Tracheostomy Management Sheet Temporary, Less Than 14 Day old PATENT Upper Airway Patient ID: Stoma Formed On: Current Tube Type: Fenestrated?: Size: Cuffed?: Management principles for this patient - read at each shift change • These patients have an intact upper airway that can be used to ventilate the patient, as long as the trachy tube or other material (e.g. blood clot) is not occluding the trachea • Spontaneously breathing patients can breath in and out through both the intact airway and the tracheostomy tube/stoma • IPPV by face mask can be hampered by leak through the tracheostomy tube/stoma • Airway management using usual methods to place an oral or nasal endotracheal tube in the trachea is available, although the endotracheal tube may need to be advanced further than usual so that the cuff is at or below the tracheostomy site • Percutaneously inserted tracheostomy tubes can be VERY DIFFICULT to re-insert within 14 days of placement, and it can be VERY EASY to create FALSE tracts and cause TRAUMA and BLEEDING in attempts to re-insert the tracheostomy tube Q1 Is Exhaled CO 2 still detectable? Q2 Is Saturation acceptable (greater than 80%) and not dropping? Q3 Is Chest Wall moving? Q4 Are Breath sounds audible (at any airway or by auscultation)? 5 ASSESS YES to ALL FOUR (there is time) NO to ANY of the FOUR (life is IMMEDIATELY THREATENED) Surgical “T” Surgical “Slit” Percutaneous Immediate actions in event of concern with tracheostomy (dislodgement or occlusion) 3 GET HELP (press Red Emergency Button if desired) 4 GET EQUIPMENT (Get HELP to bring this to the corridor outside Bed Area) 1 Increase FiO 2 to 100% on ventilator or increase oxygen flow to MAXIMUM on T-piece humidifier or trache-mask • Arrest Trolley • C-Mac Video-Laryngoscope • Emergency Procedure Trolley (Cart 2) • Bronchoscope Trolley • IC Charge of Shift • IC On Site Medical Officer • IC Consultant Or other accessible senior airway practitioner if IC consultant not immediately contactable 2 Ensure inner cannula (if present) is clean and unobstructed by removing and inspecting / replacing 6 Do not touch anything related to the tracheostomy tube or ventilation equipment 7 Prepare for emergency intubation 8 Prepare for emergency percutaneous tracheostomy tube insertion 9 Monitor patient for further deterioration 10 Consider calling Rapid Response Team, especially out of normal hours C2 C5 C6 C7 C4 C3 T2 T1 USUAL ORAL or NASAL Airway Management AFTER REMOVING TRACHEOSTOMY TUBE Sub-stomal approach to trachea Crico-thyroidotomy VIABLE AIRWAY OPTIONS Replacement of Tracheostomy With Percutaneous Insertion Kit 6 Call Rapid Response Team (press Red Emergency Button) 7 Prepare for emergency intubation 8 Prepare for emergency percutaneous tracheostomy tube insertion 9 Disconnect ventilator from tracheostomy tube 10 Attempt bag ventilation via face mask with 100% Oxygen 11 If chest not rising and falling, deflate tracheostomy tube cuff and try again 12 If chest not rising and falling and leak audible from tracheostomy tube or site, occlude tracheostomy tube and try again 13 If chest still not rising and falling, remove tracheostomy tube and occlude tracheostomy hole with gloved finger or thumb and try again
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Tracheostomy Management SheetTemporary, Less Than 14 Day old
PATENT Upper Airway
Patient ID:
Stoma Formed On:
Current Tube Type:
Fenestrated?:
Size:
Cu�ed?:
Management principles for this patient - read at each shift change• These patients have an intact upper airway that can be used to ventilate the patient, as long as the trachy tube or other material
(e.g. blood clot) is not occluding the trachea• Spontaneously breathing patients can breath in and out through both the intact airway and the tracheostomy tube/stoma• IPPV by face mask can be hampered by leak through the tracheostomy tube/stoma• Airway management using usual methods to place an oral or nasal endotracheal tube in the trachea is available, although the
endotracheal tube may need to be advanced further than usual so that the cu� is at or below the tracheostomy site• Percutaneously inserted tracheostomy tubes can be VERY DIFFICULT to re-insert within 14 days of placement, and it can be
VERY EASY to create FALSE tracts and cause TRAUMA and BLEEDING in attempts to re-insert the tracheostomy tube
Q1 Is Exhaled CO2 still detectable?Q2 Is Saturation acceptable (greater than 80%) and not dropping?Q3 Is Chest Wall moving?Q4 Are Breath sounds audible (at any airway or by auscultation)?
