What should be done if a postoperative patient with tongue cancer pulls out their tracheostomy tube on the third postoperative day?

Management of Accidental Tracheostomy Tube Dislodgement in a Post-Operative Tongue Cancer Patient

When a post-operative tongue cancer patient pulls out their tracheostomy tube on POD 3, you should immediately attempt to replace the tracheostomy tube with the same size or one size smaller tube while ensuring oxygenation through both the stoma and upper airway. 1, 2

Immediate Actions

1. Call for help immediately - Seek assistance from experienced personnel (anesthesiologist, ENT surgeon, or critical care team) 1, 2

2. Assess and maintain oxygenation:

   • Apply oxygen via face mask to the upper airway
   • Apply oxygen directly to the stoma site
   • Monitor oxygen saturation continuously 2

3. Attempt tracheostomy tube replacement:

   • Try to reinsert the same size tracheostomy tube first
   • If unsuccessful, use a tube one size smaller (which should be available at bedside) 1
   • Avoid multiple blind attempts as this can create false passages 2

If Replacement Fails

1. Consider upper airway management:

   • Since this is a post-operative tongue cancer patient, the upper airway may be compromised but potentially patent 1
   • Prepare for possible difficult intubation through the oral route if needed 1, 2
   • Consider video laryngoscopy as first choice for intubation 2

2. Monitor for signs of respiratory distress:

   • Stridor, obstructed breathing pattern, agitation
   • Increasing subcutaneous emphysema
   • Neck swelling or hematoma formation 2

Special Considerations for POD 3 Tracheostomy

1. Stoma tract maturity:

   • At POD 3, the tracheostomy tract is not fully mature but should still be patent enough to allow replacement 1, 3
   • A surgically created tracheostomy (likely in this tongue cancer case) has a better chance of successful replacement than a percutaneous tracheostomy at this early stage 1

2. Equipment preparation:

   • Ensure availability of:
     • Replacement tracheostomy tubes (same size and one size smaller)
     • Suction equipment
     • Oxygen delivery devices
     • Difficult airway equipment including intubation supplies 2

Post-Replacement Management

1. Confirm proper placement:

   • Verify with capnography
   • Assess bilateral chest rise
   • Auscultate for equal breath sounds 2

2. Secure the tube properly to prevent further dislodgement:

   • Use tracheostomy ties or securing devices
   • Consider suturing the flange to the skin in high-risk patients 1

3. Consider imaging (chest X-ray or CT) to confirm proper placement and assess for complications 2

4. Document the incident and develop a clear plan for ongoing airway management 1

Common Pitfalls to Avoid

1. Don't delay seeking help - Early involvement of specialists improves outcomes 1, 2

2. Don't rely solely on pulse oximetry - It may not immediately reflect ventilation problems 1, 2

3. Don't perform multiple blind attempts at reinsertion - This increases the risk of creating false passages 2

4. Don't forget that the patient has had tongue cancer surgery - This makes the upper airway potentially difficult to manage if tracheostomy replacement fails 1, 4

Prompt management of accidental decannulation in this post-operative period is critical as the patient likely has significant upper airway edema from the tongue cancer surgery, making the tracheostomy essential for maintaining a patent airway 1.