Endotracheal-and-Tracheostomy-Suctioning

Endotracheal and Tracheostomy Suctioning: Comprehensive Guidelines and Clinical Considerations

Types of Tracheostomy Tubes

• Single Lumen Tracheostomy:

  • Features a single-chamber design providing direct airway access.

  • Commonly used in emergency situations or when frequent cleaning is not required.

• Double Lumen Tracheostomy:

  • Contains both an outer and an inner cannula.

  • Allows for easier maintenance and cleaning without removal of the entire tube, as the inner cannula can be removed for cleaning while maintaining airway patency.

Partial Laryngectomy

• In this procedure, the upper airway connection between the trachea and larynx remains intact.

• This anatomical configuration creates a dual pathway system, allowing air to flow through both the natural upper airway and the tracheostomy opening.

• Key Clinical Considerations:

  • Upper airway patency is maintained.

  • The trachea remains connected to the larynx.

  • The tracheostomy provides secondary airway access.

  • The patient may retain some vocal cord function.

  • Air leakage is possible during positive pressure ventilation.

• Understanding this anatomy is crucial for effective suctioning techniques and ventilation strategies, especially in emergency situations.

Complete Laryngectomy

• This surgical procedure involves the permanent disconnection of the upper airway from the tracheal system.

• This fundamental anatomical alteration necessitates specialized clinical approaches for airway management and emergency interventions.

• Critical Clinical Implications:

  • Complete separation of the upper airway from the trachea.

  • The tracheostomy serves as the sole respiratory opening.

  • There is no air exchange through the nose or mouth.

  • Oral or nasal interventions provide no respiratory benefit.

  • All airway management must occur through the tracheostomy.

• Critical Alert: Patients with complete laryngectomy will not benefit from any airway interventions performed through the mouth or nose. All respiratory support must be directed through the tracheostomy opening.

Indications for Suctioning

• Patient Criteria: A patient with an endotracheal or tracheostomy tube who requires airway clearance.

• Clinical Signs: Airway obstruction or increased secretions compromising ventilation.

• These fundamental indications guide clinical decision-making on when suctioning interventions are necessary to maintain airway patency and optimize patient ventilation.

Considerations in Outdoor Environments

• Patients with tracheostomy tubes (partial or complete) face unique physiological challenges in cold environments due to their altered airway anatomy, as the natural warming and humidification mechanisms of the upper respiratory tract are bypassed.

• Environmental Adaptations:

  • Loss of natural air warming capability through nasal passages.

  • Direct exposure of tracheal tissues to cold atmospheric air.

  • Requirement for protective covering when outdoors in cool weather.

  • Use of gauze or breathable fabric materials for protection.

• Critical Safety Note: Occlusive dressings cannot be utilized as they will completely obstruct the breathing pathway for patients with complete laryngectomy. Only breathable materials should be used for protection.

• Most patients develop personal strategies using fabric pieces or blankets for warmth and protection in cold outdoor environments.

Emergency Tracheostomy Management (Complete Laryngectomy) Decision Tree

• Tracheostomy Tube Reinsertion:

  • Have the patient raise their chin and inhale.

  • Insert the tube much like an adult OPA.

  • Seat, secure, and inflate the cuff (if applicable).

• Tracheostomy Suctioning:

  • Insert the catheter until a cough is stimulated.

  • Withdraw the catheter $0.5$ cm.

  • Suction for $10$ seconds, every $1$ minute, as needed (QIM PRN).

  • Twist the catheter during withdrawal.

• Oxygen Therapy:

  • Apply a Non-Rebreather (NRB) mask over the tracheostomy.

  • Perform Positive Pressure Ventilation (PPV) with an infant mask over the tracheostomy.

  • Perform PPV directly onto the tracheostomy tube adapter.

• Medical Directive Overview (Note): If the patient has a partial laryngectomy, it will be necessary to cover the tracheostomy while providing positive pressure ventilation with a bag valve mask seated on the patient's face.

Endotracheal and Tracheostomy Suctioning Medical Directive

• $01$ Introduction and Purpose: Establishes comprehensive guidelines for Advanced Care Paramedics (ACPs) and Primary Care Paramedics (PCPs) performing airway suctioning procedures in emergency situations.

• $02$ Primary Indications: Patient with an endotracheal or tracheostomy tube experiencing airway obstruction or increased secretions requiring immediate intervention.

• $03$ Patient Criteria: No specific age restrictions, level of consciousness limitations, or vital sign parameters that preclude the procedure when clinically indicated.

