Tracheostomy Emergencies

Why this matters

A home ventilator, a speaking valve, and “they always look like that” delay the actions that matter. A tracheostomy emergency is usually a blocked tube or a tube that has come out. It is not a mystery lung disease. Look at the neck. Take off what does not belong. Suction. If the tube is gone, bag the stoma.

Clinical sequence

1. Ask the caregivers three questions. Did the tube come out? When was it last suctioned? Where is the inner cannula?
2. Take the speaking valve, the cap, and the heat-and-moisture exchanger off. Those pieces block the airway when the patient is in trouble.
3. Remove the inner cannula on most adult tracheostomies and look at it. If it is plugged, removing it may have already opened the airway. Then pass a suction catheter. If the catheter will not pass, the tube is blocked or out of place. Do not keep pushing.
4. Put a waveform on whatever you bag. End-tidal carbon dioxide is that trace on the monitor.

Two Different Necks

• Tracheostomy. The patient may still have an upper airway. If the tube fails, some patients can get oxygen from the mouth. If the stoma is open, it is usually the better first target. Use a bag on the mouth only if that path still connects to the lungs.
• Laryngectomy. There is no upper airway that will save the patient. The stoma is the airway. Covering the mouth and bagging the face does nothing. Ask. Look for a laryngectomy bracelet. Treat the neck. Do not try only an oral tube.

If you cannot tell which neck you have, give oxygen to the stoma and the face until you know. Oxygen to both places is a safety step. It is not indecision.

Six steps when they are deteriorating

1. Put high-flow oxygen on the face and the stoma. Sit them up if they are breathing.
2. Remove the speaking valve, the cap, and the heat-and-moisture exchanger.
3. Remove the inner cannula, look at it, and suction if a catheter will pass.
4. If the catheter will not pass, stop pushing. The tube is blocked or displaced.
5. If the tube is out or has clearly failed, try to bag the stoma with a pediatric mask or the connector in your training. A small endotracheal tube, or a replacement tracheostomy tube, is only for clinicians who are trained and authorized.
6. Confirm whatever you are bagging with a waveform when you can.

Teaching points

• A new postoperative tracheostomy, days old rather than months old, may not have a healed tract. Pushing a tube in blindly can make a false passage. Give oxygen and go to a hospital that can replace it. Follow your protocol. Do not pull the outer tube on a fresh tracheostomy without a plan.
• DOPE still applies: displacement, obstruction, pneumothorax, and equipment. A home-ventilator alarm is a clue. It is not a diagnosis. Do not just turn the ventilator up and walk away.

Common errors

• Bagging through a capped speaking valve and calling the patient impossible to ventilate.
• Trying only an oral tube in a patient with a laryngectomy.
• Never looking at 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
• Difficult Airway Society guidelines hub — oxygenate, limit attempts, change the plan; laryngectomy vs tracheostomy is a different airway
• NASEMSO National Model EMS Clinical Guidelines (2022) — tracheostomy tube obstruction / displacement themes
• Tell a laryngectomy apart from a tracheostomy before you choose the mouth or the stoma. Your protocol owns replacement tubes and intubation through the stoma.