Knowledge, Skills and Experience Managing Tracheostomy Emergencies: A Survey of Critical Care Medicine trainees
AA Nizam, SC Ng, M Kelleher, N Hayes, E Carton
Department of Critical Care Medicine, Mater Misericordiae University Hospital, Eccles St, Dublin 7
Since the development of percutaneous tracheostomy, the number of tracheostomy patients on hospital wards has increased. Problems associated with adequate tracheostomy care on the wards are well documented, particularly the management of tracheostomy-related emergencies. A survey was conducted among non-consultant hospital doctors (NCHDs) starting their Critical Care Medicine training rotation in a university affiliated teaching hospital to determine their basic knowledge and skills in dealing with tracheostomy emergencies. Trainees who had received specific tracheostomy training or who had previous experience of dealing with tracheostomy emergencies were more confident in dealing with such emergencies compared to trainees without such training or experience. Only a minority of trainees were aware of local hospital guidelines regarding tracheostomy care. Our results highlight the importance of increased awareness of tracheostomy emergencies and the importance of specific training for Anaesthesia and Critical Care Medicine trainees.
Since the development of percutaneous tracheostomy, the number of hospital patients with tracheostomy tubes has increased over the last 20 years1. Tracheostomy tubes allow prolonged mechanical ventilation through a more secure airway than a translaryngeal tube. The presence of a tracheostomy tube can also facilitate speech, oral feeding and increased patient mobility. However, these potential benefits are associated with well recognised hazards both during and after insertion. Tracheostomy patients are increasingly being cared for in multiple locations throughout the hospital. In these settings, Anaesthesia or Critical Care Medicine trainees are often called urgently to manage tracheostomy related airway emergencies. It is therefore important that clear education and training is available for the healthcare staff involved. The 4th National Audit Project (NAP) of the Royal College of Anaesthetists concluded that the majority of significant tracheostomy related complications resulted from displaced or blocked tracheostomy tubes and that the implementation of multi-disciplinary tracheostomy care protocols can improve outcomes2.The survey was carried out to heighten hospital awareness of tracheostomy related emergencies and to improve education and training for Anaesthesia and Critical Care Medicine trainees.
We compiled a questionnaire on tracheostomy care for NCHDs beginning their Critical Care Medicine training rotation in a university affiliated tertiary level teaching hospital in Ireland. Survey questions were based on a literature review and the expert opinion of Anaesthetists and Intensivists experienced in tracheostomy management. Data collected included the base specialty of the NCHD and the number of year(s) of training and Critical Care Medicine experience. We ascertained what experience trainees had in managing tracheostomy related emergencies and their level of confidence in dealing with such emergencies. We also asked what previous specific teaching trainees had received in managing tracheostomy emergencies and if they were aware of local hospital guidelines for tracheostomy care. The survey also included questions that tested basic knowledge, skills and understanding of tracheostomy care (Table 1).
We used descriptive statistics to summarize respondent characteristics. Trainee level of confidence in dealing with tracheostomy emergencies was recorded on a 0 – 10 scale (0 = no confidence, 10 = fully confident, median values). Correlation between the number of survey questions answered correctly and trainee level of confidence with tracheostomy care is reported using Spearman Rank correlation coefficient. All data were collected, analyzed, and presented anonymously.
Thirty-four non-consultant hospital doctors (NCHDs) completed the survey. Twenty-nine respondents were Anaesthesia trainees, 4 were Emergency Medicine trainees and one was a Surgical trainee. Nineteen trainees (56%) had at least 6 months Critical Care Medicine experience prior to the survey. Twenty respondents (59%) had been called to manage a tracheostomy related airway emergency during their previous hospital training but only 10 (29%) were aware of local hospital guidelines of tracheostomy care. Only 18 trainees (53%) had previously received specific tracheostomy training.
On a scale of 0 - 10 (0 = no confidence, 10 = full confidence), trainees who had managed a tracheostomy emergency in the past would have more confidence (7/10) in dealing with a similar emergency compared to trainees who had no previous exposure (4/10). The overall confidence of NCHDs in handling tracheostomy emergencies was 6/10 but the level of confidence in managing tracheostomy emergencies did not correlate with the number of correct answers to survey questions about tracheostomy care (R = 0.25).