• $04$ Safety Requirements: Mandatory aerosolization Personal Protective Equipment (PPE) for all personnel. Procedures cannot be performed without proper protective equipment.

Suctioning Guidelines (Age-Specific)

• These evidence-based guidelines provide standardized approaches to balance effective secretion removal with patient safety, minimizing the risk of hypoxemia and tissue trauma.

• < 1 year:

  • Suction pressure: $60-100$ mmHg

  • Maximum duration: $10$ seconds

  • Interval between attempts: $1$ minute

• $ext{ extit{ extgreater} } 1$ year to < 12 years:

  • Suction pressure: $100-120$ mmHg

  • Maximum duration: $10$ seconds

  • Interval between attempts: $1$ minute

• $ext{ extit{ extgreater} } 12$ years:

  • Suction pressure: $100-150$ mmHg

  • Maximum duration: $10$ seconds

  • Interval between attempts: $1$ minute

Clinical Considerations for Suctioning

• Pre-oxygenation Protocol:

  • Pre-oxygenate with $100\%$ oxygen before suctioning for $30-60$ seconds prior to each attempt.

  • This critical step optimizes oxygen levels, helps prevent hypoxemia, and maintains adequate oxygen reserves during the procedure.

• Patient Cooperation:

  • In alert patients, encourage voluntary coughing to help clear the airway before mechanical suctioning.

  • This natural reflex promotes more effective secretion removal and may reduce the need for invasive intervention.

  • Patient cooperation enhances procedure effectiveness while maintaining their sense of control and comfort.

  • Clinical Pearl: Voluntary coughing by alert patients can be more effective than mechanical suctioning for loose secretions. Always assess the patient's ability to cooperate before proceeding with invasive measures.

Suctioning an Endotracheal Tube: Systematic Approach

• $01$ Patient Consent and Preparation:

  • Explain the procedure and obtain consent from conscious patients.

  • For unconscious patients, implied consent applies for life-saving interventions.

• $02$ Procedure Initiation Cross-Check (PICC):

  • Complete a standardized verification process specific to endotracheal suctioning to ensure all safety measures are in place.

• $03$ Patient Positioning:

  • Place the patient in a sitting or semi-sitting position when possible to optimize airway access and facilitate secretion drainage.

• $04$ Pre-oxygenation:

  • Provide $100\%$ oxygen for $30-60$ seconds to maximize oxygen reserves before airway manipulation.

• Equipment Preparation:

  • Choose a suction catheter no larger than $\frac{1}{2}$ the inner diameter of the endotracheal tube.

  • Lubricate the catheter with water or saline if available.

  • Prepare all equipment before initiating the procedure.

• Catheter Insertion:

  • Insert the suction catheter without activating suction until a cough reflex is stimulated or resistance is felt.

  • For alert patients, encourage coughing prior to suctioning.

• Suctioning Technique:

  • Withdraw the catheter $0.5$ cm, then begin suctioning.

  • Continue suction while gently twisting and withdrawing the catheter. The total suctioning time must not exceed $10$ seconds.

• Assessment and Clearing:

  • Assess suctioning effectiveness.

  • Clear the suction catheter between attempts by drawing up saline or sterile water through the catheter.

• Re-oxygenation and Completion:

  • Re-oxygenate the patient for an entire minute between attempts.

  • Once the airway is clear, reattach the bag-valve mask and continue positive pressure ventilation.

• Time Management: The $10$-second maximum suctioning time is critical to prevent hypoxemia. Monitor the patient closely for signs of oxygen desaturation during the procedure.

Closed Circuit Inline Suction for ETT

• Inline Suctioning Considerations:

  • Closed circuit inline suction catheters provide continuous ventilation during suctioning procedures.

  • Reduces the risk of hypoxemia and maintains positive end-expiratory pressure (PEEP) when applicable.

• Key Advantages:

  • Maintained ventilation during suctioning.

  • Reduced risk of hypoxemia.

  • Lower infection control risk.

  • Decreased patient disconnection time.

• Critical Alert: If $ext{SpO}_2$ decreases post-suctioning, ensure the suction catheter is fully retracted in the T-piece and not obstructing ventilation airflow.

• The inline suction system allows for efficient airway clearance while maintaining mechanical ventilation support throughout the procedure.

Suctioning an I-Gel Supraglottic Airway (SGA)

• Supraglottic airway devices present unique suctioning challenges requiring specialized techniques and understanding of device anatomy.

