How to manage a patient desaturating with a size 6 tracheostomy tube?

Management of a Desaturating Patient with Size 6 Tracheostomy

Immediately assess tracheostomy patency by removing any attached devices (caps, speaking valves, humidifiers), then pass a soft suction catheter through the tube—if it does not pass easily beyond the tube tip into the trachea, remove the tracheostomy tube entirely and provide emergency oxygenation via both the face and stoma simultaneously. 1

Initial Assessment and Immediate Actions

Apply High-Flow Oxygen to BOTH Airways

• Deliver high-flow oxygen to both the face AND the tracheostomy stoma simultaneously using two separate oxygen sources (may require using the oxygen cylinder from the resuscitation trolley) 1
• Apply waveform capnography immediately to assess ventilation and guide interventions 1
• Check pulse oximetry to monitor response to interventions 1

Remove All Obstructing Devices

Critical first step: Remove any device attached to the tracheostomy tube that could cause obstruction 1:

• Decannulation caps 1
• Speaking valves (especially dangerous if cuff is inflated) 1
• Humidifying devices (Swedish noses) that can become blocked with secretions 1
• Remove the inner cannula if present—this alone may resolve the obstruction 1

Assess Tracheostomy Patency

Pass a Soft Suction Catheter

• Use ONLY a soft suction catheter (never a bougie or stiff introducer) to test patency 1, 2
• The catheter must pass easily beyond the tube tip and into the trachea 1
• Do NOT use gum-elastic bougies or similar stiff introducers—these can create false passages if the tube is partially displaced 1, 2
• If the suction catheter does not pass easily, the tube is malpositioned or blocked 1

Critical Warning About Ventilation

Do NOT attempt vigorous hand ventilation through a potentially displaced tube—this causes life-threatening surgical emphysema and makes subsequent airway management increasingly difficult 1, 2. Only use gentle ventilation AFTER confirming patency with a suction catheter 1, 2.

If Tube is Patent but Patient Still Desaturating

• Continue ABCDE assessment 1
• Ensure cuff is inflated to allow effective positive pressure ventilation 1
• Perform therapeutic suction for secretions 1
• Consider other causes of desaturation (pneumothorax, pulmonary edema, etc.) 1

If Tube is NOT Patent: Remove It Immediately

Remove the tracheostomy tube without delay if: 1, 2

• Suction catheter will not pass
• Patient continues to deteriorate
• Suspected tube displacement or blockage

After Tube Removal: Emergency Oxygenation Options

Primary Emergency Oxygenation (choose based on upper airway patency) 1:

If Upper Airway is Patent:

• Apply bag-valve-mask ventilation to the FACE 1
• Must occlude the stoma (use gloved finger or gauze) to prevent air leak 1
• Use oral/nasal airway adjuncts as needed 1
• Consider supraglottic airway device 1

If Upper Airway is Obstructed or Uncertain:

• Apply pediatric facemask or laryngeal mask airway directly over the stoma 1
• May need to occlude nose and mouth if large air leak occurs 1
• Ventilate through the stoma opening 1

Secondary Emergency Oxygenation (If Primary Measures Fail)

Two simultaneous airway teams may be needed—one at the head/face, one at the neck 1:

Option 1: Oral Intubation

• Use a long, uncut endotracheal tube advanced beyond the stoma to bypass the anterior tracheal wall opening 1
• This is appropriate if upper airway is accessible 1

Option 2: Stoma Intubation

• Insert a smaller tracheostomy or endotracheal tube (at least one size smaller than the original size 6 tube—use size 5.0 or smaller) through the stoma 1
• Use fiberoptic guidance when available to ensure correct placement and avoid false passages 1
• In emergencies without fiberoptic scope, blind or digitally-assisted bougie placement may be attempted but risks malposition 1

Confirm Placement

• Use waveform capnography to confirm correct tube placement and effective ventilation 1

Special Considerations for Size 6 Tracheostomy

• A size 6 tracheostomy is relatively small—consider that the stoma may be difficult to re-cannulate, especially if the tract is not mature 1
• If the tracheostomy is recent (less than 7 days old), the stoma tract tissues will have recoiled, making replacement significantly more difficult 1
• For mature tracheostomies, stoma intubation may be more appropriate than oral intubation 1

Key Pitfalls to Avoid

• Never delay tube removal in a deteriorating patient to attempt fiberoptic inspection unless the patient is stable and equipment/expertise is immediately available 1
• Never use stiff introducers or bougies for initial patency assessment—use only soft suction catheters 1, 2
• Never ventilate vigorously through an unconfirmed airway—this causes massive surgical emphysema 1, 2
• Never forget to occlude the stoma when ventilating via the upper airway 1
• Never forget to apply oxygen to BOTH airways simultaneously during the emergency 1