Beyond the algorithm...
John Moore
Teaching the teachers
Tracheostomy Safety Project
2011
When the expert arrives...
• There will be one of 3 situations
1. First responder has resolved the situation
Supportive intervention only
2. Stable patient oxygenating by face or stoma
May need sedation or anaesthetic to facilitate reintubation or re-fashioning of stoma
Non-emergency situation
3. A loss of airway crisis......
Advanced
algorithm
Failed definitive airway management
• Get further help as appropriate
• Continue to attempt to oxygenate/ventilate via stoma
and upper airway/Face mask/LMA
• Advanced upper airway management with FOB. LMA,
Aintree, Advanced laryngoscopes
• FOB into stoma without Aintree maybe more flexible
• Cricothyroidotomy
• New percutaneous or surgical tracheostomy
Cases...
Beyond the algorithm
Post-op major max-fax 2 days
On HDU, coughing+
Increasing oxygen requirements
CO2 shows reduced trace...
45 mins later
Patient becoming very agitated
SaO2 89% on CPAP
Team arrive
Patient now SaO2 80%
Still breathing but awful respiratory pattern
Patient critically hypoxia
Airway likely difficult
Management please
• Algorithm
• The right team
• Equipment
• When to give drugs and which ones
• Alternative airway
Recovering swine flu patient ICU
Percutaneous tracheostomy
4 days ago
Weaning well since
Now very tachypnoeic
No problem..........
use the algorithm
Patient quickly deteriorates and arrests!
You take trach out but can’t ventilate through
airway or stoma
Could it be something else..
You bronchoscope......
Options...