• The I-Gel design incorporates specific features that facilitate both airway management and gastric decompression.

• The I-Gel's anatomical design allows for dual-channel access: a primary airway channel for ventilation and oxygenation, and a secondary gastric channel for decompression and secretion management. Understanding these pathways is essential for effective clinical application.

Supraglottic Airway Gastric Port Suctioning

• Gastric port suctioning through supraglottic airways requires careful differentiation from standard gastric decompression procedures and specific scope of practice considerations.

• $1$ Scope of Practice Limitations: This procedure is NOT gastric decompression for PCP or ACP. It specifically addresses gastric secretions impacting SGA seal integrity.

• $2$ Alternative Procedures: Nasogastric and orogastric tube insertion for gastric decompression are separate scheduled II acts that cannot be performed by PCPs.

• $3$ Troubleshooting Sequence: PCPs may proceed only after comprehensive airway troubleshooting, including SGA reseating, size adjustment, and DOPES mnemonic assessment.

• $4$ Specific Indication: The procedure is permitted only when gastric secretions around the SGA opening prevent proper seal formation after all other interventions have failed.

• Clinical Decision Point: Gastric port suctioning should be considered a last-resort intervention when mechanical airway issues have been ruled out and gastric content is clearly compromising device function.

• Visual Identification and Technique: The gastric port provides direct access to the esophageal opening through a dedicated channel in the I-Gel device. This secondary pathway allows for targeted intervention without compromising the primary airway seal or ventilation effectiveness. Proper identification of the gastric port ensures accurate catheter placement and effective secretion removal while maintaining patient safety and device integrity throughout the procedure.

Clinical Considerations for SGA Gastric Port Suctioning

• Differential Diagnosis: When gastric secretions are not immediately evident, consider alternative causes of difficult ventilation before proceeding with gastric port suctioning:

  • Improper Device Size: Incorrect I-Gel sizing can compromise seal integrity and ventilation effectiveness.

  • Incorrect Insertion Depth: Inadequate or excessive insertion depth affects proper positioning and function.

  • Inadequate Pressure Application: Lack of posterior or inferior pressure may prevent optimal seal formation.

  • Airway Obstruction: Foreign material or anatomical issues blocking the airway passage.

• Procedure Endpoint: Turn off suction when fluid clears completely or if no fluid appears after $15$ seconds of continuous suctioning.

DOPES Mnemonic for Airway Troubleshooting

• This is a systematic assessment framework for identifying and resolving supraglottic airway complications in clinical practice.

• D - Displacement Assessment: Has the SGA migrated or changed position within the pharynx? Check for proper anatomical positioning and depth of insertion.

• O - Obstruction Assessment: Has the SGA become occluded with a foreign object? Examine for visible debris, secretions, or anatomical blockage.

• P - Pneumothorax Assessment: Has barotrauma occurred from aggressive ventilations? Consider tension pneumothorax as a cause of decreased oxygenation.

• E - Equipment Failure Assessment: Is there wrong SGA size or equipment malfunction? Check the entire system: monitor, BVM, ETCO₂, extension tube, SGA.

• S - Secretions Assessment: Are thin secretions or thick mucus obstructing the SGA? After ruling out other causes, attempt gastric port suctioning.

Indications and Contraindications for Suctioning (General and SGA Gastric Port Specific)

• Indications: A patient with an endotracheal tube, SGA (with a gastric suction port), or tracheostomy tube, AND airway obstruction or increased secretions compromising ventilation.

• Contraindications for SGA Gastric Port Suctioning: No absolute contraindications when clinically indicated and proper equipment is available.

• Clinical judgment remains paramount in determining appropriate intervention timing and technique selection based on individual patient presentation and airway anatomy.

Conditions for SGA Gastric Port Suctioning

• Patient Parameters:

  • Age: N/A (no specific restrictions apply).

  • LOA (Level of Awareness): N/A (level of awareness is unrestricted).

  • Vital Signs: N/A (HR, RR, SBP parameters are not limited).

• Specific Clinical Conditions:

  • Known or suspected gastric secretions following SGA placement.

  • Evidence of emesis after device insertion.

  • Persistent difficult ventilation despite comprehensive troubleshooting efforts.

  • Failed improvement with standard airway management techniques.

• Clinical Decision Framework: Gastric port suctioning should be considered when mechanical causes of ventilation difficulty have been systematically ruled out and gastric content is identified as the primary cause of seal compromise.

