Tracheostomy Emergencies

and Management

Charles S. Williams RRT, AE-C

 Learner objectives
 Recognize a tracheostomy patient needing
emergency intervention.
 Identify common causes of tracheostomy
emergencies.
 Describe ways to establish an emergent
airway.
 Review various tips for suctioning a
patient with a tracheostomy tube.
Signs of Tracheostomy Tube
Problems
 Signs of Tracheostomy Tube
Problems
 Patient showing signs of respiratory distress
 Increased work of breathing/retractions
 Decreased breath sounds/chest rise
 Altered mental status
 Changes in vital signs
 Cyanosis
 Ventilator high pressure alarms
 Common Causes of
Tracheostomy Problems

The most common causes of

respiratory distress for a patient
with a tracheostomy tube in
place are, tube blockage from
secretions and tube
dislodgement.
 Common Causes of
Tracheostomy Tube Problems
D - Dislodged/ Displaced

O - Obstruction

P - Pneumothorax

E - Equipment Failure
 D – Dislodged

Trach tubes may become dislodged from:

 Improper airway positioning

 Trach ties or Dale straps too loose.
 Vigorous coughing or sudden movements.
 Sudden weight changes (i.e. a connected
Ambu bag).
 O – Obstruction

Trach tubes may become obstructed from:

 Improper positioning of the patient.

 Secretions
 Bleeding
 Foreign objects
 Edema in the trachea (rare)
 Managing Trach Tube Problems
First: Attempt to pass suction catheter

Tip - Measure catheter against obturator

Managing Trach Tube Problems
If catheter cannot pass to If catheter is able to pass
measured depth… to measured depth…

…obstruction is within the …obstruction is below the

trach tube trach tube.
 Tube is most likely
dislodged/displaced.
 Managing Trach Tube Problems
If obstruction is within the If obstruction is below the
trach tube… trach tube….

…instill normal saline, attempt

…clean or replace the inner suctioning and bag ventilation.
cannula.
•Prepare to change the trach tube
 Changing a Trach Tube
 Trach Tube, obturator, syringe and ties (ready to go)
 Proper positioning of the patient (neck hyperextended, supine).
 Towel/shoulder roll
 Suction equipment
 Manual resuscitator bag and masks
 Water soluble lubricant
 Normal saline/sterile water
 Changing a Trach Tube

1. Gather equipment
2. Position patient flat and midline
3. Hyperextend neck (towel roll)
4. Lubricate new tube
5. Deflate old cuff w/ syringe (Do not cut)
6. Undo old ties, remove tube
7. Put in new trach, remove obturator
8. Attempt to ventilate
9. Secure new trach tube
 Changing a Trach Tube
 Always have at least
two people!

 If you meet any

resistance: ST OP!
 Possible Complications When
Inserting a Trach Tube
 Creation of a false lumen or passage

 Subcutaneous air

 Pneumothorax or Pneumomediastinum

 Bleeding
 Confirming Placement of Trach
or ET Tube
 No resistance encountered while inserting
tube
 Equal chest rise
 Bilateral breath sounds
 End-tidal CO2 detection
 Improved skin color, vitals signs, pulse
oximetry
 Inserting a Trach Tube
The “guidewire” technique:

 May use a nasogastric tube or suction catheter

 Inserting a Trach Tube
The “Fingertip” technique:

 Trach tube removed

 Thyroid gland isthmus causing
 Tracheostomy tube in obstruction
place  Skin opening and tracheal window not
aligned
 Inserting a Trach Tube
The “Fingertip” technique:

 Neck extended  Tracheostomy tube inserted as finger is

 Gloved forefinger inserted into stoma, removed
below thyroid ishtmus
 Managing Trach Tube Problems

If attempts at re-inserting a new tube are unsuccessful:

or

 Apply an occlusive  Begin BVM to stoma

dressing to the stoma ventilation (pediatric mask?)
 Begin BVM ventilation  Must for Laryngectomy
patients!
If other interventions are unsuccessful, then consider:

 Endotracheal tube into stoma

or
Oral intubation (if appropriate), while
maintaining occlusive dressing over stoma.
 Inserting an ET Tube

 Measure ET tube Confirm placement

against trach tube 1.
2.
Breath sounds
End-tidal CO2
 Do not cut ET tube  Secure ET tube
 P – Pneumothorax

Pneumothorax can develop from:

 High Peak Inspiratory Pressures

 High Positive End-Expiratory Pressures (PEEP)
 Vigorous bagging with Ambu
 Underlying disease (COPD)
 Trauma
 Signs and Symptoms of a
Pneumothorax
 Shortness of breath/
respiratory distress
 Diminished or absent breath
sounds
 Tracheal deviation
 Sub-Q emphysema
 Cyanosis
 Signs and Symptoms of a
Pneumothorax
 Patient
needs immediate
needle decompression!
(2nd intercostal space) ACLS

 Donot wait for X-ray

confirmation!
 E – Equipment

Equipment problems can result from:

 Ventilator/power failure
 Vent circuit problems (disconnected,
obstructed)
 Trach supplies and equipment missing

Troubleshoot all equipment and maintain necessary supplies

Every patient with a tracheostomy tube should have
the following equipment at bedside:

 Spare trach tubes (same size and one smaller)

 Obturator placed in a clear, plastic bag at HOB
 Manual resuscitator bag, masks
 Suction equipment
 Suctioning Tips

 “Safe suction” measurement

 Fenestrated Trach Tube
 Ballard in-line suction
 Sources

 EMS Management of Tracheostomy Emergencies

 Tracheosomy Care for All Ages: Maryland Institute For Emergency
Medical Services
 Dislodged Tracheostomy, Paradorn Pattanong M.D.
Questions?

Thank You!