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 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.
Patent upper airway: the ‘Green algorithm’
This algorithm is paired with a green bedhead sign and assumes a potentially patent upper airway, as the upper airway remains
connected to the trachea and theoretically allows ventilation by this route. As the tracheostomy may have been performed
to manage a difficult or impossible upper airway, the paired green bedhead sign emphasises this along with any airway devices
or techniques used successfully. The algorithm follows a standard ‘ABC’ approach, an assessment of tracheostomy patency
and finally techniques of ventilating patients with a tracheostomy.
Laryngectomy: the ‘Red algorithm’
This algorithm is paired with a red bedhead sign and indicates that the patient does not have an upper airway in continuity
with the lungs and therefore cannot be ventilated via this route. The principles of the algorithm are the same,
without the conventional upper airway management steps.
When all types of tracheostomies are considered, the likelihood that an airway stoma encountered in an emergency situation
is a laryngectomy is between 1 in 20 and 1 in 30. A patient with a tracheostomy is more likely to come to harm
by not having oxygen applied to the face if confusion surrounds the nature of the stoma; the default emergency action
is therefore to apply oxygen to the face and the stoma for all neck breathers when there is any doubt as to the nature of a stoma.
Any oxygen applied to the upper airway can be removed in the case of a laryngectomy once this has been confirmed to be the case.
Ventilation via laryngectomy stomas can be achieved using paediatric face masks or laryngeal masks applied to the anterior neck.
The Resuscitation Council (UK) is pleased to have been involved with this very important project and has now endorsed the algorithms.
All healthcare professionals who may encounter patients with either a tracheostomy or laryngectomy are strongly encouraged
to visit the website (www.tracheostomy.org.uk) and review
the algorithms and ensure that they are adequately trained to apply them when required to do so.
Dr Carl Gwinnutt
This article was originally published in
the Resuscitation Council (UK) Newsletter – Winter 2012
© Resuscitation Council (UK) 2012
This page last updated: 9 March 2012