SGA Gastric Port Suctioning Technique

• The procedural approach maintains consistency with established tracheal suctioning protocols while accounting for the unique anatomy and access of supraglottic airway devices.

• Critical Timing Difference: While standard tracheal suctioning is limited to $10$ seconds, SGA gastric port suctioning allows up to $15$ seconds because oxygenation continues through the primary airway channel during the procedure.

• This extended timeframe provides an additional safety margin while maintaining effective secretion removal through the dedicated gastric access port without compromising ventilation support.

Sizing Appropriate Suction Catheter Diameter

• Proper catheter selection ensures effective suctioning while preventing damage to the gastric port and surrounding tissues.

• Catheter Selection Chart: Size compatibility ensures optimal suction effectiveness while preventing gastric port damage or catheter entrapment.

• Technical Specifications: Understanding the dimensional relationships between device sizes and catheter diameters prevents equipment incompatibility and ensures successful procedure completion.

• Safety Consideration: Using oversized catheters can damage the gastric port or become entrapped. Undersized catheters may provide inadequate suction capability for viscous secretions.

Catheter Length and Depth Measurement

• Accurate measurement and marking of insertion depth prevents excessive advancement into the esophageal or gastric spaces while ensuring adequate reach for effective secretion removal.

• $01$ External Measurement: Measure catheter length against the external portion of the I-Gel from the gastric port opening to the proximal end of the device.

• $02$ Depth Marking: Mark the catheter with tape at the measured distance to provide a visual reference during insertion.

• $03$ Insertion Limit: Insert catheter only to the marked depth to prevent excessive advancement and potential injury.

• Depth Control: Excessive catheter advancement beyond the marked length can cause esophageal trauma or perforation. Always respect predetermined insertion limits.

Advanced Catheter Depth Considerations

• Precision in catheter placement requires understanding the anatomical pathway and relationship between the I-Gel gastric port and underlying esophageal structures.

• The gastric channel provides direct access to the esophageal opening, requiring careful depth control to achieve effective secretion removal without advancing too deeply into the gastrointestinal tract.

• Key Measurement Principles:

  • External measurement provides baseline insertion depth.

  • Tape marking serves as a visual insertion limit.

  • Gentle resistance indicates appropriate positioning.

  • Excessive advancement increases injury risk.

• Proper technique balances effective secretion access with patient safety through controlled, measured insertion to predetermined depths.

Preparing the I-Gel Gastric Port and Channel

• $01$ Lubrication Preparation: Apply a small bolus of lubricant to the proximal end of the gastric channel to facilitate smooth catheter insertion and prevent tissue trauma.

• $02$ Channel Priming: Insert the catheter a short distance into the channel and move it in and out to prime the pathway and distribute the lubricant evenly.

• $03$ Catheter Insertion: Insert the suction catheter into the gastric channel until the pre-marked tape marker is reached, ensuring controlled depth.

• $04$ Securing and Suctioning: Secure the catheter with tape, set appropriate suction pressure, and continue until fluid disappears or no return after $15$ seconds.

• Procedure Success Indicators: Effective lubrication reduces insertion resistance and patient discomfort while facilitating smooth catheter advancement through the gastric channel.

Advantages of Gastric Port Suctioning

• Minimally Invasive: Utilizes existing device anatomy without additional airway manipulation or patient discomfort.

• Simple Technique: Easy skill to perform with standard suction equipment and established clinical protocols.

• Targeted Intervention: Specifically removes secretions that affect SGA positioning and seal integrity without compromising ventilation.

• These procedural advantages make gastric port suctioning a valuable tool for managing specific complications while maintaining primary airway function and patient stability.

Limitations of Gastric Port Suctioning

• Foreign Body Limitations: Not designed to remove solid foreign bodies or thick emesis that may require more aggressive intervention techniques.

• Airway Specificity: Not intended for clearing the ventilatory tract or performing tracheal suctioning through the primary airway channel.

• Clinical Limitation: Gastric port suctioning addresses only secretions affecting the SGA seal. It does not replace comprehensive airway assessment or alternative interventions for mechanical airway problems.

• Understanding these limitations ensures appropriate procedure selection and prevents inappropriate application when alternative interventions would be more effective.

Risks and Complications of Gastric Port Suctioning

• $1$ Minimal Risk Profile: Generally a low-risk procedure when performed according to established protocols and safety guidelines.

• $2$ Tissue Irritation: Continuous or prolonged suction can cause irritation to esophageal or gastric tissues, particularly with extended procedures.

