Simulation scenario testing for the
management of critical airway incidents in
Critical Care.
Tracheostomy Management
Contents
1.
2.
3.
4.
Respiratory distress in patient on critical care on CPAP with trachy (obstructed)
Hypoxic patient on day 1 post laryngectomy (partially displaced)
Dislodged trachy on the ward with mild respiratory distress (totally displaced)
Respiratory distress on critical care ward post head & neck surgery, ventilated patient via
trachy, obstructed and displaced
Scenario 1
Respiratory distress in patient on critical care on CPAP with trachy
(obstructed)
Scenario
You are on the ITU and are called to see a 60 year old man who has been on the ITU for 2 weeks and
is recovering from an infective exacerbation of COPD. He required mechanical ventilation for 6 days
and after a failed extubation, he had a percutaneous tracheostomy performed 6 days ago. He has a
single lumen cuffed tracheostomy in situ which has not been changed. He has been weaning steadily
and was breathing spontaneously on a CPAP circuit with 5 cm H2O CPAP and 40% O2, at 30 l/min
flow.
HR is 120/min and Resp rate 45/min with obvious use of the accessory muscles of respiration. His
SpO2 is 86%. There is no vocalisation.
Manikin
Critical Care Environment
Partially obstructed trachy in situ (can we make or fake this?)
HR 120, BP 160/100
RR 45, ventilating through trachy spontaneously, SpO2 86%
Kit List
CPAP Circuit – elephant tubing with trachy connector +/- CPAP valve
Spare NRB Mask with green oxygen tubing
Bougie
Spare trachy tube
Intubation equipment including ETT and LMA and bougie
Waters’ circuit
Fibre-optic scope
Suction catheters to fit down trachy
Bed head trachy sign and algorithm
What are you going to do?
Section 1 – Assessing the patency of the tracheostomy
Expect an ABC approach
1.1 Decide at outset that this is a trachy patient with a potentially patent upper airway. Follow the
patent upper airway algorithm.
1.2 Call for help (Anaesthetics / Critical Care senior help AND ENT / Max Fax)
1.3 Administer 100% O2 to the face via new facemask
1.4 AND 100% O2 to the tracheostomy initially by turning up the FI O2 of the CPAP circuit, or by
attaching a Waters’ circuit (Don’t argue about hypoxic drive!)
1.5 Check that the trachy cuff is inflated (it is)
1.6 Is the patient breathing spontaneously? Minimal ventilation. Bag doesn’t move (if Waters’ circuit
attached). No mouth breathing. This should take candidate down the ‘obstructed’ trachy route. If
they are unsure, then stop the manikin breathing – respiratory arrest.

Assess clinically (listen or feel) minimal breath heard / felt (set to none on manikin?)

