What is the best next step in securing the airway of a patient with a recent tracheostomy who has experienced unintentional decannulation?

Orotracheal Intubation Under Direct Laryngoscopy

In this patient with a recent tracheostomy (discharged the same day) who is maintaining adequate oxygenation (saturating well on nonrebreather), the best next step is orotracheal intubation under direct laryngoscopy using a long, uncut endotracheal tube advanced beyond the stoma site. 1, 2

Rationale for Oral Intubation in This Clinical Scenario

This patient has a very fresh tracheostomy (placed recently enough that he was just discharged today), meaning the stoma tract is immature and has likely already begun to recoil after decannulation. 2 The critical factors favoring oral intubation include:

• The patient is stable with adequate oxygenation on nonrebreather mask, allowing time for controlled airway management rather than emergent stoma manipulation 1, 2
• Fresh tracheostomy stomas (< 7 days) have significantly recoiled tissues, making blind replacement through the stoma dangerous and prone to creating false passages 2
• The upper airway is patent in this patient (he had a stroke requiring prolonged intubation, not upper airway obstruction), making oral intubation feasible 1

The Specific Technique

Use a long, uncut endotracheal tube and advance it carefully beyond the stoma opening to bypass the anterior tracheal wall defect and establish a secure airway below the tracheostomy site. 1, 2 This technique:

• Avoids the risk of creating a false passage through immature stoma tissues 1, 2
• Provides definitive airway control with confirmation via waveform capnography 1, 2
• Allows the stoma to be managed electively once the airway is secured 1

Why NOT Direct Stoma Intubation in This Case

Attempting to replace the tracheostomy tube or insert an endotracheal tube directly through this fresh stoma carries substantial risk:

• The stoma tract in a same-day discharge patient is not mature and tissues have recoiled, making the anatomy distorted 2
• Blind insertion risks creating a false passage anterior to the trachea, which can be catastrophic 1, 2
• Even with a smaller tube (one half-size smaller), the immature tract makes successful placement unlikely without fiberoptic guidance 1, 2
• Fiberoptic guidance through the stoma would be ideal but requires immediate availability of equipment and expertise, which may not be present in the emergency department 1, 2

When Stoma Intubation Would Be Preferred

Direct stoma intubation is more appropriate when: 1, 2

• The tracheostomy is established/mature (typically > 7 days old)
• The upper airway is known to be difficult or obstructed (not the case here)
• Fiberoptic equipment and expertise are immediately available to guide safe placement through the stoma 1, 2

Critical Pitfalls to Avoid

• Never use stiff introducers or bougies for stoma cannulation attempts, as they easily create false passages in fresh tracheostomies 2
• Never delay definitive airway management by attempting multiple blind passes through an immature stoma in a stable patient who could be safely intubated orally 1, 2
• Never assume the stoma tract remains patent just because the tube was recently in place—tissues recoil rapidly after decannulation 2

Alternative Approach if Oral Intubation Fails

If oral intubation proves difficult or impossible, then proceed with fiberoptic-guided placement through the stoma using a smaller endotracheal or tracheostomy tube, with an airway catheter or bougie railroaded over the bronchoscope. 1, 2 Without fiberoptic capability, apply bag-valve-mask ventilation to the face while occluding the stoma with gauze or a gloved finger to maintain oxygenation until definitive expertise arrives. 1, 2