• $3$ Infection Risk: Potential for introducing infection if the catheter becomes contaminated during handling or the insertion process.

• Educational Resources: Refer to BCEHS video resources and Ontario medical directives for definitive guidance when differences exist.

• Risk Mitigation: Proper sterile technique, appropriate timing limits, and adherence to established protocols minimize complication risks while maximizing procedure effectiveness.

Key Points for SGA Gastric Port Suctioning

• Comprehensive Airway Management: Utilize appropriate basic airway management techniques as the foundation for all interventions before considering advanced procedures.

• Systematic Troubleshooting: Apply the DOPES mnemonic systematically to identify and address ventilation concerns through evidence-based problem-solving.

• Targeted Intervention: Use SGA gastric port suctioning as indicated when specific criteria are met, and other interventions have proven ineffective.

• Clinical Excellence: Mastery of these key principles ensures optimal patient outcomes while maintaining safety standards and appropriate scope of practice boundaries.

Indications for Emergency Tracheostomy Reinsertion

• Patient Presentation:

  • Existing tracheostomy with displaced inner or outer cannula.

  • Respiratory distress or inadequate ventilation.

  • An available tracheostomy cannula for the identified patient.

• Clinical Rationale for Tracheostomy:

  • $01$ Upper Airway Bypass: Management of upper airway obstruction, commonly due to laryngeal cancer or other obstructive pathology.

  • $02$ Secretion Management: Facilitate the management of airways with copious secretions that cannot be adequately cleared through natural mechanisms.

  • $03$ Prolonged Ventilation: Enable long-term mechanical ventilation support for patients requiring extended respiratory assistance.

Conditions for Emergency Tracheostomy Reinsertion

• Emergency tracheostomy reinsertion protocols provide broad clinical flexibility to address life-threatening situations across diverse patient populations without restrictive criteria.

• Age: N/A (no specific restrictions).

• LOA (Level of Awareness): N/A (no consciousness limitations).

• Vital Signs: N/A (HR, RR, SBP unrestricted).

• Clinical Flexibility: The absence of restrictive parameters allows providers to focus on immediate life-saving interventions based on clinical presentation rather than arbitrary criteria.

Contraindications for Emergency Tracheostomy Reinsertion

• Available Knowledgeable Caregiver: The procedure should be deferred when a caregiver is available who possesses the knowledge and capability to safely replace the tracheostomy tube.

• Inadequate Visualization: Contraindicated when paramedics cannot properly landmark or visualize the tracheostomy site for safe tube reinsertion.

• PPE Requirements: Absolute contraindication to proceed without appropriate aerosolization personal protective equipment.

• Safety Priority: These contraindications prioritize patient safety and appropriate resource utilization while maintaining clinical effectiveness in emergency situations.

Emergency Tracheostomy Reinsertion Guidelines

• Clinical protocols establish clear boundaries for emergency tracheostomy reinsertion attempts while maintaining patient safety and procedural effectiveness.

• Maximum Attempts: Limited to $2$ attempts per patient to minimize trauma and complications.

• Attempt Definition: Each insertion of the cannula into the tracheostomy constitutes one attempt.

• Attempt Limitation Rationale: The two-attempt limit prevents excessive tissue trauma while providing a reasonable opportunity for successful reinsertion in emergency situations.

Main Components of a Tracheostomy Tube

• Outer Cannula:

  • Primary structural component that maintains tracheostomy patency.

  • Features a neck plate with attachment holes for ties or Velcro straps.

  • Available in cuffed (with balloon) or uncuffed configurations.

• Inner Cannula:

  • Removable component fitting inside the outer cannula with a locking mechanism.

  • Equipped with a standard $15$mm bag valve mask adapter connection point.

  • Enables cleaning without tube removal.

• Obturator:

  • Insertion guide providing a smooth surface for tracheostomy tube placement.

  • Fits inside the tube during insertion to prevent tissue trauma and facilitate proper positioning.

• Component Integration: Understanding the relationship between these components is essential for proper assembly, insertion, and maintenance of tracheostomy tubes in clinical practice.

Cuffed vs. Uncuffed Tracheostomy Tubes

• The choice between cuffed and uncuffed tracheostomy tubes depends on specific clinical requirements, patient ventilation needs, and communication considerations.

• Uncuffed Tracheostomy:

  • Advantages: Facilitates communication and speech, allows swallowing function, permits airflow through the pharynx.

