Laryngectomy & Tracheostomy Emergency Management & Patient Perspective
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Transcript of Laryngectomy & Tracheostomy Emergency Management & Patient Perspective
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Laryngectomy & Tracheostomy
Emergency Management&
Patient Perspective
Amy Kerr, SLTMr Taran Tatla, ENT Consultant
Wednesday 17th July 2013
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Altered Airway
• Huge impact on people’s lives• Discoordinated care can result in dangerous,
potentially fatal situations• Practices variable• Awareness & knowledge can be lacking• Catastrophic events– Opportunity to do better
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Artificial Airway Incidents
• Majority due to airway loss:– Displaced trache– Tube occlusion (partial or complete)– Airway obstruction / stenosis
• Potential factors:– Lack of staff education– Confusion with anatomy– Lack of equipment / resources
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What is the purpose of an Artificial Airway?
• Provide adequate ventilation and oxygenation• Maintain a patent airway• Eliminate airway obstruction• Reduce the potential for aspiration• Provide access for secretion clearance
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Normal anatomy
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Tracheostomy
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Laryngectomy
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Total Laryngectomy
• Removal of larynx• Separation of trachea from oesophagus• Permanent stoma
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Contributing factors to an emergency
• Over production of sputum• Coughing • Irritation of trachea• Undue movement of the tracheostomy tube• Multiple suctioning attempts• Dry, hardened secretions• Sputum plug blocking airway or tracheostomy tube• Cuff integrity compromised• Aspiration of stomach contents• Dysphagia
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National Patient Safety Agency
• Approached by the National Association of Laryngectomy Clubs – due to concerns re: emergency care
• 171 surveys returned
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National Patient Safety• 26/171 patients required ambulance assistance and felt that staff didn’t
have the right equipment available.
• 30/171 patients required emergency treatment in hospital and felt that the hospital staff did not know how to manage their specific needs.
• The main concerns for both were lack of:• Tracheostomy masks for delivering oxygen• Suction units for clearing stoma• Tracheal forceps to remove plugs
• A patient wrote of his experience in A+E with chest pains. “The nurse was going to give oxygen. I told the nurse I was a neck breather and she then said put the mask on him and we’ll force the air down”
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Emergency Management
• Ventilation• Suctioning• Aspiration• Loss of airway• Cardiopulmonary resuscitation
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Ventilating Tracheostomy vs Laryngectomy patients
• Via the stoma* / tracheostomy ^• Trache patients – inflate cuff to form seal• Laryngectomy – insert a trache/endotracheal tube into
stoma and inflate cuff
• *never via the mouth for a laryngectomy• ^must not forget standard oral airway manoeuvres in
an emergency with an obstructed tracheostomy
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Suctioning
• Tracheostomy:– ensure non-fenestrated inner cannula and suction
via the tracheostomy
• Laryngectomy :– suction via the stoma, no need to place
tracheostomy tube.
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Aspiration – Tracheostomy
• Reduce risk by changing to a cuffed tube and inflating cuff, change to a non-fenestrated inner cannula
• NB: inflating cuff will help reduce aspiration of secretions but not completely eliminate
• Request SLT assessment• If chronic consider use of medication to
reduce secretions
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Aspiration - Laryngectomy
• If no Surgical Voice Restoration (SVR), very low risk unless recent Head & Neck Surgery
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Total Laryngectomy - SVR• If patient has SVR then ensure;– The voice prosthesis is in place – if dislodged and you
are able to see the tract – place catheter– Is the voice prosthesis leaking? If it is leaking continue
NBM and request SLT assessment
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Loss of airway
• Tracheostomy:• Suction – if unable to pass catheter remove inner
cannula – remove secretions• If still unable to pass catheter patient may require a
trache change– Consider positioning of trache, type of trache
• Remember standard oral airway manoeuvres
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Loss of Airway
• Laryngectomy:• Place tracheostomy / endotracheal tube via stoma• Laryngectomy tube (monitor stoma size)• Suction as required• Humidification:
– Regular nebulisers– Humidified oxygen– Ensure adequate hydration to thin & loosen secretions
• Speaking valves (e.g. Passy-Muir) NOT for use with laryngectomy patients!
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Cardiopulmonary Resuscitation
• Tracheostomy:• Inflate cuff (if tube not blocked or displaced)• Bag ventilate via tracheostomy tube connector
(catheter mount)• If the tracheostomy tube is removed due to blockage/
displacement & unable to be replaced:– If the upper airway is patent, cover the stoma (swabs/ hand)
and ventilate via the upper airway (e.g. Bag-valve-mask)– If the upper airway is not patent, ventilate via a paediatric
mask or laryngeal mask airway (LMA) applied to the stoma• Compression to breath ratio 30:2
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Cardiopulmonary Resuscitation
• Laryngectomy:• Bag via stoma using a paediatric mask or LMA• Insert a trache / endotracheal tube and inflate cuff to
form seal• Compression to breath ratio 30:2
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UK National Tracheostomy Safety ProjectNTSP
www.tracheostomy.org.uk
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Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012 Jun 26. doi: 10.1111/j.1365-
2044.2012.07217, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd."
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Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012 Jun 26. doi: 10.1111/j.1365-
2044.2012.07217, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd."
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Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012 Jun 26. doi: 10.1111/j.1365-
2044.2012.07217, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd."
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Reproduced from McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012 Jun 26. doi: 10.1111/j.1365-
2044.2012.07217, with permission from the Association of Anaesthetists of Great Britain & Ireland/Blackwell Publishing Ltd."
![Page 27: Laryngectomy & Tracheostomy Emergency Management & Patient Perspective](https://reader033.fdocuments.in/reader033/viewer/2022061516/568160e7550346895dd01b67/html5/thumbnails/27.jpg)
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