Intraoperative Airway Management Considerations for Adult Patients Presenting With Tracheostomy: A Narrative Review

Tracheotomy is a surgical procedure through which a tracheostomy, an opening into the trachea, is created. Indications for tracheostomy include facilitation of airway management during prolonged mechanical ventilation, treatment of acute upper airway obstruction when tracheal intubation is unfeasible, management of chronic upper airway obstructive conditions, and planned airway management for major head and neck surgery. Patients who have a recent or long-term tracheostomy may present for a variety of surgical or diagnostic procedures performed under general anesthesia or sedation/analgesia. Airway management of these patients can be challenging and should be planned ahead of time. Anesthesia personnel should be familiar with the different components of cuffed and uncuffed tracheostomy devices and their connectivity to the anesthesia circuits. An appropriate airway management plan should take into account the indication of the tracheostomy, the maturity status of the stoma, the type and size of tracheostomy tube, the expected patient positioning, and presence of patient's concurrent health conditions. Management of the patient with a T-tube is highlighted. Importantly, there is a need for multidisciplinary care involving anesthesiologists, surgical specialists, and perioperative nurses. The aim of this narrative review is to discuss the anesthesia care of patients with a tracheostomy. Key aspects on relevant tracheal anatomy, tracheostomy tubes/devices, alternatives of airway management, and possible complications related to tracheostomy are summarized with a recommendation for an algorithm to manage intraoperative tracheostomy tube dislodgement.

'Speaking valve' aspiration in a laryngectomy patient

Tracheo-oesophageal speech using a one-way speaking valve is a common mode of speech rehabilitation for laryngectomy patients. Aspiration of this device can cause significant airway obstruction and pose anaesthetic and surgical challenges during its retrieval. In this case report, we describe our management of a patient who had had a laryngectomy who aspirated his speaking valve through his stoma. Emergency retrieval of the valve was performed, during which difficulties were encountered, first in obtaining an adequate seal for pre-oxygenation, and second in maintaining adequate oxygen saturation. We discuss some innovative techniques that could be used to address these issues.

New use of a tracheal tube for rescue breathing in laryngectomees in the community

The currently recommended method for rescue breathing in people who have had a laryngectomy is mouth-to-stoma. Even if they know what to do, by-standers are likely to find this technique unhygienic and therefore unacceptable. There is no equivalent of the pocket face mask for laryngectomees. This paper describes the practical differences that affect rescue breathing in patients with laryngectomy stomas and proposes a new use of a tracheal tube for rescue breathing in laryngectomees. Ten patients with permanent tracheal stomas scheduled for ENT surgery were ventilated successfully through a tracheal tube with the cuff applied to the outside of their tracheal stomas, following induction of anaesthesia and before the start of surgery. Observations of oxygen saturation, end-tidal carbon dioxide, expired tidal volume and chest movements were within acceptable limits. This device was simple to use and is hygienic and inexpensive. Laryngectomees' relatives, friends or carers with minimal training could use the tube in a mouth-to-tube-to-stoma technique should the need for rescue breathing arise. It could also be used by paramedic and medical staff in a mouth or bag-to-tube-to-stoma technique until a definitive airway can be inserted.