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Tracheostomy and Laryngectomies are high-risk procedures in increasingly complex patients, meaning that it is not always clear how they should be managed in emergency scenarios – ear nose and throat (ENT) specialists, anaesthetists or the intensive care team? An early experience of the chaos that ensued during an emergency tracheostomy caused Dr Brendan McGrath to reflect on how better to manage the situation.

“I remember asking for some relevant equipment that took 10 or 15 minutes to find. Fortunately, the patient was okay in the end. But there could be Head & Neck surgeons trying to do one thing, anaesthetists trying to do something else. Or a patient may be on the ward and under the care of neither ICU nor ENT, and if a problem arose, we could spend 10 minutes trying to find the person in charge, by which time it may be too late. Talking with colleagues, I realised that there were actually no guidelines on what to do, even though about 10% of all patients in ICU ended up having tracheostomies.”

Galvanised by the support of like-minded colleagues in the North West of England, Dr McGrath searched for existing guidance on managing emergency tracheostomies, looking both nationally and internationally. Although some helpful instructions were available, they were aimed at very specific patient groups or problems. Dr McGrath recognised a clear need to create overarching guidance to cover everyone.

“We started off by drafting a universal guideline for the emergency management of all patients with tracheostomy problems. It was just a single side of A4 and we invited representations from other disciplines involved in tracheostomy care to help too.”

To formulate these guidelines, Dr McGrath and co-workers needed to understand the problems that tracheostomy patients encounter, so working alongside the National Patient Safety Agency (NPSA) they analysed tracheostomy-related critical incidents that were reported nationally. Sifting through two years of data, certain themes emerged that mirrored what Dr McGrath and his colleagues had experienced locally, largely reflecting the weighty burden of tracheostomy management, often without sufficient expertise, training and infrastructure to safely manage patients (1).

“When we started looking with the NPSA, the themes that came out were a lack of training and a lack of familiarity with equipment, a lack of immediately available equipment at the bedside and deficiencies in the infrastructure supporting the management these patients.”

These multidisciplinary guidelines were developed for all of the stakeholders involved in emergency tracheostomy: medical, nursing and allied health staff from ICU, Anaesthesia, Head & Neck Surgery and Emergency Medicine. These guidelines were then taken to various different medical colleges and speciality groups for formal consideration, and subsequently shared on various different websites for consultation to make them as universal and accessible as possible.

The National Tracheostomy Safety Project incorporates the following key stakeholder groups with multi-disciplinary expertise in airway management:

  • The Difficult Airway Society
  • The Intensive Care Society
  • The Royal College of Anaesthetists
  • ENT UK
  • The British Association of Oral and Maxillofacial Surgeons
  • The College of Emergency Medicine
  • The Resuscitation Council (UK)
  • The Royal College of Nursing
  • The Royal College of Speech and Language Therapists
  • The Association of Chartered Physiotherapists in Respiratory Care
  • The National Patient Safety Agency

With the support of these organisations, the groups developed into the National Tracheostomy Safety Project (NTSP), tasked with improving the care of patients.

The guidelines were simplified into a single A4 algorithm and so resources were needed to support them. (2) The aim of the NTSP was to create a comprehensive one-stop-shop for tracheostomy care. They began making videos detailing complicated procedures, which were hosted on their website with involvement from e-Learning for Healthcare (eLFH). This lead to collaborations with the Advanced Life Support Group (ALSG) and the Resuscitation council to develop international tracheostomy courses, and the publication of multidisciplinary guidelines in ‘Comprehensive Tracheostomy Care,’ effectively the NTSP manual

Being a quality improvement project in hospitals, the NTSP attempts to put the training in place to prevent emergencies. “We’ve been running courses ourselves now since 2008, about 80 courses so far. In fact, demand was so high, we were having so many requests to run courses that we went to the ALSG and set up a course with them, which effectively runs itself. Hospitals can either go to our website and find the majority of the material to create a training course themselves or they can go to the ALSG and sign up to their training packages and learn how to train their staff with resources from ALSG”.

Discussing paediatric guidelines that they also developed Dr McGrath said: “The initial focus was on adult tracheostomies because the emergencies mainly involved adults. Tracheostomies in children are more commonly performed because of breathing problems caused by anatomical abnormalities. Furthermore, because paediatrics tracheas are a lot smaller, inner tubes, which are a key safety feature of adult tracheostomies, tend not to be used in paediatric tracheostomies. Although the cause and treatment of adult and paediatric tracheostomies can be quite different, the same approach was taken to create the tracheostomy algorithms.

