EMS clinician must be prepared for a difficult airway situation (see Chapter 3). Unless the tracheotomy was concomitant with laryngectomy, the patient may be intubated orally. He or she can also be reintubated through the existing stoma, using an appropriately sized endotracheal tube. A gum elastic bougie can be used to facilitate such a tube change.
Bleeding from a tracheotomy can occur early or later after its placement. Bleeding at the site, until definitive hemostasis can be accomplished, may be controlled with application of hemostatic dressings. Bleeding within the airway, causing respiratory distress, may be cleared with suctioning through the tracheotomy inner cannula or tube. In critical circumstances, the tracheotomy tube may be removed so that the stoma can be reintubated with an endotracheal tube that is advanced distal to the site of bleeding to secure the airway. In some cases, the endotracheal tube cuff may also tamponade the bleeding source, and overinflation of the tracheotomy cuff or the endotracheal tube cuff may be considered.
While tracheotomies provide a potential source of respiratory distress, it is important that their presence does not result in overlooking other causes, as discussed. If supplemental oxygen is necessary, humidification is appropriate to prevent drying of secretions.
Summary
Respiratory distress is a very common complaint in the prehospital setting. The initial evaluation should be focused on identifying immediate threats to life and determining needs for immediate intervention, such as NIPPV, bag‐valve‐mask ventilation, or advanced airway management (supraglottic airway or endotracheal intubation). Once this evaluation is completed, efforts should be focused on attempting to determine the underlying cause of the problem. Respiratory distress may be caused by a primary pulmonary, cardiovascular, or infectious problem issue, or as part of the compensation for another nonpulmonary problem.
In general, treatment should include titrated oxygen with cardiac rhythm, pulse oximetry, and waveform capnography monitoring while ensuring timely transport. In stable situations, the emphasis should focus on avoiding overtreatment and resisting the urge to give multiple medications in an undirected fashion. However, short‐acting inhaled bronchodilators should be initiated if there is a concern for bronchospasm, and nitrates should be considered as first‐line therapy in the patient with findings consistent with ADHF or SCAPE.
References
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