies also have an inner cannula that resides inside of the tracheostomy tube itself and is removable, which allows for cleaning of the anchored trach tube without the removal of the entire device (Figure 2). Some patients can also have speaking valves or caps that attach to the outside of the tracheostomy tube. The obturator is a rigid inner cannula used to place the tracheostomy under normal conditions. This will be removed after placement and replaced with an inner cannula.
The Call
A 56-year-old male called 9-1-1 complaining of fever, cough, and shortness of breath.
En route: Paramedics were updated on the patient’s past medical history, which included a recent tracheostomy placement about 1 month prior for neck cancer.
Scene findings: The patient was found inside his home, sitting on the edge of the bed. He appeared acutely ill with severe respiratory distress. The primary survey revealed strong peripheral pulses, tachypnea, and subcostal retractions with present breath sounds bilaterally.
On secondary examination, the patient’s skin was warm and diaphoretic. It was also noted that the patient had a tracheostomy tube in place, and on lung exam, he had diminished bilateral breath sounds with diffuse wheezing. No bleeding was observed from the stoma site. The remainder of the secondary survey is unremarkable.
Vital signs: BP 154/92, HR 115, RR 24, O2 saturation 74% on room air, and ETCO2 50.
The patient’s wife informed paramedics that the patient had only started becoming sick earlier that morning with symptoms of fever and cough. Additionally, she stated that the patient had been diagnosed with laryngeal cancer a couple of months ago, and the tracheostomy tube had been placed preventatively for future airway protection.
Medications: Albuterol nebulized PRN.
Allergies: NKDA.
Troubleshooting: There are a few important additional history components that should be queried in tracheostomy patients—the age of the tracheostomy, the reason for tracheostomy, and whether the patient is on mechanical ventilation or requiring oxygen support. In the case of this patient, his trach was over a month old and therefore was considered mature. This is an important detail, as it indicates his tract is well healed, and very unlikely that a false tract is the cause of his respiratory issues. He was not on mechanical ventilation at the time of his encounter.
Interventions
The patient was placed on high-flow oxygen for respiratory support. The tracheostomy inner cannula was removed, revealing a large mucous clot that was almost completely occluding the distal portion of the tracheostomy tube. The patient had immediate resolution of his respiratory distress, and his oxygen saturation increased to 90-92% on room air. Paramedics then placed the patient on oxygen for continued hypoxia. The transport was otherwise uneventful to the receiving hospital.
Clinical Course and Outcome
The patient remained hemodynamically stable in the ED and throughout his hospital course. A CXR was performed in the ED and revealed right lower lobe pneumonia, for which the patient was admitted and placed on IV antibiotics. He improved clinically over the next few days and was discharged from the hospital with an improvement of his infection and resolution of his hypoxia.
Take-home Points
- Know the anatomy and the terminology
- The first question is: is it a trach issue or a lung issue?
- Remember the ABCs and measurement of end-tidal CO2 for ventilation assessment
- Assess for obstruction: Attempt least invasive maneuvers first (Figure 3)
- Any trach bleeding should be concerning and should be transported
References
- Morris LL, Afifi MS. Tracheostomies: the complete guide. Springer Publishing Company, LLC; 2010.
- Marino PL. The ICU Book. 4th ed. Lippincott Williams & Williams; 2014.
Resources
- Tintinalli JE, Ma OJ, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill; 2020.
- McGrath BA, et al. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. N Anaesthesia; 2012. 67 (9), 1025-1041.
- Dickson R, Patrick, C. The Terrible Tracheostomy. MCHD Paramedic Podcast, Episode 69; 2020. http://soundcloud.com/mchdpp/trach-final.
- Emergency tracheostomy management—Patent upper airway. https://www.tracheostomy.org.uk/storage/files/Patent%20Airway%20Algorithm.pdf
Courtney Hill, MD/DO, is an emergency medicine resident at HCA Houston Healthcare in Kingwood, Texas.
Robert Dickson, MD, is EMS medical director at Montgomery County Hospital District EMS and faculty at HCA Houston Healthcare in Kingwood, Texas.
Casey Patrick, MD, is medical director for Harris County ESD 11 Mobile Healthcare and assistant medical director for Montgomery County Hospital District EMS in Conroe, Texas.
Comments
Me llama la atención, que el caso se refiere a... " Un hombre de 56 años llamó al 9-1-1 quejándose de fiebre, tos y dificultad para respirar.", y que en la evaluación inicial ni secundaria, no se haya determinado si había o no fiebre.
En el protocolo no consideran la toma de la temperatura axilar?
—Agustin Dimitris