What is the management for surgical emphysema post-tracheostomy?

Management of Surgical Emphysema Post-Tracheostomy

Immediately assess tracheostomy tube patency by passing a soft suction catheter through the tube, and if the catheter does not pass easily or the patient is deteriorating, remove the tracheostomy tube without delay. 1, 2

Initial Assessment and Immediate Actions

The priority is determining whether the tracheostomy tube is patent and properly positioned, as surgical emphysema often indicates tube displacement or tracheal wall injury. 1, 2

• Apply high-flow oxygen simultaneously to both the face and tracheostomy stoma using two separate oxygen sources 1, 2
• Remove any attached ventilation devices from the tracheostomy tube 2
• Pass a soft suction catheter only through the tracheostomy tube to assess patency—the catheter must pass easily beyond the tube tip and into the trachea 1, 2
• Apply waveform capnography immediately to confirm airway patency and guide interventions 1, 2
• Monitor pulse oximetry continuously 2

Critical Pitfall to Avoid

Never use stiff introducers or gum-elastic bougies for initial assessment, as these can create false passages if the tube is partially displaced, worsening the surgical emphysema. 1, 2

When to Remove the Tracheostomy Tube

Remove the tracheostomy tube immediately if any of the following are present: 1, 2

• The suction catheter will not pass through the tube
• The patient continues to deteriorate despite oxygen administration
• Subcutaneous emphysema is present or worsening
• There is suspected tube displacement or blockage

Do not delay tube removal in a deteriorating patient to attempt fiberoptic inspection unless the patient is clinically stable and appropriate equipment with expertise is immediately available. 1, 2

Post-Removal Emergency Oxygenation

After removing the tracheostomy tube, reassess both the upper airway (mouth) and the tracheostomy stoma, applying oxygen to both sites. 3, 1

Primary Oxygenation Options:

• Via oro-nasal route: Apply bag-valve-mask ventilation to the face while occluding the stoma with a gloved finger or gauze to prevent air leak 1, 2
• Via tracheostomy stoma: Apply a pediatric facemask or laryngeal mask airway directly over the stoma, occluding the nose and mouth if there is a large leak 3, 1
• Use supraglottic airway devices or oral/nasal airway adjuncts as needed 2

Secondary Emergency Oxygenation (If Primary Measures Fail)

If effective oxygenation cannot be achieved with primary measures, advanced airway techniques are required: 3, 1

• Oral intubation: Use a long, uncut endotracheal tube advanced beyond the stoma to bypass the anterior tracheal wall opening 3, 1, 2
• Stoma intubation: Insert a smaller tracheostomy tube or endotracheal tube through the stoma, using fiberoptic guidance when available to ensure correct placement and avoid creating false passages 3, 1, 2
• Confirm all tube placements using waveform capnography 3, 1, 2

Special Consideration for Recent Tracheostomies

If the tracheostomy is less than 7 days old, the stoma tract tissues will have recoiled, making replacement significantly more difficult and increasing the risk of creating a false passage. 2

Prevention of Worsening Emphysema

Avoid vigorous attempts at ventilation via a potentially displaced tracheostomy tube, as this is a primary mechanism for worsening surgical emphysema and can cause pneumothorax or pneumomediastinum. 1, 4, 5

• Only use gentle hand ventilation after confirming tube patency with a suction catheter 1
• High airway pressures through a malpositioned tube can force air into the mediastinum and subcutaneous tissues 4, 5
• The mechanism involves air tracking along tissue planes from tracheal wall injury, false passages, or paratracheal tube placement 5, 6

Underlying Pathophysiology

Surgical emphysema post-tracheostomy results from: 4, 5, 6

• Direct trauma to the anterior or posterior tracheal wall during tube placement or manipulation
• False passage creation during insertion
• Paratracheal tube placement or dislocation
• Insufficient closure of soft tissue layers allowing air leakage
• High ventilation pressures forcing air through injured tissue planes

Monitoring and Ongoing Care

Patients with surgical emphysema post-tracheostomy require close monitoring in a high-dependency or critical care setting, as they have the potential to deteriorate rapidly. 7

• Trained staff should continuously monitor the patient until physiologically stable 3
• An appropriately skilled anesthetist or airway specialist must be immediately available 3
• A written emergency airway management plan should be in place and communicated to all staff 3
• Consider chest imaging if pneumothorax or pneumomediastinum is suspected based on clinical deterioration 5, 7