The National Tracheostomy Safety Project -
      The emergency management of
       tracheostomies and laryngectomies

Introduction
 
It is estimated that there are approximately 12,000 tracheostomies and 600 laryngectomies performed each year in the UK. Some of these patients will suffer early complications due to haemorrhage, usually around the time of surgery or subsequent blockage or displacement. The likelihood and nature of such harm as a result of the latter depends to some extent upon the patient’s location at the time (e.g. critical care unit, operating theatre, ward, community). This probably reflects the underlying condition of the patient and the nursing and medical infrastructure available for both routine and emergency care. Even being in a critical care area is no guarantee of safety; NAP4 found that death occurred in up to 50% of patients in these areas when a tracheostomy became displaced.

The need for guidelines
 
Following a cluster of serious adverse incidents in the Northwest relating to tracheostomies and laryngectomies, a group of local Anaesthetists and Intensivists reviewed similar events reported to the NPSA and identified a number of clear, common themes contributing to poor outcome, not least the lack of awareness amongst individuals of the differences between the airway structure of patients with tracheostomies and laryngectomies. Although some institutions had produced local guidelines to help with the management of these patients, based on individually acquired skills, experience or lessons learned from previous errors there was no commonality. It was clear that simple, clear and authoritative guidelines were urgently required, to facilitate training and management, along the lines of those produced by the Difficult Airway Society (DAS) to manage failed intubation and by the Resuscitation Council (UK) to manage cardiac arrest.

This process started with the production of draft guidelines, tested and evaluated by local experts, the formation of a multidisciplinary working group (DAS, Intensive Care Society (ICS), ENT UK, and the British Association of Oral and Maxillofacial Surgeons) and a comprehensive literature review. Feedback was also invited using a process of open peer review. What became apparent at an early stage of the process was the need for distinct guidelines for management of emergencies for patients with either a tracheostomy or laryngectomy, with both carrying a clear message emphasising the need for oxygenation of the patient and the need to call for help early. As the project expanded from a local to a national initiative, the group adopted the name National Tracheostomy Safety Project.

The algorithms
 
The algorithms themselves only provide a reference point or focus for the wider educational process. The guidelines development process and detailed explanation of how the algorithms are used is scheduled for publication in 2012 in the journal Anaesthesia. The key messages in both algorithms are simple; get help early and ensure oxygenation by whatever means.