Concluding, Dr McGrath described the promising results from collaborations with hospitals around the world that have come together to form the Global Tracheostomy Collaborative (www.globaltrach.org). “With the help of significant funding from the Health Foundation, we’ve shown reductions in severity or harm with the implemented guidelines, with data showing reduced length of stay, reductions in the number, nature and severity of incidents (3) as well as improvements in the quality of care using surrogate markers (for example, patients talking and eating earlier following their tracheostomy).” In identifying and stressing the issues in tracheostomy management, the NTSP guidelines, together with the requisite training, aim towards decisive and cohesive management of all tracheostomy patients. We hope that the NTSP will grow and continue to disseminate this essential information internationally (4).


If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.



  1. McGrath BA, Thomas AN. Patient safety incidents associated with tracheostomies occurring in hospital wards: a review of reports to the UK National Patient Safety Agency. Postgraduate medical journal. 2010;86(1019):522-5. Epub 2010/08/17.
  2. McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012;67(9):1025-41. Epub 2012/06/27.
  3. McGrath BA, Calder N, Laha S, Perks A, Chaudry I, Bates L, et al. Reduction in harm from tracheostomy-related patient safety incidents following introduction of the National Tracheostomy Safety Project: our experience from two hundred and eighty-seven incidents. Clinical otolaryngology : official journal of ENT-UK ; official journal of Netherlands Society for Oto-Rhino-Laryngology & Cervico-Facial Surgery. 2013;38(6):541-5. Epub 2013/10/10.
  4. McGrath B, Wilkinson K, Shah RK. Notes from a Small Island: Lessons from the UK NCEPOD Tracheotomy Report. Otolaryngology–head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2015;153(2):167-9. Epub 2015/06/07.

Accurate long-term pulse oximetry monitoring with greater patient comfort, lower cost and application beyond the ICU

Image courtesy Xhale Assurance

FDA Approval of the Nasal Alar SpO2 Sensor

On the 18th of March 2015, Xhale Assurance, developer of the patented Assurance® Nasal Alar SpO2™ Sensor, announced its approval by the US Food and Drug Administration (FDA) and the global launch of this second-generation pulse oximetry sensor (1,2). The new Xhale Assurance® Nasal AlarSpO2™ Sensor is compatible with the majority of pulse oximetry monitors used in many different healthcare settings. Pentland Medical is now marketing this product as the Nasal Alar SpO2 Sensor (3).

Oxygen Supplementation in Patient Treatment

Acute and chronic medical conditions can be associated with hypoxia and require supplemental oxygen therapy. The acute medical conditions include attacks of asthma, pneumonia or respiratory distress syndrome (RDS). In premature babies, oxygen supplementation is given for the condition of bronchopulmonary dysplasia (BPD).

The chronic conditions requiring oxygen supplementation include chronic obstructive pulmonary disease (COPD), heart failure and sleep apnoea. In the treatment of these conditions, oxygen is usually administered through a nasal continuous positive airway pressure (NCPAP) machine, a nasal tube or a ventilator.

Pulse Oximetry in the Evaluation of Blood Oxygenation

It is important to monitor the requirements for and effects of oxygen supplementation as too much oxygen can be as harmful as too little. Pulse oximetry is a non-invasive method used to measure the oxygen level (or oxygen saturation) in the blood of the peripheral tissues, usually using a sensor attached to the finger.

The technology is based on detection of the light absorptive characteristics of oxygenated haemoglobin and the pulsating properties of the blood flow in the peripheral arteries and arterioles. With each heartbeat, there is a small increase in vascular volume, with an associated increase in oxygen-rich haemoglobin.

The pulse oximeter consists of a clip-like sensor that houses a light source, a light detector, and a microprocessor. One side of the sensor contains an infrared and a red light source which are transmitted through the tissues to the light detector on the other side. The oxygen-rich haemoglobin absorbs more of the infrared light; oxygen-poor hemoglobin absorbs more of the red light. The microprocessor calculates these differences and converts the information to a digital readout of the amount of oxygen being carried in the blood. This information enables the attending physician or nurse to evaluate the need for supplemental oxygen.

Use and Advantages of the Nasal Alar SpO2 Sensor

The Nasal Alar SpO2 Sensor fits comfortably on the nasal ala that is lateral to the nostril (nares) and does not require any adhesive to keep it secure (3). The Nasal Alar SpO2 Sensor can be easily removed and reapplied for use during the patient’s hospital stay (3). The nasal ala is a highly vascular region that is fed anatomically by both the external and internal carotid arteries. This multi-directional arterial supply provides strong, reliable photoplethysmography signals that respond rapidly to changes in the patient’s arterial oxygen saturation. These signals can be lost when using sensors located on the finger (4).

