Obstructed
tracheostomy
tubes
A TRACHEOSTOMY IS a percuta-
neously or surgically created
opening in the anterior wall of
the trachea inferior to the cricoid
cartilage that provides tracheal
access for airway management.
A temporary or permanent tra-
cheostomy tube is inserted into
the opening to maintain airway
patency. A common complication
associated with tracheostomy
tubes is obstruction. Obstruction
of the tracheostomy tube is a life-
threatening emergency, so if you
suspect your patient has or is de-
veloping a tracheostomy tube ob-
struction, you’ll need to intervene
immediately.
Be prepared for trouble
Whenever you care for a patient
with a tracheostomy tube, you
need to be ready for any emer-
gency that can threaten airway
patency, leading to respiratory dis-
tress and failure. (See Be prepared!
for a list of equipment that should
be readily accessible at the pa-
tient’s bedside.)
To recognize an obstructed tra-
cheostomy tube, closely monitor
www.Nursing2010.com
By Joan Webber-Jones, EdM, RN-C, ONC
your patient for signs and symp-
toms of respiratory distress such
as shortness of breath, tachypnea,
labored breathing, diaphoresis,
agitation, accessory muscle use,
reduced SpO2, hypoxemia, and
hypercapnia.
All blocked up
Common causes of tracheostomy
tube obstruction include:
• a dried mucous plug. This is the
most common cause of obstruc-
tion.1 Airway suctioning is the
most important intervention for
maintaining a patent airway and
preventing mucous plugs. Most
tracheostomy patients have a
diminished cough reflex and re-
quire suctioning to remove air-
way secretions.2 Coarse crackles
and rhonchi are indications for
suctioning. Inhaled, heated, or
room temperature humidification
is vital for maintaining tube pa-
tency.1 It’s also important to keep
the patient properly hydrated,
such as with I.V. fluids. If the
patient demonstrates signs and
symptoms of respiratory distress,
suction the tracheostomy tube to
Clearing
the air
try to remove any mucous plugs
that may be present.3 If you feel
resistance and the patient’s signs
and symptoms don’t improve with
suctioning, another problem is
causing the respiratory distress.
• an overinflated herniated tra-
cheostomy tube cuff. Overinflation
of the tracheostomy tube cuff can
obstruct the tube lumen by the in-
creasing pressure, causing it to
narrow. Overinflation can also
cause the cuff to distend distally
and partially or completely cover
and obstruct the distal lumen.4
Tracheostomy tube cuff herniation
may occur from a manufacturing
defect and cuff fabric fatigue. High
compliance (low volume, high
pressure) cuffs have a history of
herniation if overinflated.4 Cuff
pressure should be between 20 to
25 mm Hg to achieve an air seal.
If suctioning doesn’t improve the
patient’s signs and symptoms, de-
flate the tracheostomy tube cuff
with the healthcare provider’s order
to ensure the cuff hasn’t herniated
over the tip of the tube, obstruct-
ing it. Attempt to pass a suction
catheter through the tube again; if
January | Nursing2010 | 49
you feel resistance, the tube is show if it’s kinked, and a new tube Resizing of the tracheostomy tube
still obstructed and cuff hernia- is inserted. is required for the tube to be
tion isn’t the problem.3 • a displaced tracheostomy tube. securely placed in the trachea
• tracheostomy tube bevel resting A tracheostomy tube may be dis- having bypassed the pocket, fis-
against the tracheal wall. If the dis- placed in subcutaneous tissue, a tula, or blind pouch.2
tal tube lumen rests against the tracheoesophageal fistula, or an
tracheal wall, the patient’s respira- abnormal anatomical tissue Prevention and aftercare
tory status will slowly deteriorate. pocket. If the upper airway is The best way to prevent an ob-
Bag-mask ventilation will become patent, the patient can breathe struction from occurring is to
increasingly difficult with in- and may show minimal signs and monitor the patient closely. Know
creased resistance to bag compres- symptoms of respiratory compro- the type of tracheostomy tube
sion. A chest X-ray is performed mise, such as mild tachypnea.6 If that’s in place and the possible
to identify tube placement. If the the upper airway isn’t patent, the risks associated with the tube.