  • Disadvantages: Large air leakage during ventilation, unreliable ETCO₂ readings, compromised ventilation efficiency.

• Cuffed Tracheostomy:

  • Advantages: Reliable ventilation and oxygenation, prevents aspiration, accurate ETCO₂ monitoring.

  • Clinical Use: Home or long-term ventilation, mechanical ventilator support, aspiration risk patients.

• Critical Reminder: The cuff must be deflated for safe removal during emergency reinsertion procedures.

Uncuffed Tracheostomy Disadvantages

• Understanding the limitations of uncuffed tracheostomy tubes is crucial for appropriate clinical management and setting realistic expectations for ventilation effectiveness.

• Ventilation Challenges: Large air leakage with uncuffed tubes results in unreliable ventilation and oxygenation, compromising respiratory support effectiveness during emergency situations.

• Monitoring Limitations: Significant air leakage produces inaccurate ETCO₂ readings, reducing the reliability of capnography for ventilation assessment and patient monitoring.

• Functional Benefits: Despite ventilation challenges, uncuffed tubes better facilitate patient communication and swallowing function through maintained upper airway flow.

• Patients with uncuffed tracheostomy tubes typically maintain airflow through their pharynx into the nose and mouth, while those requiring long-term ventilation will have cuffed tubes to support mechanical ventilation and prevent aspiration.

Clinical Considerations for Tracheostomy Reinsertion

• Cannula Preference: A new replacement inner or outer cannula is strongly preferred over cleaning and reusing an existing contaminated one for optimal patient safety and infection control.

• Family/Caregiver Involvement: Utilize available family members or caregivers who possess the knowledge and experience to replace the tracheostomy cannula when they are present and capable.

• Best Practice: Family caregivers often have extensive experience with their specific patient's tracheostomy care and may be the most qualified individuals to perform the reinsertion safely and efficiently.

Tracheostomy Tube Reinsertion: Initial Steps

• $01$ Patient Consent: Promptly explain the procedure and obtain informed consent from conscious patients. For unconscious or altered level of consciousness patients, implied consent applies for life-saving interventions.

• $02$ Procedure Initiation Cross-Check (PICC): Complete a standardized verification process specific to emergency tracheostomy tube re-insertion to ensure all safety measures and equipment are properly prepared.

• $03$ Patient Positioning: Place the patient in a sitting or semi-sitting position when clinically feasible to optimize access to the tracheostomy site and facilitate proper tube alignment.

• Communication Priority: Even in emergency situations, clear communication about the procedure helps reduce patient anxiety and may improve cooperation during the intervention.

Tracheostomy Tube Preparation

• New Tube Preference: Open a new tracheostomy tube when available to ensure sterility and optimal functionality for the reinsertion procedure.

• Existing Tube Preparation (if new tube unavailable): Deflate the cuff with a $10$ml syringe, remove (but retain) the inner cannula, and insert the obturator into the outer cannula.

• Lubrication: Lubricate the end of the tracheostomy tube with water or water-based lubricant to facilitate smooth insertion and reduce tissue trauma.

• Obturator Consideration: While the absence of an obturator does not prevent tracheostomy tube reinsertion, paramedics must exercise extreme caution to avoid damaging tracheal soft tissue with the unprotected outer cannula end.

• Careful preparation minimizes insertion difficulty and reduces the risk of complications during emergency reinsertion procedures.

Tracheostomy Tube Insertion Technique

• $1$ Airway Extension: Raise the patient's chin and extend their head backward to maximally open the tracheostomy and align anatomical structures.

• $2$ Synchronized Insertion: Insert the tracheostomy tube during patient inspiration using a curved upward motion following natural tracheal anatomy.

• $3$ Tube Stabilization: Hold the tube firmly against the neck and immediately remove the obturator to restore airway patency.

• $4$ Inner Cannula Placement: Insert the new inner cannula and twist to lock securely in position.

• $5$ Cuff Inflation: If applicable, inflate the cuff with approximately $6-8$ ml of air for proper seal.

• $6$ Securing and Verification: Secure the tube with neck ties and auscultate the chest to confirm proper placement and breath sounds.

• Insertion Timing: Coordinating insertion with patient inspiration takes advantage of natural tracheal opening and reduces insertion resistance.

Clinical Considerations and Safety Points for Tracheostomy Reinsertion

• $1$ Tube Reuse Guidelines: Avoid reusing original dislodged tracheostomy tubes. If a new tube is unavailable, ensure thorough cleaning with saline or water before reinsertion to minimize infection risk.

