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Chapter 33. Performing an Elective Percutaneous Dilational Tracheotomy in a Patient on Mechanical Ventilation

You are an airway practitioner and have been asked to participate in a PDT on the 28-year-old female in the ICU. The surgeon has just inserted the tracheostomy tube and you are ventilating the patient using an Ambu bag through the ETT that you have pulled back to 1 cm above the tracheotomy insertion site. Once the tracheostomy tube is in place, you connect the Ambu bag to the tracheostomy tube and start to ventilate the patient. However, you notice that there is no end-tidal CO2 tracing and there is a lot of resistance to ventilation, the oxygen saturation is slowly declining, and there is some subcutaneous emphysema in the neck area. What is your immediate response?

A. remove the tracheostomy tube and the ETT and begin BMV

B. tell the surgeon to reinsert the tracheostomy tube

C. tell the surgeon to prepare for a surgical cricothyroidotomy

D. remove the tracheostomy tube and push the indwelling ETT into the trachea 2 to 4 cm distally and ventilate through the ETT

E. assess the location of the tracheostomy tube using a fiberoptic bronchoscope

(D) If there is no ETCO2 and ventilation is difficult immediately following the placement of a tracheostomy tube, it is most prudent to remove the tracheostomy tube and advance the indwelling ETT to pass beyond the tracheotomy site (2–4 cm distally) and resume ventilation.

You have secured the airway and placed the patient back on the ventilator. About 5 minutes later while you are catching up on your charting, the ventilator starts to alarm high airway pressures and the blood pressure has declined. Auscultation reveals decreased breath sounds on the right. What do you do next?

A. administer 500 mL of Ringers Lactate intravenously and vasopressor to raise the propofol-induced hypotension

B. call for a chest x-ray

C. fiberoptic bronchoscopy to remove mucus plugs

D. do a needle decompression in the midclavicular line at the right second intercostal space of the chest or insertion of a chest tube

(D) Tension pneumothorax is one of the known complications of tracheotomy. In the presence of hemodynamic instability, the practitioner should immediately perform a needle decompression in the midclavicular line at the right second intercostal space of the chest or insert a chest tube for decompression.

Three days after the PDT was performed, as ...

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