or attach a Waters’ circuit and look for spontaneous breathing Bag doesn’t move

ask for Capnography this is not attached initially, but can be set up if requested
1.7 Check patency of tracheostomy with suction catheter. Suction catheter will not pass
1.8 Remove, unblock and replace the inner tube – there is no inner tube
If they ask...
Is there any mouth breathing? No
Look for subcutaneous emphysema. None
Check for obvious displacement, blood or secretions. Not obviously displaced
Exclude a speaking valve. None present
Is there an inner tube? No
1.9 Deflate the trachy tube cuff. Reassess mouth and trachy breathing. No breathing detected at
mouth or trachy.
Section 2 – Removal of tracheostomy and emergency oxygenation
Clinical course
The patient continues to deteriorate with SpO2 75% on 100% O2. Manikn becomes apnoeic and
unresponsive. Make manikin unable to be ventilated and stop breathing
2.1 Remove the blocked tracheostomy. Reassess ventilation via stoma and mouth
If the candidate doesn’t remove the trachy, progress to severe bradycardia (as a hint!) then asystolic
cardiac arrest. (Will have to follow 2 mins CPR 30:2 with 1mg Adrenaline bolus, then address the
airway. Continue with arrest until trachy taken out)
2.2 Simple bag and mask with guedel. No ventilation. SpO2 drop to 70%. HR starts to fall to 80 bpm
2.3 Insertion of LMA as rescue device. No ventilation. SpO2 still 70%. HR falls to 50 bpm
2.4 Oral intubation.
This should be made easy. Manikin should become able to be ventilated but remain apnoeic
Need an uncut tube beyond the stoma or to keep occluding the stoma otherwise ventilation will fail.
Ventilation is possible and SpO2 starts to improve to 90%, HR up to 110 bpm, BP 180/110 mmHg
2.5 Stoma intubation may be attempted if the oral intubation fails or the candidate doesn’t attempt
intubation at all. Re-insertion of a new trachy tube or a small ETT results in successful ventilation and
improvement as above.
2.6 Tracheal stoma ventilation (small facemask, LMA or intubation) may be attempted if failed upper
airway management. This results in SpO2 staying only at 80% as a definitive attempt at securing the
airway is required.
Section 3 – Stabilisation and further management
Clinical course
The patient starts to breathe spontaneously again through the ETT.
SpO2 94%, HR 110 bpm, BP 150/100 mmHg.
3.1 Need expert help to sedate and ventilate
3.2 Need to formally redo the trachy as it is a 6 day old perc. If skills (and time) allow then attempted
re-insertion of trachy over suction catheter, bougie or fibre-optic scope are all acceptable. This
results in stable vital signs as above and successful ventilation spontaneously via the tracheostomy.
Section 4 - Further discussion
Sedate and ventilate or trial of decanulation. Depends on how far off he was prior to this critical
incident. If decanulation was not imminent, probably best to ventilate.
Will need the percutaneous tracheostomy re-fashioning with the aid of a bronchoscope
What measures could we use to try and stop this tracheostomy from occluding in the first place?


Regular suction by healthcare staff competent to look after the tracheostomy
Use of humidification

Use of a double lumen tracheostomy with a cleanable inner tube
What are the pro’s and con’s of a double cannula tube?
Pro’s
Able to remove inner tube and clean easily.
Much less likely to obstruct
Can use fenestrated tubes with fenestrated inners to allow vocalisation
Con’s
Smaller internal diameter can increase breathing resistance compared to a similar external
diameter single lumen tube
Often need an inner tube (which may have been misplaced) to connect to a breathing circuit
in an emergency
Still need replacing after 30 days (10-14 days for simple single lumen tracheostomies)
Increased potential for error when using different inner cannulae with breathing circuits. Eg
fenestrated inner tube with CPAP
Scenario 2
Hypoxic patient on day 1 post laryngectomy (partially displaced)
Scenario
You are called to see a 58 year old man on the High Dependency Unit who is day 1 post total
laryngectomy. There was some bleeding from the stoma at the end of the operation so he had a
double-cannula tracheostomy tube inserted into the stoma. There is a sign attached to his bed head
stating that he has had a total laryngectomy.
He had been doing well and was awake, breathing spontaneously on 40% humidified oxygen via a
trachy mask. He started to cough and quickly became distressed and looks blue. The nursing staff ask
to you come quickly.
Manikin
Critical Care Environment
Partially obstructed trachy in situ (can we make or fake this?)
HR 120, BP 110/55
RR 30, ventilating through trachy spontaneously, SpO2 82%
Kit List
Trachy Mask
Spare NRB Mask with green oxygen tubing
Bougie
Spare trachy tube
Intubation equipment including ETT and LMA and bougie
Waters’ circuit
Fibre-optic scope
Suction catheters to fit down trachy
Bed head trachy sign and algorithm
What are you going to do?
Section 1 – Assessing the patency of the tracheostomy
Expect an ABC approach
1.1 Decide at outset that this is a laryngectomy patient with no upper airway. Follow the
laryngectomy algorithm.
1.2 Call for help (Anaesthetics / Critical Care senior help AND ENT / Max Fax)
1.3 Administer 100% O2 to the face via new facemask (This is a default emergency action. Acceptable
for a candidate to state that face oxygen is not required as there has been a laryngectomy.)
1.4 AND 100% O2 to the tracheostomy initially by turning up the FI O2 of the humidified circuit, or
by attaching a Waters’ circuit
1.5 Check that the trachy cuff is inflated (it is)
1.6 Is the patient breathing spontaneously? Minimal ventilation. Bag doesn’t move (if Waters’ circuit
attached). No mouth breathing! This should take candidate down the ‘obstructed’ trachy route. If
they are unsure, then stop the manikin breathing – respiratory arrest.