• $2$ Secretion Pathophysiology: Airway secretions increase with tracheostomy tubes due to a natural response to a foreign body, reduced laryngeal sensation with cuff inflation causing secretion pooling, and decreased cough effectiveness.

• $3$ Obturator Safety: If the obturator remains in place post-insertion, it will completely obstruct airflow through the tracheostomy tube. Immediate removal is essential for patient ventilation.

• Critical Safety Alert: Never leave the obturator in place after insertion. This will cause complete airway obstruction and immediate respiratory compromise.

Oxygen Therapy Guidelines for Tracheostomy Patients

• Clinical Indications: Provide supplemental oxygen to patients with a tracheostomy or tracheostomy tubes using nonrebreather mask or bag valve mask delivery systems tailored to their unique airway anatomy.

• Primary Indication: Supplemental oxygen delivery via nonrebreather mask or bag valve mask for patients with a tracheostomy or tracheostomy tube requiring respiratory support.

• Safety Requirements: No absolute contraindications exist for oxygen therapy delivery through a tracheostomy. However, paramedics must wear appropriate aerosolization personal protective equipment for all procedures.

• PPE Requirement: Aerosolization PPE is mandatory for all healthcare providers participating in oxygen therapy delivery to tracheostomy patients to prevent infectious disease transmission.

Supplemental Oxygen Delivery Protocol

• $01$ Patient Consent: Explain the procedure and obtain informed consent from conscious patients. Implied consent applies for unconscious or altered consciousness patients requiring life-saving intervention.

• $02$ Airway Assessment: Look, listen, and feel for breathing and airflow at both the mouth and the tracheostomy/tracheostomy tube to determine respiratory pathway functionality.

• $03$ Medical Alert Identification: Check for a Medic Alert bracelet indicating complete or partial laryngectomy status to guide the appropriate treatment approach and intervention selection.

• Critical Clinical Distinction: A patient with complete laryngectomy will not benefit from any airway or breathing interventions initiated through the mouth or nares. All respiratory support must be directed through the tracheostomy opening.

Non-Rebreather Mask Oxygen Delivery

• Non-rebreather mask application for tracheostomy patients requires modification of standard techniques based on available oxygen sources and patient anatomy.

• Single Oxygen Source Available: Apply the oxygen source directly to the tracheostomy opening. Do not apply oxygen to the patient's face as it will provide no respiratory benefit. Consider using a pediatric non-rebreather mask over the tracheostomy site when space is minimal for proper seal and oxygen delivery.

• Two Oxygen Sources Available: Apply oxygen sources to both the tracheostomy and the patient's face to maximize oxygen delivery through all potential respiratory pathways. Monitor oxygen saturation (SpO₂) closely to assess patient improvement and adjust the delivery method as needed.

• Equipment Adaptation: Pediatric non-rebreather masks often provide a better fit and seal around tracheostomy openings due to their smaller size and more flexible design.

Positive Pressure Ventilation via BVM: Initial Assessment

• Bag valve mask ventilation through tracheostomy requires systematic assessment to determine the optimal delivery approach and ensure effective respiratory support.

• Patient Consent and Preparation: Explain the procedure and obtain consent from conscious patients. Implied consent applies for unconscious patients requiring emergency intervention.

• Comprehensive Airway Assessment: Look, listen, and feel for breathing and airflow at both the mouth and tracheostomy to determine functional respiratory pathways and anatomy.

• Laryngectomy Type Identification: Check for a Medic Alert bracelet indicating complete or partial laryngectomy to guide the appropriate ventilation strategy and equipment selection.

• Assessment Priority: Understanding the patient's specific laryngectomy type is crucial for selecting the most effective ventilation approach and preventing ineffective interventions.

BVM Ventilation with Tracheostomy Opening

• $01$ Equipment Preparation: Apply a pediatric or neonatal bag valve mask onto a standard adult BVM with oxygen flowing at $12-15$ Lpm for optimal fit around the tracheostomy opening.

• $02$ Seal and Ventilation: Create an effective seal around the tracheostomy and initiate positive pressure ventilation with appropriate tidal volumes and rate.

• $03$ Air Leak Assessment: If air escapes through the mouth during ventilation, the upper airway and trachea remain connected. Transition to standard facial BVM ventilation.

• $04$ Tracheostomy Sealing: Cover the tracheostomy with a dressing to prevent air leakage when transitioning to an oral/nasal ventilation approach.

