The Difficult Airway in Adult Critical Care

Gavin G. Lavery, MD, FCARSCI, MB, BCh, BAO; Brian V. McCloskey, MB, BCh, FRCA, FFARCSI, MRCP

Disclosures

Crit Care Med. 2008;36(7):2163-2173. 

In This Article

Tube Displacement in the Critical Care Unit

ETT displacement in the intensive care unit is a life-threatening emergency that may result in significant morbidity.[157] Although sometimes viewed as unavoidable, often there are preventable factors involved.[158,159,160] Changes in patient posture or head position cause significant movement of the tube within the trachea.[161,162] The frequency of tube displacement can be reduced by good medical and nursing practice,[163] attention to the spatial arrangements around the bed, achieving appropriate sedation levels, and ensuring appropriate intensive care unit nurse staffing.[164,165] The management of ETT displacement should include consideration that the patient may no longer need an ETT.[160] If replacement is required, one must prepare for a potentially difficult reintubation.

Adverse events associated with tracheostomy tubes are quite common.[160,166] Tube displacement from the tracheal lumen may be impossible to detect on external examination but is suggested by difficulty with breathing, ventilation, or tracheal suctioning and the presence of a pneumothorax, pneumomediastinum, or surgical emphysema. If required, tube position and patency may be assessed by passing a fiberoptic scope through the lumen to visualize trachea and carina. Assessing tracheostomy tube position on chest x-ray is of no value.

If displacement occurs before a well-defined track between skin and trachea is formed (4-5 days), it may result in a life-threatening event. Displacement of a percutaneous tracheostomy tube may be problematic because the external opening of the track may not easily admit a new tube of the same size. The option to remove the tube (decannulate the patient) should be considered and if pursued, the tracheostomy opening should be dressed to make it as airtight as possible, thus facilitating effective coughing. If the patient needs a tube, and replacing the tracheostomy is not possible, then oral reintubation should be performed after which the tracheostomy should be dressed. A new tracheostomy procedure can be planned when appropriate. With a more mature tracheostomy (more than 5 days old), replacement of a displaced tube may be quite simple because the track between skin and the trachea is well formed.[167]

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