Review of unusual patient care experiences is a cornerstone of medical education. Each month, the AQI-AIRS Steering Committee abstracts a patient history submitted to the Anesthesia Incident Reporting System (AIRS) and authors a discussion of the safety and human factors challenges involved. Real-life case histories often include multiple clinical decisions, only some of which can be discussed in the space available. Absence of commentary should not be construed as agreement with the clinical decisions described. Feedback regarding this article can be sent by email to email@example.com. Report incidents or download the AIRS mobile app at www.aqiairs.org.
Case 2019-10: Not Every Airway Stoma Is a Tracheostomy
An airway alert was called for a patient with a stoma in respiratory distress .... The patient was about 60 years old and had been admitted to the trauma team two days prior due to a fall. At the time of the airway alert, she was tachypneic with SpO2 88 percent and bilateral wheezing. Upon arrival, the trauma surgeon instructed the nurse anesthetist to intubate “from above” as they were unsure about the function of the stoma. Propofol was administered and an attempt at intubation was made with a video laryngoscope noting secretions and “possible vocal cords.” The patient desaturated, and bradycardia ensued followed by cardiac arrest. Respiratory therapy provided BVM ventilation via the face while CPR was in progress. After one cycle, a decision was made to pass an ETT via the stoma, which resulted in positive ETCO2 return. Upon quality review of the case, it was noted by the physician anesthesiologist that this patient had a laryngectomy.
Airway complications are one of the most common categories of anesthesia adverse events. Many of these events are avoidable. The primary reason for the establishment of anesthesia adverse event registries such as AIRS is to identify and highlight avoidable causes in case reports such as this one. For this month’s case, the committee is indebted to the reporter who has included not only the circumstances of the event but details of the quality review that followed.
The most common indication for a laryngectomy is cancer of the larynx. Within the United States, laryngeal cancer rates have been falling on average 2.4 percent each year over the last 10 years. The five-year survival rate is 60.3 percent.1 Total laryngectomy is uncommon compared to tracheostomy. Post-laryngectomy patients may be admitted to a hospital that does not perform total laryngectomy and thus has little experience with airway management in these patients.
Further review noted a problem list that stated “laryngectomy” as well as “tracheostomy” and “vocal prosthesis.” Review of progress notes during hospitalization highlight a Swiss-cheese error where multiple providers were not clear about the nature of the airway. On admission, the emergency department RN note stated “trach collar” and “history of tracheostomy.” The emergency physician note stated tracheostomy and COPD. A second emergency RN who received appropriate handoff again noted tracheostomy. They mentioned that respiratory therapy was requested to obtain a vital capacity, but this was unable to be performed due to the tracheostomy. A consult note from a nurse practitioner mentioned tracheostomy and esophageal voice prosthesis and that the patient plugs their stoma to talk through their vocal cords. During the hospitalization, the patient was seen by two pulmonary critical care physicians and two internal medicine physicians all noting tracheostomy and voice prosthesis. At one point, a nurse wrote an SBAR note asking about an ENT evaluation. The airway event occurred just a few hours later.
Total laryngectomy patients can speak despite not having vocal cords. Laryngectomy patients can be trained to speak without a device using “esophageal speech,” which uses oscillation of the esophagus to form sounds. However, esophageal speech is quite difficult. The electrolarynx, developed in the 1940s, produces vibrations that allow speech. The electrolarynx is not popular because the resulting speech has a mechanical and robotic quality. Vocal prostheses have been employed ever since the first total laryngectomy in 1873 by Theodor Billroth. The prosthesis is placed in a tracheoesophageal puncture (TEP). The prosthesis has a one-way valve that allows air to be redirected from the trachea to the esophagus allowing for speech through esophageal vibration. The TEP can be created at the time of laryngectomy, or it can be placed later. In this case, it appears that the patient’s vocal prosthesis led some of the clinical staff to believe the patient had vocal cords.
On post-event review, most clinicians were not aware that this patient had a laryngectomy. Two consultant physicians knew this and had highlighted the esophageal voice prosthesis. However, when discussing with the other clinicians, they were not sure what implication the esophageal voice prosthesis had, and they felt this patient plugged their stoma because they were talking through their vocal cords. These providers were not aware there were implantable devices that allowed for speech without vocal cords being present.
A system-wide review was started to identify all patients in the system who have a laryngectomy and to help differentiate those from “tracheostomy” patients in the electronic health record. Algorithms and information were distributed to all teams regarding the U.K. National Tracheostomy Safety Project. There is consideration being made for placing placards in the rooms of patients with tracheostomies vs laryngectomies.
The National Tracheostomy Safety Project (NTSP) developed a sample sign designed to be placed at the head of a total laryngectomy patient’s bed. The sign, shown in Figure 1, states “This patient has a LARYNGECTOMY and CANNOT be intubated or oxygenated via the mouth.” It also has a schematic depiction of a laryngectomy patient’s upper airway. The NTSP was started by intensivists in Manchester, U.K. who wished to prevent emergencies involving tracheostomy and laryngectomy patients.2
These guidelines also include detailed algorithms for troubleshooting laryngectomy and tracheostomy stomas in emergency situations. Figure 2 (page 51) shows the laryngectomy algorithm. The third step of both algorithms is to assess stoma patency with a suction catheter. A fiberoptic scope, if available, can help identify tracheal rings, which will confirm that the stoma should be used for the airway.
Posting a sign is a good start to improving communication among hospital staff that a laryngectomy patient is present. Another option is to highlight these patients on a “high risk airway” report provided to anesthesia and code teams, or to provide a “high risk airway” colored wristband.3
Some hospitals have implemented multidisciplinary response teams specifically for difficult airways. These teams are activated when a code is called for patients with a known difficult airway or where the initial code team was unable to establish an airway.4,5 It is important to review the published experiences of other institutions that have created difficult airway teams. Only through repeated simulation can the team identify obstacles to prompt mobilization. For example, in one simulation the Johns Hopkins difficult airway response team inadvertently triggered the infant security system on the obstetrics floor. That alert locked the team into the inpatient unit while the airway cart was outside the unit. The airway team, the security department and the infant security system administrators had to develop a plan together to avoid this circumstance during a real activation. Reducing the rate of adverse events and death from airway compromise requires constant training and vigilance to identify patients at elevated risk. We hope this case and the subsequent review prevent a mistaken intubation attempt from above in a future post-laryngectomy patient.