Clinical assessment

Patients with a tracheostomy should be assessed using an ABCDE approach, with tracheostomy-specific signs grouped under ‘Exposure’. These can be considered tracheostomy ‘red-flags’.¹

A

• Stridor or abnormal inspiratory noises – narrowing or displaced tube
• Partial speech – in the case of a cuffed tube, this signifies air leak around the cuff which may indicate displacement or cuff leak/puncture.
• Oral secretions

B

• Apnoea
• Tachypnoea
• Cyanosis and hypoxia
• Audible secretions
• Accessory muscle use
• If ventilated may see increased peak airway pressures, low tidal volumes, and loss of waveform capnography

C

• Tachycardia
• Hypertension or hypotension

D

• Patient indicating increased pain around stoma site
• Agitation and panic
• Reduced responsiveness

E

• Tracheostomy signs
  • Visibly displaced tracheostomy tube
  • Visible haemorrhage from or around the tracheostomy tube
  • Large volumes of air required to inflate cuff – may indicate a leak or displaced tube

If any of these signs are present, or there is a concern that a patient with a tracheostomy is deteriorating, a systematic approach is required to manage the patient’s airway.

If bleeding around or from the tracheostomy is noted, specific management may be required.

Learning bite

A “tracheostomy-focused” ABCDE assessment should identify potential problems with a tracheostomy.