What do I do if a trach gets dislodged?!

A nurse runs into the workroom: “Ms. X’s trach is two inches out! She’s desatting to the 70’s on 60% FiO2!”

What do you do for a dislodged trach? This is the situation I faced a week ago, on a patient who wasn’t mine on the floor where I was working.

First, to clarify, dislodged=trach partially out of the stoma, decannulated=trach is all the way out of the stoma. Immature stoma is <1 week, mature stoma >1 week.

I love this slide from Vanderbilt, because it works for me, personally: keep it simple
  1. Your nurses and respiratory therapists are your life line!! Most institutions have protocols to page Anesthesia or a surgical team of some kind for these situations.
  2. Bag valve mask=Ambu bag: whatever you call it, if a patient with a trach is in distress, stabilize them with manual respiration. Apply the bag to the trach itself. If you meet “resistance” while bagging, STOP. It indicates either the trach is in a false tract, or there’s an obstruction, like a plug or extra tissue. (If it’s a false tract, you might be able to feel subcutaneous crepitus develop during bagging!)
  3. If bagging the trach doesn’t work, apply the bag to the patient’s mouth for face bag ventilation. The one caveat is laryngectomy patients: their mouths are not connected to the rest of their airways.
  4. Remove the inner cannula. Insert the suction catheter. If the catheter quickly draws back secretions, it’s still in the right place. If it doesn’t, the trach might be in a false tract.
  5. If you want to be fancy and have the skills, a fiberoptic scope can be passed from the mouth or through the stoma to look for problems.
  6. If the stoma is mature, in an emergency you can replace the trach with one that’s the same size or one size smaller. However, if the stoma is immature, the rate of closure is very high–up to 50% of the hole can close within 12 hours!
  7. Therefore, when dislodgement and definitely decannulation happens in an immature stoma, you may have to reintubate and wait for the surgeons to repair the stoma and reinsert the trach.

In my patient’s case, we ended up bagging her by mouth until respiratory therapy fiddled around with her trach enough to confirm it was in the right place and secured it with the trach collar. Stabilization is always #1! It turned out the patient had a large gap in her stoma, making the trach loose/malpositioned. The thoracic surgery team came by and put in a stitch to close the gap.

References:

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