Failing to oxygenate/ventilate
(any invasive vent, not just traches)

DOPES

• Displacement
  • too deep (unlikely, unless all of: small patient, low puncture site, and adjustable flange trache)
  • too shallow – opening may be against posterior wall
  • in soft tissue – rapidly expanding subcutaneous emphysema
  • completely out
• Obstruction
  • sputum plug
  • blood/clot plug
  • inner cannula blockage only
  • kinking
  • speaking valve plus cuff up (only likely to occur in mature traches)
• Pneumothorax
• Equipment failure
  • ventilator
    • oxygen supply / sensor failure
    • power / battery failure
    • filter saturation/failure
    • mechanical failure
  • tubing
    • kinking / compression
    • water-filled tubing limbs
  • connectors
    • disconnections
• Stacked breaths (asthmatics, dynamic hyperinflation)
  • special situation – disconnect and squeeze

Acutely blocked tracheostomy management (still on a ventilator)

“Recognise and declare life-threatening emergency”

1. Apply 15L non-rebreather oxygen to mouth
2. Disconnect ventilator
3. Remove tracheostomy inner tube
4. Pass suction catheter
   1. CAN PASS:
      1. Connect to Bag-Valve with 15L Oxygen and reservoir bag
      2. Assess for signs of collapse/consolidation/high pressures/unilateral chest wall movement
      3. CXR
      4. Specific management as indicated
   2. CANNOT PASS:
      1. Remove tracheostomy tube
      2. May attempt insertion of smaller (size 6.0 or smaller) tracheostomy tube through stoma, however this is RISKY in an immature tract (<7 days old). May create/worsen false-passage
      3. Cover tracheostomy site
      4. Bag-Valve-Mask ventilate (100% FiO2) from the mouth and prepare to intubate (staff, equipment, drugs)
      5. Intubate from above
         1. May be difficult, depending on indication for tracheostomy, and any subcutaneous emphysema from tracheostomy malfunction
         2. Consider advanced airway equipment / most senior operator
         3. Balloon below tracheostomy site
         4. CXR once intubated