Tracheostomy Emergencies

Why This Is Hard

Home vents, speaking valves, and “they always look like that” delay the only moves that matter: oxygenate, open the tube, or replace the airway. A tracheostomy emergency is usually obstruction or dislodgement — not a mystery lung disease. NAEMSP-style EMS teaching and UK National Tracheostomy Safety Project algorithms all run the same pass: look at the neck, remove what does not belong, suction, and ventilate the stoma if the tube is gone.

Two Different Necks

• Tracheostomy (trach): still has a potential upper airway. If the tube fails, some patients can be oxygenated from the mouth — but the stoma is usually the better first target if it is patent.
• Laryngectomy: no upper-airway connection that will save you. The stoma is the airway. Covering the mouth and bagging the face does nothing. Ask, look for a laryngectomy bracelet, and treat the neck.

If you cannot tell, oxygenate the stoma and the face until you know — dual oxygenation is a safety move, not indecision.

Crash Pass (Education)

1. High-flow oxygen to the face and stoma. Sit them up if they are breathing.
2. Remove speaking valve, cap, HME. These are obstruction machines when the patient is in trouble.
3. Remove the inner cannula (most adult trachs). Look. If it is plugged, you may have already won.
4. Pass a suction catheter. If it will not pass, the tube is blocked or dislodged — do not keep pushing.
5. If the tube is out or clearly failed: attempt to ventilate the stoma with a pediatric mask or appropriate connector per training. A small ETT or replacement trach is protocol-and-training only.
6. Confirm whatever you are ventilating with waveform EtCO₂ when you can.

Street Rules

• Caregivers are a resource. “Did the tube come out? When was it last suctioned? Inner cannula?”
• Fresh post-op trachs (days, not months) may not have a mature tract. Blind reinsertion can make a false passage. Oxygenate and move toward a facility that can replace it — follow protocol.
• DOPE still applies: displacement, obstruction, pneumothorax, equipment. A home vent alarm is a clue, not a diagnosis.

Field Pitfalls

• Bagging a capped speaking valve and calling the patient “not ventilable.”
• Oral intubation only on a laryngectomy patient.
• Ignoring the inner cannula.

Practice

Related: Failed Oxygenation: DOPE-S, Waveform Capnography.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• National Tracheostomy Safety Project — green/red algorithms: oxygenate stoma and face, remove valve, inner cannula, suction
• NASEMSO National Model EMS Clinical Guidelines (2022) — tracheostomy tube obstruction / displacement themes
• Know laryngectomy vs tracheostomy. Protocol owns replacement tubes and stoma intubation.