Patients who are tracheostomy and ventilator dependent are at increased risk for complications the longer they remain in this condition. One common complication is tracheomalacia. Progressive tracheomalacia can lead to air leaks around the tracheostomy cannula balloon. Initially, this can be managed by placing a longer tracheostomy cannula deeper into the trachea, however, these are often unavailable in the emergency department . A second line strategy is to temporarily over-inflate the balloon, however, with chronic overinflation, eventually both the trachea and the neck stoma become too large, leading to an inability to maintain appropriate positive pressure (PEEP) and tidal volume necessary to ventilate the patient .
Trick: Duoderm patch
In order to minimize air leak to maintain PEEP, you need to create an occlusive dressing around the stoma. This can be achieved with a Duoderm dressing. Puncture the center of the duoderm dressing with a pair of suture scissors. Do not make linear cuts, as this may lead to extension of the fenestration. Push the tracheostomy cannula through the fenestrated Duoderm so that the dressing makes a tight seal around the cannula. Then insert the cannula into the neck in the usual fashion and closely adhere to the Duoderm to the skin.
With luck, this will temporize the patient until a longer tracheostomy cannula can be ordered or a surgical repair can be performed.
Special thanks to Dr. Darren Mareiniss.
Check out more tricks of the trade.
- Epstein SK. Late complications of tracheostomy. Respir Care. 2005 Apr;50(4):542-9. PMID 15807919
- Inoue S, Abe R, Kawaguchi M, et. al. Use of a laryngeal mask airway to stop a supraglottic air leak which prevented adequate ventilation via a tracheostomy in a patient with cerebral palsy and pneumonia. J Anesth. 2011 Jun;25(3):415-7. doi: 10.1007/s00540-011-1112-9. Epub 2011 Mar 13. PMID 21400211