• Ventilation Indicator: Air escaping through the mouth indicates maintained upper airway connection, allowing for a transition to standard ventilation techniques with appropriate tracheostomy sealing.

BVM Ventilation with Tracheostomy Tube

• $01$ Initial Assessment: Obtain consent, assess breathing at the mouth and tracheostomy tube, and identify the laryngectomy type through Medic Alert bracelet verification.

• $02$ Obstruction Removal: Remove the tracheostomy tube speaking cap or stoma cover if present to ensure unobstructed airflow through the tube.

• $03$ Inner Cannula Verification: If removed, re-insert the inner cannula into the outer cannula of a double-lumen tube, equipped with a standard $15$mm BVM adapter connection.

• $04$ Direct Connection: Remove the mask from the BVM and connect directly to the $15$mm adapter with oxygen at $12-15$ Lpm for optimal ventilation delivery.

• If air leakage occurs through the mouth, indicating upper airway connection, transition to standard facial ventilation and seal the tracheostomy tube with a speaking cap, stoma cover, or appropriate dressing.

• Equipment Compatibility: The standard $15$mm adapter ensures universal compatibility with bag valve mask systems, facilitating efficient positive pressure ventilation delivery.

Advanced BVM Considerations with Tracheostomy Tube

• If air escapes through the patient's mouth during positive pressure ventilation, this indicates maintained connection between the upper airway and trachea. Standard positive pressure ventilation using an adult bag valve mask on the patient's face becomes the preferred approach.

• Critical Sealing Requirements (when transitioning to facial ventilation):

  • Speaking cap replacement.

  • Stoma cover application.

  • Appropriate dressing placement to prevent air leakage.

• Medication Delivery: When managing patients with tracheostomy tubes, aerosolized medications can be effectively delivered via bag valve mask using standard multi-dose inhaler (MDI) adapter systems.

• This approach maximizes ventilation effectiveness while maintaining appropriate medication delivery pathways for respiratory therapeutics when clinically indicated.

Clinical Considerations and Laryngectomy Types

• Complete Laryngectomy Limitation: Patients with complete laryngectomy receive no benefit from airway or breathing interventions initiated through the mouth or nares. All interventions must target the tracheostomy.

• Medication Delivery: Aerosolized medications can be delivered through tracheostomy tubes via bag valve mask using standard multi-dose inhaler (MDI) adapter systems.

• Laryngectomy Type Review:

  • Partial laryngectomy: The upper airway remains patent with the trachea attached to the larynx. The tracheostomy provides a secondary tracheal opening.

  • Complete laryngectomy: The upper airway is permanently disconnected from the trachea. The tracheostomy serves as the sole tracheal opening.

• Anatomical Recognition: Correctly identifying laryngectomy type through medical alert bracelets or patient history is essential for selecting appropriate intervention strategies and avoiding ineffective treatments.

Respiratory Distress Recognition in Tracheostomy Patients

• Early identification of respiratory distress in patients with tracheostomy or tracheostomy tubes requires understanding modified presentation patterns and assessment techniques.

• Respiratory Symptoms: Dyspnea, tachypnea, and tachycardia present as primary indicators of respiratory compromise requiring immediate assessment and intervention.

• Oxygenation Status: Poor oxygen saturation (SpO₂) readings provide an objective measurement of respiratory effectiveness and intervention success.

• Airway Sounds: Grunting, snoring, gurgling, or stridor through the tracheostomy indicate airway obstruction or secretion accumulation requiring clearing.

• Physical Signs: Accessory muscle use demonstrates increased work of breathing and respiratory system stress requiring supportive intervention.

• Behavioral Changes: Restlessness, confusion, agitation, and anxiety may indicate hypoxemia or hypercarbia affecting neurological function.

• Assessment Focus: Monitor respiratory distress signs specifically at the tracheostomy site rather than relying solely on traditional oral/nasal indicators that may not be present.

Clinical Excellence

• Mastery of endotracheal and tracheostomy suctioning techniques ensures optimal patient outcomes through evidence-based practice, safety-focused protocols, and a comprehensive understanding of airway anatomy and pathophysiology.

• "Excellence in airway management requires continuous learning, precise technique, and unwavering commitment to patient safety in every clinical encounter."

• Key Takeaways: Successful airway management through suctioning and emergency procedures depends on systematic assessment, appropriate equipment selection, proper technique execution, and recognition of individual patient anatomy and clinical needs.