What to do if a tracheostomy (tracheal tube) falls out?

Emergency Management of a Dislodged Tracheostomy Tube

When a tracheostomy tube falls out, immediately attempt to replace it with the same size tube or one size smaller while ensuring oxygenation through both the stoma and upper airway, and call for help from experienced personnel such as anesthesiologists or ENT surgeons. 1

Immediate Actions

1. Apply oxygen immediately:

   • Apply oxygen via face mask to the upper airway
   • Apply oxygen directly to the stoma site
   • Monitor oxygen saturation continuously 1

2. Assess the patient:

   • Check for respiratory distress, stridor, or increased work of breathing
   • Monitor vital signs including heart rate, respiratory rate, and oxygen saturation
   • Look for signs of subcutaneous emphysema or bleeding 2

3. Tube replacement:

   • Attempt to reinsert the same size tracheostomy tube first
   • If unsuccessful, use a tube one size smaller (should be available at bedside) 2, 1
   • Use a soft suction catheter as a guide for reinsertion (avoid stiff introducers like gum-elastic bougies which may create false passages) 2

Replacement Technique

1. Position the patient:

   • Extend the neck slightly (unless contraindicated)
   • Ensure good lighting

2. Replacement steps:

   • Gently insert a soft suction catheter through the stoma to confirm tracheal patency 2
   • If catheter passes easily, use it as a guide for tracheostomy tube insertion
   • Apply gentle pressure during insertion; never force the tube 2
   • Confirm proper placement by:
     • Feeling for air movement
     • Ability to pass a suction catheter
     • Patient's clinical response
     • End-tidal CO2 if available

3. If replacement is difficult:

   • Do not make multiple blind attempts as this can create false passages 1
   • Deflate the cuff of the partially displaced tube (if present) to allow airflow around the tube to the upper airways 2
   • Consider upper airway management if tracheostomy replacement fails 1

When Tube Cannot Be Replaced

1. If the patient is stable but tube cannot be replaced:

   • Continue oxygen to face and stoma
   • Position patient upright
   • Transport to a tertiary care facility 2

2. If the patient is deteriorating:

   • Remove the tracheostomy tube completely if it's blocked or displaced 2
   • Consider oral intubation if the upper airway is potentially patent 2, 1
   • Avoid vigorous attempts at ventilation via a displaced tracheostomy tube as this can cause significant surgical emphysema 2

Special Considerations

• Timing matters: The maturity of the tracheostomy tract affects ease of replacement:

  • Surgical tracheostomies have a better chance of successful replacement than percutaneous tracheostomies in the early post-operative period 1
  • Fresh tracheostomies (less than 7-10 days old) may close rapidly, making reinsertion difficult 2

• Bleeding: Blood in tracheal secretions may precede catastrophic hemorrhage and requires immediate evaluation 2

• Post-replacement care:

  • Secure the tube properly using tracheostomy ties or securing devices 1
  • Consider suturing the flange to the skin in high-risk patients 1
  • Document the incident and develop a clear plan for ongoing airway management 1

Common Pitfalls to Avoid

• Never rely solely on pulse oximetry, as it may not immediately reflect ventilation problems 1
• Never make multiple blind insertion attempts through the stoma 1
• Never use excessive force when attempting to reinsert a tube 2
• Never delay seeking expert help if initial replacement attempts are unsuccessful 1
• Never use stiff introducers like gum-elastic bougies as these can create false passages 2

Remember that prompt management of accidental decannulation is critical, especially in patients with significant upper airway edema or obstruction where the tracheostomy is essential for maintaining a patent airway 1.