Stoma 1
Intubation of an established stoma may be relatively straightforward, and, in some cases, the tracheostomy stoma may be the easier airway.
There are many examples of emergency teams getting confused and distracted in a tracheostomy emergency however, and there is a temptation to try to place something into the stoma. If you are used to managing upper airways (mouth/nose) then stick to what you are comfortable and experienced with. Similarly, if you are experienced in changing or inserting tracheostomy tubes, then this may be a good option.
Placing anything blindly into a stoma risks entering a false passage in the anterior tissues of the neck, especially in relatively newly formed stomas.
Question: Can you think of safer ways to intubate the trachea via the stoma?
Intubation of an established stoma may be relatively straightforward, and, in some cases, the tracheostomy stoma may be the easier airway.
There are many examples of emergency teams getting confused and distracted in a tracheostomy emergency however, and there is a temptation to try to place something into the stoma. If you are used to managing upper airways (mouth/nose) then stick to what you are comfortable and experienced with. Similarly, if you are experienced in changing or inserting tracheostomy tubes, then this may be a good option.
Placing anything blindly into a stoma risks entering a false passage in the anterior tissues of the neck, especially in relatively newly formed stomas.
Question: Can you think of safer ways to intubate the trachea via the stoma?
Answer: Fig 1 describes a safer way to intubate the trachea.
The video in Fig 2 demonstrates the use of a Cook Aintree catheter with an endoscope to instrument a stoma. Whilst this type of hollow bougie allows the connection and delivery of supplemental oxygen via the device, this should only be done if the catheter is visually confirmed to be in the trachea. Delivering gas (even under low pressure) into the soft tissues or small airways can cause significant problems.
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A safer way to intubate the trachea would be an endoscopically guided technique, such as:
Most endoscopes can be manoeuvred and therefore steered into the trachea whilst directly visualising the tip position. Visually confirming that your device is in the trachea is critical before you advance (‘railroad’) a tube into the stoma and attempt ventilation. Waveform capnography is another crucial element of confirming that the airway is patent after placement. If there is no alternative, attempting blind insertion of a tracheostomy tube (preferably with the obturator inserted) or bougie may be possible. Digital manipulation of a bougie into the trachea has been described, involving putting a finger into the trachea, identifying the tracheal rings and then guiding a bougie into the airway. This clearly requires experience. |
Fig 1 Safer intubation
Intubation of an established stoma may be relatively straightforward, and, in some cases, the tracheostomy stoma may be the easier airway.
There are many examples of emergency teams getting confused and distracted in a tracheostomy emergency however, and there is a temptation to try to place something into the stoma. If you are used to managing upper airways (mouth/nose) then stick to what you are comfortable and experienced with. Similarly, if you are experienced in changing or inserting tracheostomy tubes, then this may be a good option.
Placing anything blindly into a stoma risks entering a false passage in the anterior tissues of the neck, especially in relatively newly formed stomas.
Question: Can you think of safer ways to intubate the trachea via the stoma?
Answer: Fig 1 describes a safer way to intubate the trachea.
The video in Fig 2 demonstrates the use of a Cook Aintree catheter with an endoscope to instrument a stoma. Whilst this type of hollow bougie allows the connection and delivery of supplemental oxygen via the device, this should only be done if the catheter is visually confirmed to be in the trachea. Delivering gas (even under low pressure) into the soft tissues or small airways can cause significant problems.