Laryngectomy & Tracheostomy
Emergency Management
&
Patient Perspective
Amy Kerr, SLT
Mr Taran Tatla, ENT Consultant
Wednesday 17th July 2013
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
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
What is the purpose of an Artificial Airway?
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Provide adequate ventilation and oxygenation
Maintain a patent airway
Eliminate airway obstruction
Reduce the potential for aspiration
Provide access for secretion clearance
Normal anatomy
Tracheostomy
Laryngectomy
Total Laryngectomy
• Removal of larynx
• Separation of trachea from oesophagus
• Permanent stoma
Contributing factors to an emergency
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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
National Patient Safety Agency
• Approached by the National Association of
Laryngectomy Clubs – due to concerns re:
emergency care
• 171 surveys returned
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”
Emergency Management
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Ventilation
Suctioning
Aspiration
Loss of airway
Cardiopulmonary resuscitation
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
Suctioning
• Tracheostomy:
– ensure non-fenestrated inner cannula and suction
via the tracheostomy
• Laryngectomy :
– suction via the stoma, no need to place
tracheostomy tube.
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
Aspiration - Laryngectomy
• If no Surgical Voice Restoration (SVR), very low
risk unless recent Head & Neck Surgery
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
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
Loss of Airway
• Laryngectomy:
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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!
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
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
UK National Tracheostomy Safety Project
NTSP
www.tracheostomy.org.uk
Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management
of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012 Jun 26. doi: 10.1111/j.13652044.2012.07217, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell
Publishing Ltd."
Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management
of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012 Jun 26. doi: 10.1111/j.13652044.2012.07217, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell
Publishing Ltd."
Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management
of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012 Jun 26. doi: 10.1111/j.13652044.2012.07217, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell
Publishing Ltd."
Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management
of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012 Jun 26. doi: 10.1111/j.13652044.2012.07217, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell
Publishing Ltd."