5 ASSESS
YES to ALL FOUR(there is time)
NO to ANY of the FOUR(life is IMMEDIATELY THREATENED)
Surgical “T” Surgical “Slit” Percutaneous
Immediate actions in event of concern with tracheostomy(dislodgement or occlusion)
3 GET HELP (press Red Emergency Button if desired)
4 GET EQUIPMENT (Get HELP to bring this to the corridor outside Bed Area)
1 Increase FiO2 to 100% on ventilator or increase oxygen �ow to MAXIMUM on T-piece humidi�er or trache-mask
• Arrest Trolley• C-Mac Video-Laryngoscope• Emergency Procedure Trolley (Cart 2)• Bronchoscope Trolley
• IC Charge of Shift• IC On Site Medical O�cer• IC Consultant
Or other accessible senior airway practitionerif IC consultant not immediately contactable
2 Ensure inner cannula (if present) is clean and unobstructed by removing and inspecting / replacing
6 Do not touch anything related to the tracheostomy tube or ventilation equipment
7 Prepare for emergency intubation
8 Prepare for emergency percutaneoustracheostomy tube insertion
9 Monitor patient for further deterioration
10 Consider calling Rapid Response Team,especially out of normal hours
C2
C5
C6
C7
C4
C3
T2
T1
USUALORAL or NASALAirway ManagementAFTER REMOVINGTRACHEOSTOMY TUBE
Sub-stomal approach to trachea
Crico-thyroidotomy
VIABLE AIRWAY OPTIONS
Replacement of TracheostomyWith Percutaneous Insertion Kit
6 Call Rapid Response Team (press Red Emergency Button)
7 Prepare for emergency intubation
8 Prepare for emergency percutaneous tracheostomy tube insertion
9 Disconnect ventilator from tracheostomy tube
10 Attempt bag ventilation via face mask with 100% Oxygen
11 If chest not rising and falling, de�ate tracheostomy tube cu� and try again
12 If chest not rising and falling and leak audible from tracheostomy tube or site, occlude tracheostomy tube and try again
13 If chest still not rising and falling, remove tracheostomy tube and occlude tracheostomy hole with gloved �nger or thumb and try again
Tracheostomy Management SheetTemporary, 14 Day or older
PATENT Upper Airway
Patient ID:
Stoma Formed On:
Current Tube Type:
Fenestrated?:
Size:
Cu�ed?:
Management principles for this patient - read at each shift change• These patients have an intact upper airway that can be used to ventilate the patient, as long as the trachy tube or other material
(e.g. blood clot) is not occluding the trachea• Spontaneously breathing patients can breath in and out through both the intact airway and the tracheostomy tube/stoma• IPPV by face mask can be hampered by leak through the tracheostomy tube/stoma• Airway management using usual methods to place an oral or nasal endotracheal tube in the trachea is available, although the
endotracheal tube may need to be advanced further than usual so that the cu� is at or below the tracheostomy site• Tracheostomy stoma is generally well formed and stable, and replacing the tracheostomy tube is generally easy, requiring few or no
tools as long as the replacement tracheostomy tube is the same size or smaller
Q1 Is Exhaled CO2 still detectable?Q2 Is Saturation acceptable (greater than 80%) and not dropping?Q3 Is Chest Wall moving?Q4 Are Breath sounds audible (at any airway or by auscultation)?