The nasal alar site has the following advantages:

  1. This site has no clinically significant sympathetic tone and, therefore, does not lose signal due to the patient being cold, anxious or stressed.
  2. This site is less affected when patients experience diminished peripheral perfusion, as in cardiovascular disease, hypovolaemia or following medications that cause vascular changes.
  3. The nasal alar site is less subject to signal distortion due to sensor interference from ambient light.
  4. The strong signal from this location provides consistent accuracy, even at very low oxygen saturations.
  5. The nasal alar site location makes the sensor less likely to be dislodged, which reduces alarms.
  6. The nasal alar attachment site is easily accessed by an anaesthetist during surgery; the non-adhesive attachment makes the sensors easy to reposition.

Clinical Evaluation of the Nasal Alar SpO2 Sensor

Recent studies support the feasibility and accuracy of nasal alar pulse oximetry (5). The many unique features of this nasal alar pulse oximetry sensor have encouraged clinical studies to evaluate its role beyond the operating theatre, in patients with acute, chronic or long-term medical conditions.

In February 2015, the results of a usability and acceptance study for the use of the Nasal Alar SpO2 Sensor in a non-hospital setting, showed that 50 volunteer subjects were able to wear the sensor for seven days (6). All 50 study participants reported that, when compared to wearing a finger pulse oximeter, the Nasal Alar SpO2 Sensor was more comfortable and interfered less with daily living activities (6). Although the use of oximeter sensors at sites such as the finger and forehead have been associated with skin pressure complications, there are no reported complications from the use of the Nasal Alar SpO2 Sensor (6,7).

The benefits of the Nasal Alar SpO2 Sensor include.

  1. Reliable, consistent and accurate oxygen saturation measurement, that is unaffected by reduced peripheral perfusion.
  2. Sensitive and rapid detection of changes in oxygen saturation.
  3. Ease of access to the alar nasal sensor attachment site, even during surgery.
  4. Comfort when wearing the sensor for long periods of time, with no complications.
  5. The nasal alar location of the sensor resists monitoring fluctuations or signal distortion due to ambient light or motion.
  6. Cost savings, when compared to finger and forehead sensors.

Cost: Nasal Alar SpO2 Sensor

The Nasal Alar SpO2 Sensor costs less than £20 ($30 USD) each (3). Patient studies have shown that the sensors are durable which means a significant cost saving can be expected in longer term monitoring (8). Digital sensors cost £8 ($12 USD), and forehead sensors are up to £16 ($24 USD). In the US, the average stay in ICU is 3.8 days and during this time, digital sensors will require replacement (8).

In conclusion, these results indicate that the Nasal Alar SpO2 Sensor can be used comfortably, safely, effectively and at relatively low cost, not only in the operating room during anaesthesia or in intensive care, but also in a variety of situations within and outside the hospital.

This report has been received and reviewed by Dr Richard Melker, Xhale Assurance, on 25th June, 2015, prior to online publication.

If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.


(1) Xhale website. http://xhale.com Accessed June 18, 2015

(2) Press Release. Xhale Assurance Announces FDA Approval of its Second Generation Nasal Alar SpO2 Sensor. March 18, 2015. http://xhale.com/xhale-assurance-announces-fda-approval-of-its-second-generation-nasal-alar-SpO2-sensor/ Accessed June 18, 2015

(3) Pentland Medical. Nasal Alar SpO2 Sensor. Product information. http://www.pentlandmedical.co.uk/index.php/products/pulse-oximetry-sensor/ Accessed June 18, 2015

(4) Davis DP, Aguilar S, Sonnleitner C, Cohen M, Jennings M. Latency and loss of pulse oximetry signal with the use of digital probes during pre-hospital rapid-sequence intubation. Prehosp Emerg Care 2011;15(1):18-22. http://informahealthcare.com/doi/abs/10.3109/10903127.2010.514091 Accessed June 18, 2015

(5) Morey TE, Rice MJ, Vasilopoulos T, Dennis DM, Melker RJ. Feasibility and accuracy of nasal alar pulse oximetry. Br J Anaesth 2014;112(6):1109-14. http://bja.oxfordjournals.org/content/112/6/1109.long Accessed June 18, 2015

(6) Melker, RJ, et al. Usability/Acceptance Study Final Report Xhale Assurance Nasal Alar Sensor. Feb. 2015. Unpublished data. On file, Xhale Assurance.

(7) Lee M, Eisenkraft JB, Forehead pulse oximeter-associated pressure injury. A Case Rep. 2014 Jan 15;2(2):13-5. doi: 10.1097/ACC.0b013e3182a66b29. http://www.ncbi.nlm.nih.gov/pubmed/25611043 Accessed June 18, 2015

(8) Pfuntner A, Wier LM, Steiner C. Costs for Hospital Stays in the United States, 2010. HCUP Statistical Brief #146. January 2013. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb146.pdf. Accessed June 18, 2015


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