Dislodged Tracheostomy Tube: Do ICU Staff Know What To Do?
Dislodged Tracheostomy Tube: Do ICU Staff Know What To Do?
Abstract & Commentary
By David J. Pierson, MD, Editor, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, is Editor for Critical Care Alert.
Synopsis: When asked what they would do if a recently placed tracheostomy tube became dislodged in a mechanically ventilated patient, most ICU physicians and nurses gave the incorrect response of attempting to replace it rather than manually bagging or orally reintubating the patient.
Source: Casserly P, et al. Br J Anaesth. 2007;99(3):380-383.
Casserly and colleagues administered a case-based questionnaire to physician and nursing staffs at 2 large teaching hospitals in Ireland, to determine their knowledge and experience with respect to a common and potentially deadly event in mechanically ventilated patients with fresh tracheostomies: dislodgement of the tube from the airway during vigorous coughing. The scenario presented was of a patient with a Glasgow Coma Scale score of 6 who had undergone surgical tracheotomy 48 hours previously. Subjects were asked whether they had personally encountered this complication, and what their first response would be. They were also shown a photograph of a fresh tracheostomy and tube in situ, with stay sutures plainly shown, and asked whether they knew what the sutures were for and how they were to be used in the emergency setting.
The 70 participants in the study were 11 otolaryngology (ENT) specialist registrars and senior registrars with a mean of 5.7 ± 3.7 years of experience; 5 ENT residents with 1.2 ± 0.4 years of experience; 21 anesthesia specialist registrars with 7.4 ± 4.4 years' experience; 5 anesthesia residents with 1.8 ± 0.8 years' experience; 15 ICU nurses with 10 ± 7.6 years' experience; and 13 ENT ward nurses with 10 ± 6.4 years' experience.
Only 13 of the 70 participants (19%; primarily senior ENT and anesthesia physicians) indicated that they had personal experience with a dislodged tracheostomy tube in a ventilated patient within 48 hours of surgical placement. There was dramatic variation in what the respondents said they would do. Most (73%) of the ENT specialist registrars and half of the anesthesia specialist registrars would orotracheally intubate the patient or perform bag-mask ventilation, while 20% of the ENT residents, 100% of the anesthesia residents, 74% of the ICU nurses, and 100% of the ENT ward nurses opted to attempt reinsertion of the tracheostomy tube. Among those study participants who opted for reinsertion of the tube, 46% of the anesthetists, 63% of the ICU nurses, and 69% of the ENT ward nurses did not know what the stay sutures were for; 6%, 81%, and 16% of these staff members, respectively, did not know the purpose and use of the obturator shown in the photograph next to the tracheostomy site. The authors conclude that knowledge among non-ENT staff of what to do in a tracheostomy emergency is inadequate and constitutes an important patient safety issue.
Commentary
A fresh tracheostomy tract typically takes about a week to mature, and attempted reinsertion of a dislodged tube via the surgical stoma can create a false lumen, with disastrous consequences when positive-pressure ventilation is resumed. It is for this reason that the emergency management of patients whose tracheostomy tubes come out within the first few days after the procedure should be bag-mask ventilation and/or prompt orotracheal intubation, rather than an attempt at reinsertion of the dislodged tube at the bedside. In this study many of the physicians in training—and most of the nurses—who were confronted with this scenario in a hypothetical patient would make the wrong choice.
With the advent of the percutaneous dilatational technique, physicians in several non-ENT specialties, with variable training and experience in complex airway management, are performing tracheotomies on mechanically ventilated patients and subsequently supervising management. Accidental dislodgement of the tracheostomy tube during the first several days is not uncommon and can be life-threatening, particularly in patients with severe oxygenation problems and/or high demands for pressure and volume from the ventilator. The findings of this study should serve as a reminder of the need for all staff physicians, nurses, and respiratory therapists involved in managing patients with tracheostomies to be up to speed on the appropriate management of this complication.
Casserly and colleagues administered a case-based questionnaire to physician and nursing staffs at 2 large teaching hospitals in Ireland, to determine their knowledge and experience with respect to a common and potentially deadly event in mechanically ventilated patients with fresh tracheostomies: dislodgement of the tube from the airway during vigorous coughing.Subscribe Now for Access
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