Different Flags
Like any assessment of the unwell patient, you should always start with ‘A for airway’. In the case of a patient with a tracheostomy, there may be two airways to consider, or with a laryngectomy, only one.
Any airway problem can cause the patient to become unwell and show signs of distress. Conversely, patients with tracheostomies can become unwell with all the problems that other patients get too. It is easy to become fixated with the tracheostomy.
The ‘flags’ can be divided up into different categories:
Fig 1 is a video that describes the red flags.
Airway flags
If the patient has a cuffed tracheostomy correctly sited in the trachea, no gas should escape through the mouth.
If the patient is talking to you, or audible air leaks or bubbles of saliva are seen or heard at the mouth or nose, then gas is escaping past the cuff. This may imply that the cuff is damaged or the tube tip is not correctly sited.
Grunting, snoring or stridor are also signs that there is an airway problem.
If the patient is attached to a ventilator, a change or a flat capnography waveform indicates a problem with the airway.
Breathing flags
Listening to the patient, or observation of the patient or instrumentation, may show that the patient:
- Is not breathing (apnoea), which is detected by capnography or clinically
- Has difficulty in breathing (or with ventilation), which may be
reported by the patient or observed clinically:
- Accessory muscle use
- Increased respiratory rate
- Higher airway pressures
- Lower tidal volumes
- Has hypoxia
- Is making whistling noises or has noisy breathing
Circulation flags
If a patient finds it hard to breathe, then this stresses the cardiovascular system. Patients may become tachycardic and/or hypertensive, especially if they become hypoxic or hypercarbic (raised CO2). The heart rate and blood pressure may fall if the airway problem is not addressed and cardiac arrest is inevitable if oxygenation is restored.
Specific tracheostomy flags
Careful observation may show that the patient:
- Has a visibly displaced tracheostomy tube. If this is an adjustable flange tube, check to see where it was last positioned
- Has blood or blood-stained secretions around the tube - a recently performed or changed tracheostomy bleeds a little, but if in doubt, you should get it assessed
- Reports increased discomfort or pain
- Requires a lot of air to keep the cuff inflated, which may be
because:
- The cuff is damaged or has an air leak (in which case, it needs to be replaced)
- The tube may be displaced and the cuff needs hyper-inflation to keep it 'sealed'
General flags
Any physiological changes can be due to an airway problem. Specifically, changes in:
- Respiratory rate
- Heart rate
- Blood pressure
- Level of consciousness
Imagine if someone obstructed your airway right now. What would you do? You would get agitated and distressed very quickly. A patient with anxiety, restlessness, agitation or confusion may have an airway problem. Always check the airway!