tube is against the tracheal side- patient will demonstrate signs Check for thick, viscous, and dry
wall, it’s removed and another in- and symptoms of respiratory sputum, and keep the patient hy-
serted 2 to 3 cm above the carina compromise and requires imme- drated. If the patient has abnormal
and centered in the trachea.2 A diate attention. You may identify breath sounds or a weak cough,
patient with a long neck, tracheal a displaced tube when passing be prepared to prevent or manage
stenosis, or tracheomalacia (an the suction catheter into the tra- the potential obstruction.
abnormal collapse of the tracheal cheostomy tube. If you feel resis- After an obstruction has been
wall) is a candidate for a tra- tance at 7 to 8 cm and obtain resolved, monitor the patient close-
cheostomy tube with a longer dis- minimal sputum, suspect a dis- ly for excess respiratory secretions.
tal vertical extension to prevent placed tube. Also be suspicious if Assist with airway clearance and
recurrence.2 the patient can speak clearly with suction, and be sensitive to any tis-
• a kinked tracheostomy tube. This an unplugged tracheostomy tube; sue edema that may have devel-
may occur during postoperative re- a displaced tube may allow the oped. Monitor the patient’s oxygen
covery in patients with long tra- patient’s exhalations of air to pass saturation, maintaining a satura-
cheostomy tubes.5 When the tube by the vocal cords, producing tion level of 92% or above. As the
is inserted and locked in place at speech. If the tracheostomy tube patient recovers and is getting
the tracheal faceplate, it can be- is correctly placed in the trachea, ready for discharge, provide the
come kinked because it can’t move the patient can’t speak without patient and caregivers with infor-
in either direction. The patient will plugging the tracheostomy tube mation about proper tracheostomy
experience severe respiratory com- because exhaled air exits through care to prevent tracheostomy tube
promise, but a bronchodilator isn’t the tracheostomy tube and doesn’t obstruction at home. Teach the
effective and a chest X-ray appears reach the vocal cords.6 An X-ray patient the signs and symptoms of
normal. Removal of the tube will is performed to confirm placement. a dried mucous plug and how to
prevent one from occurring. ■
Be prepared!
REFERENCES
To be ready for an airway emergency, make sure the following equipment is
1. Kapadia FN. Factors associated with blocked
available at the patient’s bedside: tracheal tubes. Intensive Care Med. 2001;27(10):
• a duplicate tracheostomy tube (the same size and type as the one the patient 1679-1681.
has in place) and another tube made by the same manufacturer that’s one size 2. St. John JE, Malen JF. Contemporary issues
smaller in adult tracheostomy management. Crit Care
Nurs Clin North Am. 2004;16(3):413-430.
• a manual resuscitation bag and oxygen source
3. Regan EN, Dallachiesa L. How to care for a
• suction source and suction equipment, including suction catheters that are half patient with a tracheostomy. Nursing. 2009;
the size of the tracheostomy tube 39(8):34-39.
• large diameter or tonsil-tip suction catheter 4. Saini S, Taxak S, Singh MR. Tracheostomy
tube obstruction caused by an overinflated
• small diameter suction catheters that will fit into the tracheostomy tube
cuff. Otolaryngol Head Neck Surg. 2000;122(5):
• tracheostomy tube obturator 768-769.
• water-soluble lubricant 5. Sharma A, Elliot S, Mallick A. Kinking of a
• tracheostomy insertion tray long tracheostomy tube can present as severe
acute asthma. Anaesthesia. 2002;57(12):1238-
• 10-mL syringe (for a cuffed tube) 1240.
• tracheostomy tube securement device 6. Seay SJ, Gay SL, Strauss M. Tracheostomy
• tracheostomy collar with heated or room temperature humidity emergencies. Am J Nurs. 2002;102(3):59, 61, 63.
• inner cannula cleaning materials.2 Joan Webber-Jones is a nurse educator at Fletcher
Allen Health Care in Burlington, Vt.

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