Module 2: Breathing with

This section concerns acute adverse events in connection with a tracheostomy and ventilator, and what helpers can do. Fortunately, acute adverse events are rare. Much of that described here concerning tracheostomies are routines to help prevent acute problems from arising. Nonetheless, there is a risk that an acute adverse event can arise, especially in terms of problems with the ventilator, cannula and airways. As the helper of someone with a tracheostomy, it is therefore essential that you are aware of what can happen and what you should do.

Click here to practise an imaginary emergency situation (in Norwegian)

Telephoning for help

In an emergency situation TELEPHONE the emergency number (113 in Norway)!

1. If an emergency situation arises, always telephone for help.
2. Remember that those at the other end of the telephone can help assess how critical the situation is.
3. If the situation is not critical and you try to resolve the situation yourself, always bear in mind that you might have to telephone for help. The situation could get worse and it might be difficult to handle on your own.

Get other help!

1. Can anyone else help?
2. Other personnel nearby? Relatives?
3. If the situation is not critical or resolved, and you are not sure what to do, you can contact the specialist department in charge of the treatment.

Remember to keep the following information at hand

1. Emergency number: 113 (in Norway)
2. The address of your current location.
3. Telephone number of the duty room or similar if in an institution.
4. Telephone number of the specialist department in charge of the treatment/therapy.
5. GP’s telephone number.

Telephoning for help

1. When telephoning for help it is important to remain calm and give the required information.
2. ISBAA provides a guide on what to say during an emergency situation.

Acute breathing difficulties

Acute breathing difficulties can arise for many reasons in connection with a tracheostomy or ventilator. Some examples are:

• Ventilator problems
• A pinched ventilator tube.
• The cannula or other parts of the ventilator’s circuit can be blocked by mucus.
• Mucus in the larger airways below the cannula or mucus further down in the lungs.
• Conditions that affect parts of the lungs can cause breathing difficulties, e.g., pneumonia, partial collapse of the lungs due to mucus plugs, blood clots in the lungs and air leakage from the lungs into the space between the lungs and chest wall (pneumothorax).

It is impossible for helpers of ventilator users to know why breathing problems start. However, it is still important to learn how to help whilst waiting for professional help. The following provides a guide on how to assess the situation.

• Examine the ventilator, ventilator circuit and cannula: Has the cannula fallen out? Is there a kink in the ventilator tube or is it blocked in any other way? Check whether the ventilator is blowing as it should.
• Consider using a bag: Always have access to a bag! A bag allows you to give more air to the user than a ventilator. It is important to use a bag if the problem is not obvious (for example, a kink in the ventilator tube), but can easily be resolved or when the user still has insufficient air or the ventilator is not working or the situation is unclear.
• Check the cannula: If the breathing difficulties do not improve with bag ventilation, check the cannula. The inner cannula, speech valve or filter could be blocked, if attached. These must be removed. Continue bag ventilation.
• If the breathing difficulties continue, mucus could be blocking the cannula or airways below the cannula. Try clearing it with suction! Give bag ventilation!
• Consider removing the cannula: If the breathing difficulties continue and the suction catheter cannot pass beyond the cannula, the cannula must be completely blocked. Remove the cannula! Should this be done, there are three options:
  • Bag ventilation with a paediatric mask covering the hole in the throat.
  • Bag ventilation with a large mask over the mouth and nose, whilst covering the hole at the same time.
  • Insert an emergency cannula and ventilate with a bag.

Sounding of ventilator alarms

Ventilator alarms can sound for many reasons. The most important thing to do when a ventilator alarm sounds is to assess the user.

• Is the user having trouble breathing? If so, assess the situation as described under Acute breathing difficulties. Normally it will suffice to disconnect the ventilator, administer a bag and then find out which alarm has sounded. You could also connect to the spare ventilator if the situation is under control.
• Is the user distressed? If a ventilator alarm is still sounding and not working as intended, use the spare ventilator. If the situation is then under control, find out which alarm has sounded.
• If the user is not distressed and the ventilator seems to be working as intended, check the alarm. Consider using the spare ventilator.

Each ventilator has its own special alarms. The relevant alarms will also depend on how the settings of the ventilator have been set. These are described in more detail in the description of each ventilator.

Cannula falls out

It takes a lot for a cannula to fall out, as it is held in place by the cuff and cannula tape. Nonetheless, if the cannula is pulled, for example, when moving, it could fall out.

If it falls out, there are three options:

1. Bag ventilation with a paediatric mask covering the hole in the throat (see the video below).
2. Bag ventilation with a large mask over the mouth and nose, whilst covering the hole at the same time.
3. Insert an emergency cannula and ventilate with a bag. Reconnect the ventilator.