Common indications for tracheostomies in palliative care patients include: chronic long-term ventilation, aid with ventilation weaning, and upper airway obstruction. Tracheostomies require careful observation and specialized management; an operational knowledge of the procedure can avoid complications and improve a patient’s well-being.
Essentially, tracheostomy equipment consists of a cannula (or tube), cuff, obturator, and ties. The cannula maintains the patency of the stoma and airway, and it facilitates movement of air into the trachea. Tracheostomy cannulas can be cuffed or uncuffed. Obturators are inserted into the lumen of the cannula and provide for increased rigidity during placement of the tracheostomy tube. Tracheostomy ties wrap around the patient’s neck and secure the tracheostomy tube to the patient.
• Short-term: bleeding from surgical site (~5%), wound infection, subcutaneous emphysema, pneumothorax, tracheostomy tube obstruction, recurrent laryngeal nerve damage, and posterior tracheal wall injury.
• Long-term: dysphagia, airway obstruction from secretions, infection, rupture of the innominate artery, tracheo-innominate artery fistula (<0.7%), tracheoesophageal fistula, tracheal dilation, tracheal stenosis (1-2%), granuloma formation, and tracheal ischemia and necrosis.
Complications and emergencies
• If a patient with a tracheostomy becomes acutely dyspneic, it may be due to partial or complete blockage by retained secretions. Ask the patient to cough and then attempt to suction the tracheostomy in place with a flexible suction catheter. If the tracheostomy stoma and tract is not fully matured, do not attempt to remove the cannula as it may be difficult to re-insert.
• Bleeding from the surgical site is among the most common early complications. Treatments include packing around the edges of the stoma with gauze, correction of coagulopathies, and cautery or suturing of the site of bleeding.
• If accidental decannulation occurs:
- If the tube has been in place less than 5 days, consider endotracheal intubation if a tracheostomy tract cannot be immediately re-established.
- If the tube has been in place for 5-10 days, the tract should be well formed and should not suddenly close. Slowly reinsert the tracheostomy tube with obturator following the path of the airway.
- If it is not possible to insert a new cannula and the patient cannot breathe comfortably on their own through the stoma, use a bag-valve mask to ventilate them through the upper airway. Ventilate smoothly to prevent air from escaping through the stoma, or carefully occlude the stoma with a gloved hand to maximize oxygenation.
• Resuscitation via tracheostomy tube: Do not remove the tracheostomy and check that the cannula is clear. Ventilate by using a manual resuscitation bag attached directly to tracheostomy tube. If unable to ventilate, try suctioning. If still unable to ventilate, try to change tracheostomy tube. The last resort is oral intubation.
See reference for more information
Adapted from Kozin E, Straton J, Kapo J. Tracheostomy care. Palliative Care Network of Wisconsin. Fast facts and concepts #250. Internet. Accessed on April 5, 2020.