Assess clinically (listen or feel) minimal breath heard / felt at stoma (set to none on
manikin?)

or attach a Waters’ circuit and look for spontaneous breathing Bag doesn’t move

ask for Capnography this is not attached initially, but can be set up if requested
1.7 Check patency of tracheostomy with suction catheter. Suction catheter will not pass
1.8 Remove, unblock and replace the inner tube – there is no inner tube
If they ask...
Is there any mouth breathing? No
Look for subcutaneous emphysema. None
Check for obvious displacement, blood or secretions. Not obviously displaced
Exclude a speaking valve. None present
Is there an inner tube? No
Section 2 – Removal of tracheostomy and emergency oxygenation
The candidate should work out that the tube is blocked or partially displaced and must be removed
before moving on. The next essential step is to realise that conventional oral airway management
has no place in this patient and concentrate on the tracheostomy.
Clinical course
The patient continues to deteriorate with SpO2 75% on 100% O2. Manikin becomes apnoeic and
unresponsive. Make manikin unable to be ventilated and stop breathing
2.1 Remove the blocked tracheostomy. Reassess ventilation via stoma
If the candidate doesn’t remove the trachy, progress to severe bradycardia (as a hint!) then asystolic
cardiac arrest. (Will have to follow 2 mins CPR 30:2 with 1mg Adrenaline bolus, then address the
airway. Continue with arrest until trachy taken out)
The SpO2 is too low for them to mess about with fibre-optic scopes etc. If they do, follow the above
hypoxic arrest situation
2.2 No ventilation. Move to emergency oxygenation
2.3 Apply Small Face mask to stoma (try paediatric mask or LMA)

Are they breathing spontaneously? Can you ventilate adequately?