5 ASSESS
YES to ALL FOUR(there is time)
NO to ANY of the FOUR(life is IMMEDIATELY THREATENED)
Surgical “T” Surgical “Slit” Percutaneous
Immediate actions in event of concern with tracheostomy(dislodgement or occlusion)
3 GET HELP (press Red Emergency Button if desired)
4 GET EQUIPMENT (Get HELP to bring this to the corridor outside Bed Area)
1 Increase FiO2 to 100% on ventilator or increase oxygen �ow to MAXIMUM on T-piece humidi�er or trache-mask
• Arrest Trolley• C-Mac Video-Laryngoscope• Emergency Procedure Trolley (Cart 2)• Bronchoscope Trolley
• IC Charge of Shift• IC On Site Medical O�cer• IC Consultant
Or other accessible senior airway practitionerif IC consultant not immediately contactable
2 Ensure inner cannula (if present) is clean and unobstructed by removing and inspecting / replacing
6 Do not touch anything related to the tracheostomy tube or ventilation equipment
7 Prepare for emergency intubation
8 Prepare for emergencytracheostomy tube replacement
9 Monitor patient for further deterioration
10 Consider calling Rapid Response Team,especially out of normal hours
C2
C5
C6
C7
C4
C3
T2
T1
USUALORAL or NASALAirway ManagementAFTER REMOVINGTRACHEOSTOMY TUBE
Sub-stomal approach to trachea
Crico-thyroidotomy
VIABLE AIRWAY OPTIONS
Replacement ofTracheostomy Tube
6 Call Rapid Response Team (press Red Emergency Button)
7 Prepare for emergency intubation
8 Prepare for emergency tracheostomy tube replacement
9 Disconnect ventilator from tracheostomy tube
10 Attempt bag ventilation via face mask with 100% Oxygen
11 If chest not rising and falling, de�ate tracheostomy tube cu� and try again
12 If chest not rising and falling and leak audible from tracheostomy tube or site, occlude tracheostomy tube and try again
13 If chest still not rising and falling, remove tracheostomy tube and occlude tracheostomy hole with gloved �nger or thumb and try again
Tracheostomy Management SheetTemporary, Less Than 14 Day old
BLOCKED Upper Airway
Patient ID:
Stoma Formed On:
Current Tube Type:
Fenestrated?:
Size:
Cu�ed?:
Management principles for this patient - read at each shift change• The ONLY airway the patient has is the tracheostomy stoma
• Spontaneously breathing patients can breath in and out ONLY through the tracheostomy tube/stoma
• IPPV by face mask IS UNHELPFUL and can cause harm
• Airway management using usual methods to place an oral or nasal endotracheal tube in the trachea is NOT POSSIBLE due to current upper airway anatomy and/or pathology
• Freshly inserted tracheostomy tubes can be VERY DIFFICULT to re-insert within 14 days of placement, and it can be VERY EASY to create FALSE tracts and cause TRAUMA and BLEEDING in attempts to re-insert the tracheostomy tube
Q1 Is Exhaled CO2 still detectable?Q2 Is Saturation acceptable (greater than 80%) and not dropping?Q3 Is Chest Wall moving?Q4 Are Breath sounds audible (at any airway or by auscultation)?