Most trainees had satisfactory basic knowledge of the components of a tracheostomy tube. All trainees responded correctly to survey questions on the initial management of a blocked tracheostomy tube. All trainees were aware that patients with an occluded tracheostomy tube can be ventilated oro-nasally if the tracheostomy cuff is deflated or if the tracheostomy tube is uncuffed, although 9 trainees (25%) stated they would consult with senior colleagues for advice prior to such attempts.
The majority of trainees (79%) recognised the dangers of blind re-insertion of a displaced tube in patients with a recently fashioned tracheotomy. However, 16 trainees (47%) did not understand that there was no longer continuity between the oral and nasal cavity and the trachea in total laryngectomy patients. Also, in the event of accidental tube dislodgement, 20 trainees (59%) did not know the purpose of tracheal “stay sutures” in a newly fashioned surgical tracheostomy wound. All respondents stated that specific tracheostomy teaching should be compulsory in all hospitals and should ideally be conducted at the beginning of their training rotation in each hospital.
The problems associated with adequate tracheostomy care on general hospital wards are well documented, particularly the management of tracheostomy-related emergencies. Acute airway obstruction can occur in patients who have undergone tracheostomy or laryngectomy often due to mucous plugging or tube displacement. A study reviewing 1130 tracheostomies reported a death rate of 0.35% most often secondary to hemorrhage or tube displacement3. In a review of 183 laryngectomy patients, 7% had tracheostomy tube complications, mostly due to mucous plugging associated with lack of humidification4.
This survey was conducted at the beginning of the NCHDs training rotation in order to assess their base knowledge. The survey shows that level of confidence in managing tracheostomy emergencies depends on level of Critical Care experience and previous teaching in the management of tracheostomy emergencies. It is reassuring that survey participants answered questions on the management of occluded tracheostomy tubes correctly and that the majority of respondents appreciate the danger of blind reinsertion in “fresh” tracheostomies. However, almost half our survey respondents did not appreciate that total laryngectomy patients could only be ventilated through their tracheostomy stoma. Also, at the time of tracheostomy, ear, nose and throat (ENT) surgeons routinely place “stay sutures” in the upper and lower rings of the trachea to facilitate retraction of the rings for reinsertion of a dislodged tracheostomy tube. However, many of the trainees that participated in this survey and would be primary responders to tracheostomy emergencies on the ward did not know how to use these potential life-saving “stay sutures”. Given that Anaesthesia and Critical Care Medicine trainees are frequently in charge of tracheostomy emergency calls in the ward, these findings are especially concerning.
There are several limitations to our study. Our survey was only conducted in one teaching hospital with a relatively small number of participants and thus it may not reflect all NCHDs rotating in Anaesthesia and Critical Care Medicine. The majority of respondents were Anaesthesia trainees and a greater representation of Emergency Medicine or Surgical trainees would have been beneficial. Despite these limitations, our survey suggests the need for more education and training regarding appropriate management of tracheostomy patients with airway difficulties. Use of local or national guidelines and emergency algorithms would benefit primary responders to a tracheostomy emergency. Also, simulation based training, together with formal teaching may play a vital role in educating trainees on the management of tracheostomy emergencies5. This should be mandatory at the start of every placement and should be repeated at regular intervals in order to maintain the skills learned.
AA Nizam, Department of Critical Care Medicine, Mater Misericordiae University Hospital, Eccles St, Dublin 7
1. McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaes. 2012; 17: 1025–1041
2. Cook TM, Woodall N, Frerk C. On behalf of the Fourth National Audit Project. Major complications of airway management in the UK: Results of the 4th National Audit Project of the Royal College ofAnaesthetists. Br J Anaesth 2011; 106: 617–31
3. Goldenberg D, Ari EG, Golz A, Danino J, Netzer A,Joachims HZ. Tracheotomy complications: a retrospective study of 1130 cases. Otolaryngol Head Neck Surg 2000; 123: 495– 500
4. Ganly I, Patel S, Matsuo J, Singh B, Kraus D, Boyle J.Postoperative complications of salvage total laryngectomy. Cancer 2005;103(10):2073–2081
5. Zirkle M, Blum R, Raemer DB, Healy G, Roberson DW.Teaching emergency airway management using medical simulation: a pilot program. Laryngoscope 2005;115: 495–500