No ventilation spontaneously. Bagging via the stoma is not effective. SpO2 fall to 70%
Try and support ventilation by ‘bagging’. You cannot ventilate adequately
2.4 Attempt intubation of stoma. Use 6.0 cuffed endotracheal tube or similar
Intubation is successful. Candidate may choose a small ETT or laryngectomy tube. Ideally railroaded
over suction catheter, bougie, Aintree catheter or FO scope.
Manikin becomes able to be ventilated again. SpO2 gradually improve to 90%
If they don’t intubate the stoma, there is no ventilation and a hypoxic arrest ensues.
Section 3 – Stabilisation and further management
Clinical course
The patient starts to breathe spontaneously again through the ETT.
SpO2 91%, HR 120 bpm, BP 90/50 mmHg.
3.1 Need expert help to sedate and ventilate
3.2 Transfer to ITU
3.3 ENT need to review
3.4 If time allows, Continue to assess the critically ill patient.
B
Auscultate the chest for bilateral air entry. Check SpO2
Clinical evidence of a pneumothorax? No
Wheeze or crepitations? May be LVF or bronchospasm. No added sounds
C
Ensure IV access. Present
Assess capillary refill and BP (4 secs centrally and 90/50 mmHg)
D
AVPU – unconscious
E
Nil else obvious on exposure
Further discussion
*Some double cannula tubes need the inner tubes inserted so you can attach a breathing circuit to
them.
Ensure they understand the different management of patients without a larynx
Scenario 3
Dislodged trachy on the ward with mild respiratory distress (totally
displaced)
You are called urgently to a medical ward to see a 70 year old woman. She was admitted to ITU 3
weeks ago with LVF and pneumonia and was ventilated for 10 days. She had a surgical tracheostomy
performed to aid in weaning due to her co-morbidities and her significant obesity and she was noted
to be difficult intubation. A percutaneous tracheostomy was not felt to be safe to undertake.
On your arrival she is sweaty and distressed and is pulling at the trachy mask around her neck.
What are you going to do?
ABC approach
Call for help (ENT or Max Fax & Anaesthetics if appropriate)
Administer 100% O2 to the face and the tracheostomy
Attach a Waters’ circuit to the tracheostomy and look for spontaneous breathing
The bag of the waters’ circuit attached to the trachy doesn’t move.
A
Check patency of tracheostomy – suction catheter is simplest
Is there any mouth breathing? There seems to be inspiratory noises
Look for subcutaneous emphysema. None
Look at the capnography trace, or arrange to get a capnograph set up
Check for obvious displacement, blood or secretions. Not obviously displaced
Check the cuff inflates prn. Cuff appears up
Exclude a speaking valve. None present
Is there an inner tube? Yes. Remove, unblock and replace inner tube. Reassess breathing.
There is still no tracheostomy ventilation
What are you going to do?
Hypoxic, distressed patient with non-patent tracheostomy. Not improving with facemask oxygen,
implying obstructed or inadequate upper airway or ventilator effort. Need to remove tracheostomy
as likely to be displaced or blocked.
Removal of the tracheostomy causes improvement – less noisy breathing and patient appears more
comfortable (less use of accessory muscles etc). SpO2 improves to 90%. Need to cover the stoma.
What next?
 Apply oxygen to face and stoma
 Assess rest of patient
B
Auscultate the chest for bilateral air entry. Measure SpO2 Very poor AE bilaterally, 80%.
Bibasal crepitations
Clinical evidence of a pneumothorax? No
Wheeze or crepitations? May be LVF or bronchospasm. Some wheeze throughout
Consider ordering a CXR if the patient’s condition is stable enough (pneumothorax). No time
C
D
E
Ensure IV access. Present
Assess capillary refill and BP (3 secs centrally and 180/110 mmHg). Raised JVP. HR 110 Irreg
AVPU – awake and trying to communicate
Nil else obvious on exposure
What else do we need to do?
 ECG
 CXR
 Bloods and ABG
 Treat for LVF if we think that’s the problem (probably is)
What do we do about the tracheostomy?
Decision on whether it is required or not. Depends on
 Cough and secretion management (need for airway toilet)
 Need to airway protection – eg reduced GCS, not a problem in this case
 Need for ventilator support or CPAP – none for last 3 days
 Swallowing assessment to some degree
Clinical Progress
The patient becomes increasingly short of breath whilst you are arranging a CXR and ECG. The SpO2
drops to 85% on 15l/min non-rebreathe facemask applied to the face.
What are we going to do?
Call for help – ENT / Max Fax / Anaesthetics / ‘Crash team’ if not present
Assess ABCDE as above
A – patent upper airway, tracheostomy is covered with gauze swabs
B – shallow effort, widespread crackles C/W LVF. SpO2 78% on 15l/min as above
C – Cool and shut down peripherally, BP 90 mmHg systolic, HR 100 irreg
D – Responsive only to pain
E – Nil else obvious
Arrange the ususal supportive stuff for LVF
 Diuretics
 Nitrates (BP bit low)
 Inotropes
 CPAP – Discuss now or at end as appropriate*
The patient stops breathing and becomes deeply cyanosed. There is still a cardiac output, 100 bpm,
BP 70 systolic. Crash team here, managing the circulation, candidate asked to manage airway and
ventilation. What are we going to do?
 Standard airway management (keep away from the trachy for now)

Facemask & Bag-valve-mask system – no effective ventilation

Guedel airway and LMA – still can’t ventilate and still cyanosed

Attempt oral intubation – What tube? (uncut, advance beyond the stoma) - can’t see
anything
Expert anaesthetic help arrives and can just manage to bag the patient. SpO2 90%. The crash team
think that CPAP would be a good idea. How could we facilitate this?


