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Difficult Airway Patients

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As a doctor, you may come across patients with complex airways. They should be found on dedicated wards such as respiratory, ENT, ITU or HDU - however bed pressures might lead to patients being on wards with staff who are not used to looking after them. Usually, the patients are visited daily by specialist nurses/critical care for daily input & review. You should ask them to show you what to do in an emergency. Your input should be minimal, however emergencies can occur and very rarely you might be the first person to attend.

As you likely do not have training on managing these patients, your priorities should be:
  • Call for help
  • Apply oxygen
Tracheostomy.org has great resources for healthcare staff with videos detailing the management in an emergency. You can complete the e-learning to be better equipped with managing these complex patients. 

The Basics
Ref: Comprehensive Tracheostomy Care by Dr McGrath (2014)
(a) Tracheostomy: Semi-permanent or permanent operning in the neck with a patent upper airway

(b) Laryngectomy: Surgical removal of the larynx with remnants of the trachea stitched to the anterior neck. There is no communication no between the nose, mouth and lungs.

Management
It may be difficult to tell in an emergency situation whether the patient has a tracheostomy or laryngectomy – hopefully the patient should have ONE of these signs above their bed.

Now this makes your job a whole lot easier! Patients should have a box at their bed space with a variety of equipment; suction catheters, different sized tracheostomies, dilators etc. What you need to find is their Emergency Algorithm, which takes you step-by-step how to manage an emergency situation.

Here is the national algorithm for emergency management in patients with a Tracheostomy or Laryngectomy. The algorithms guide you in a logical way, to address common, treatable issues first. The procedures get more complex as you progress through the algorithm but you can follow the early steps progressing as you feel comfortable. As always, in the first instance you should follow your local guidelines/algorithm.
  • Call for help (don't assume this has been done!). Concerning features include:
    • Airway: grunting, stridor
    • Stoma: blood stained/thick secretions, displaced tubes
    • Obs: high respiratory rate, low saturations, reduced consciousness etc.
  • Look, listen & feel at the stoma (for both tracheostomy or laryngectomy)
    • If not breathing, call the resuscitation team & start CPR if there is no pulse/are no signs of life
  • Apply oxygen in an emergency to both the stoma & mouth (however laryngectomy patients will only get oxygen delivery to the lungs via the stoma as they lack an upper airway)
  • Hopefully by this time help will have arrived with the next steps including an assessment of the patency of the stoma 
    • Removing caps/valves/inner tubes 
    • Do NOT reposition any outer tubes (as this could displace it)
    • passing a suction catheter down the tube to relieve secretions/blood that might be causing obstruction
Following management of their airway you should continue your ABCDE protocol for the deteriorating patient looking for any breathing, circulation or other causes that led to the sudden deterioration. Stay & help your senior colleagues as you will be able to offer assistance and learn advanced airway skills.

References
http://www.tracheostomy.org.uk/healthcare-staff/emergency-care

Written by Mr Sam Arman (CT2)
Edits by Dr Akash Doshi (CT2)

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