5 ASSESS
YES to ALL FOUR(there is time)
NO to ANY of the FOUR(life is IMMEDIATELY THREATENED)
C2
C5
C6
C7
C4
C3
T2
T1
Sub-stomal approach to trachea
Crico-thyroidotomy
(Temporarily)Can’t INTUBATECan’t VENTILATEORALLY OR NASALLY
VIABLE AIRWAY OPTIONS
Replacement of Trache TubeWith Percutaneous Insertion Kit
Surgical “T” Surgical “Slit” Percutaneous
Immediate actions in event of concern with tracheostomy(dislodgement or occlusion)
3 GET HELP (press Red Emergency Button if desired)
4 GET EQUIPMENT (Get HELP to bring this to the corridor outside Bed Area)
1 Increase FiO2 to 100% on ventilator or increase oxygen �ow to MAXIMUM on T-piece humidi�er or trache-mask
• Arrest Trolley• Emergency Procedure Trolley (Cart 2)• Rhinolaryngoscope (Storz) Video Display Unit
• IC Charge of Shift• IC On Site Medical O�cer• IC Consultant
Or other accessible senior airway practitionerif IC consultant not immediately contactable
2 Ensure inner cannula (if present) is clean and unobstructed by removing and inspecting / replacing
6 Do not touch anything related to the tracheostomy tube or ventilation equipment
7 Prepare drugs used for emergency intubation
8 Prepare for emergency percutaneoustracheostomy tube insertion
9 Lay out CICO Kit ready for use
10 Monitor patient for further deterioration
11 Consider calling Rapid Response Team,especially out of normal hours
6 Call Rapid Response Team (press Red Emergency Button)
7 Prepare drugs used for emergency intubation
8 Prepare for emergency percutaneous tracheostomy tube insertion
9 Lay out CICO Kit ready for use
10 Disconnect ventilator from tracheostomy tube
11 Attempt bag ventilation via tracheostomy tube with 100% Oxygen
12 If unsuccessful:– connect 100% oxygen (e.g. ambu-bag WITHOUT compression) to tracheostomy tube and wait for help– DO NOT remove or attempt to replace tracheostomy tube, as it may aid access to the airway by more experienced personnel
Tracheostomy Management SheetTemporary, 14 Day or older
BLOCKED Upper Airway
Patient ID:
Stoma Formed On:
Current Tube Type:
Fenestrated?:
Size:
Cu�ed?:
Management principles for this patient - read at each shift change• The ONLY airway the patient has is the tracheostomy stoma
• Spontaneously breathing patients can breath in and out ONLY through the tracheostomy tube/stoma
• IPPV by face mask IS UNHELPFUL and can cause harm
• Airway management using usual methods to place an oral or nasal endotracheal tube in the trachea is NOT POSSIBLE due to current upper airway anatomy and/or pathology
• Tracheostomy stoma is generally well formed and stable, and replacing the tracheostomy tube is generally easy, requiring few or no tools as long as the replacement tracheostomy tube is the same size or smaller
Q1 Is Exhaled CO2 still detectable?Q2 Is Saturation acceptable (greater than 80%) and not dropping?Q3 Is Chest Wall moving?Q4 Are Breath sounds audible (at any airway or by auscultation)?
5 ASSESS
YES to ALL FOUR(there is time)
NO to ANY of the FOUR(life is IMMEDIATELY THREATENED)
C2
C5
C6
C7
C4
C3
T2
T1
Sub-stomal approach to trachea
Crico-thyroidotomy
(Temporarily)Can’t INTUBATECan’t VENTILATEORALLY OR NASALLY
VIABLE AIRWAY OPTIONS
Replacement ofTracheostomy Tube
Surgical “T” Surgical “Slit” Percutaneous
Immediate actions in event of concern with tracheostomy(dislodgement or occlusion)
3 GET HELP (press Red Emergency Button if desired)
4 GET EQUIPMENT (Get HELP to bring this to the corridor outside Bed Area)
1 Increase FiO2 to 100% on ventilator or increase oxygen �ow to MAXIMUM on T-piece humidi�er or trache-mask
• Arrest Trolley• Emergency Procedure Trolley (Cart 2)• Rhinolaryngoscope (Storz) Video Display Unit
• IC Charge of Shift• IC On Site Medical O�cer• IC Consultant
Or other accessible senior airway practitionerif IC consultant not immediately contactable
2 Ensure inner cannula (if present) is clean and unobstructed by removing and inspecting / replacing