Oral intubation with specialist equipment +/- drugs
o Fibreoptic, ILMA etc
Attempt intubation of the tracheal stoma
o Use 6.0 cuffed endotracheal tube
o Bougie / Aintree catheter
o Fibre-optic laryngoscope
Further discussion
Application of facial CPAP in patients with a tracheostomy stoma
o May work if stoma effectively covered
o Likely to have a big leak
Discussion about intubating orally with an uncut tube beyond the stoma to ‘seal’ it. Potential
problems of endobronchial intubation.
How to re-insert a tracheostomy once the airway is secured, ie a controlled situation.
o Surgical trachy – more likely to have a defined track
o Percutaneous trachy will be difficult to change within the first 7-10 days and should be
avoided. This is due to the tissues being elastic and ‘springing’ back into position quickly.
Need to be prepared to re-fashion the tracheostomy from scratch if necessary.
o The longer you wait after removal of a trachy, the more difficult it will become to re-insert.
Potential problems include
o False passage
o Subcutaneous placement with subsequent surgical emphysema
o Mediastinal trauma, great vessels
o The use of adjunct like Aintree catheters and fibreoptic scopes
Scenario 4
Respiratory distress on critical care ward post head & neck surgery,
ventilated patient via trachy, obstructed and displaced
Scenario
You are called urgently to see a 45 year old man who is 2 days post op from a major oral squamous
cell carcinoma (SCC) resection and free flap repair. He had a surgical tracheostomy carried out perioperatively. He has a double cannula tracheostomy in situ.
He is currently receiving assisted spontaneous ventilations (on Pressure Support Ventilation) with
60% inspired oxygen.
There is a large amount of oedema of the face and neck.
He is tachycardic and hypertensive, as well as tachypnoeic with evidence of accessory respiratory
muscle use. His SpO2 is 90%
Manikin
Critical Care Environment
Partially obstructed Trachy in situ
HR 125 BP 170/105
RR 30, spontaneous ventilation via trachy, SpO2 90%
Kit List
Ventilator and tubing
NRB Mask with green oxygen tubing
Bougie
Spare Trachy Tube
Intubation equipment including ETT, LMA
Waters circuit
Suction catheters
Fibre-optic scope
Bed head sign and algorythm
What are you going to do?
Section 1 – assessing the patency of the tracheostomy
Expect an ABC approach
1.1 Decide at the outset that this is a trachy patient with a difficult but potentially patent upper
airway and follow the patent upper airway algorithm
1.2 Call for help (Anaesthetics / critical care senior help and ENT/Max Fax
1.3 Administer100% Oxygen to face via a new face mask
1.4 AND 100% O2 to the tracheostomy by increasing the FIO2 on the vent or by attaching a Waters’
circuit to the tracheostomy and look for spontaneous respiration (bag movement)
1.5 Check Trachy cuff is inflated (it is)
1.6 Is the patint breathing spontaneously? Minimal ventilation. Bag doesn’t move, no mouth
breathing. This should take the candidate down the obstructed trachy route. If they are not sure
then stop the manikin breathing - respiratory arrest

Assess clinically (listen or feel) minimal breath heard/felt

Or attach a Waters’ circuit and look for spontaneous breathing

Look for capnograph trace – there is no trace
1.7 Check patency of tracheostomy with suction catheter. Suction catheter will not pass
1.8 Remove, unblock and replace the inner tube
If they ask
Is there any mouth breathing? No
Look for subcutaneous emphysema. None
Check for obvious displacement, blood or secretions. Blood and secretions present due to
recent surgery
1.9 Deflate the cuff and reassess mouth and trachy breathing. Minimal mouth breathing present no
breathing via trachy.
Tracheostomy is displaced or completely occluded
Section 2 – Removal of tracheostomy and emergency oxygenation
Clinical course
The patient continues to deteriorate SPO2 70% on 100% O2
2.1 Remove tracheostomy, cover the stoma. Reassess the oral airway.
If the candidate doesn’t do this then progress to apnoea and hypoxic asystolic arrest.
2.2 Simple bag valve mask ventilation (not possible)
2.3 LMA as rescue device ( ventilation not possible)
2.4 Oral Intubation. This should be made difficult due to oedema, blood and secretions.
2.5 Stomal ventilation with small face mask or LMA placed over stoma. Some ventilation possible but
SPO2 only 80% as definitive airway required
2.6 Stomal intubation with small ETT, new small tracheostomy tube.
2.7 Next option is fibre-optic endoscopy through the stoma with an Aintree catheter. You can then
replace the tracheostomy over the catheter.
Section 3 – Stabilisation and further management
Clinical course
The patient begins to breath spontaneously through the airway that is in the trachea.
SPO2 90%, HR 115, BP 90/50
3.1 Need formal surgical tracheostomy refashioning in theatre