6 Do not touch anything related to the tracheostomy tube or ventilation equipment
7 Prepare drugs used for emergency intubation
8 Prepare for emergencytracheostomy tube replacement
9 Lay out CICO Kit ready for use
10 Monitor patient for further deterioration
11 Consider calling Rapid Response Team,especially out of normal hours
6 Call Rapid Response Team (press Red Emergency Button)
7 Prepare drugs used for emergency intubation
8 Prepare for emergency tracheostomy tube replacement
9 Lay out CICO Kit ready for use
10 Disconnect ventilator from tracheostomy tube
11 Attempt bag ventilation via tracheostomy tube with 100% Oxygen
12 If unsuccessful:– remove tracheostomy tube and replace with new tracheostomy tube of same type and size or one size (1.0 mm) smaller– Attempt bag ventilation via tracheostomy tube with 100% Oxygen
Tracheostomy Management SheetSurgical End Stoma
NO Upper Airway
There is NO LARYNX
Patient ID:
Stoma Formed On:
Current Tube Type:
Fenestrated?:
Size:
Cu�ed?:
Management principles for this patient - read at each shift change• The ONLY airway the patient has is the tracheostomy stoma• Spontaneously breathing patients can breath in and out ONLY through the tracheostomy tube/stoma• IPPV by face mask IS UNHELPFUL and will cause harm• Airway management using usual methods to place an oral or nasal endotracheal tube in the trachea is NOT POSSIBLE• Surgical end stomas are generally easy to re-cannulate with tracheostomy tubes• There may or may not be a small communication between trachea and oesophagus to aid speech• Tracheostomy tubes in surgically created tracheostomy end stomas are more prone to dislodgement
Q1 Is Exhaled CO2 still detectable?Q2 Is Saturation acceptable (greater than 80%) and not dropping?Q3 Is Chest Wall moving?Q4 Are Breath sounds audible (at any airway or by auscultation)?
5 ASSESS
YES to ALL FOUR(there is time)
NO to ANY of the FOUR(life is IMMEDIATELY THREATENED)
Immediate actions in event of concern with tracheostomy(dislodgement or occlusion)
3 GET HELP (press Red Emergency Button if desired)
4 GET EQUIPMENT (Get HELP to bring this to the corridor outside Bed Area)
1 Increase FiO2 to 100% on ventilator or increase oxygen �ow to MAXIMUM on T-piece humidi�er or trache-mask
• Arrest Trolley• Emergency Procedure Trolley (Cart 2)• Rhinolaryngoscope (Storz) Video Display Unit
• IC Charge of Shift• IC On Site Medical O�cer• IC Consultant
Or other accessible senior airway practitionerif IC consultant not immediately contactable
2 Ensure inner cannula (if present) is clean and unobstructed by removing and inspecting / replacing
6 Do not touch anything related to the tracheostomy tube orventilation equipment
7 Prepare drugsused for emergency intubation
8 Lay out CICO Kit ready for use
9 Monitor patient for further deterioration
10 Consider calling Rapid Response Team,especially out of normal hours
PERMANENTLYCan’t INTUBATECan’t VENTILATEORALLY OR NASALLY
NO AIRWAY ABOVE STOMA
Change Tracheostomy Tube
Sub-stomal approach to trachea
VIABLE AIRWAY OPTIONS
C2
C5
C6
C7
C4
C3
T2
T1
6 Call Rapid Response Team (press Red Emergency Button)
7 Prepare drugs used for emergency intubation
8 Lay out CICO Kit ready for use - note these patients have no larynx,so sub-stomal tracheal puncture is required, not cricothyroid
9 Disconnect ventilator from tracheostomy tube
10 If tracheostomy tube visibly mal-positioned:a De�ate cu� of tracheostomy tube and attempt re-insertion of tube – using
gentle traction on tether suture if present to stabilise and open the airwayc If successful – rein�ate cu� and attempt ventilation of patient with bag via
trachy tube
11 If re-insertion not required or unsuccessful – connect 100% oxygen (e.g. ambu-bag WITHOUT compression) to tracheostomy tube and wait for help
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