What is the management for a dislodged tracheostomy (tracheal tube)?

Management of a Dislodged Tracheostomy Tube

Remove the dislodged tracheostomy tube immediately if a soft suction catheter cannot pass through it or if the patient continues to deteriorate, then provide emergency oxygenation via both the face and stoma simultaneously while preparing for definitive airway management. 1, 2

Initial Assessment and Immediate Actions

• Apply high-flow oxygen to BOTH the face and tracheostomy stoma simultaneously using two separate oxygen sources—this is critical as you don't yet know which airway route will be functional 2, 3
• Remove any attached ventilation devices from the tracheostomy tube 2, 3
• Apply waveform capnography immediately to assess ventilation and guide your interventions 2, 3
• Monitor pulse oximetry continuously to track response to interventions 2, 3

Assess Tracheostomy Tube Patency

Use ONLY a soft suction catheter to test patency—the catheter must pass easily beyond the tube tip and into the trachea 1, 2

Critical Pitfall to Avoid:

• Never use gum-elastic bougies or stiff introducers for initial assessment, as these can create false passages if the tube is partially displaced, potentially converting a manageable situation into a catastrophic one 1, 2, 3

If Suction Catheter Passes Easily:

• The tube is patent and you can continue standard ABCDE assessment 1
• If the patient is apneic, inflate the cuff (with un-fenestrated inner tube if necessary) to allow effective positive pressure ventilation 1

If Suction Catheter Will NOT Pass:

• The tube is blocked or displaced 1
• Deflate the cuff—this may allow airflow past a partially displaced tube to the upper airways 1
• Reassess both the tracheostomy and upper airways for patency 1
• If cuff deflation improves the clinical condition, continue ABCDE assessment and await experienced assistance 1

Remove the Tracheostomy Tube Immediately If:

Do not hesitate—remove the tube in any of these scenarios: 1, 2, 3

• The suction catheter will not pass through the tube 1, 2, 3
• The patient continues to deteriorate despite oxygen administration 2, 3
• Deflating the cuff fails to improve the clinical condition 1
• Subcutaneous emphysema is present or worsening 4, 3

Why Immediate Removal is Critical:

A non-functioning tracheostomy tube offers no benefit and considerable potential for harm—vigorous attempts at ventilation through a displaced tube have caused deaths by creating massive surgical emphysema that makes subsequent airway management increasingly difficult 1, 3

Exception (Rarely Applicable):

• If the patient has a known difficult or obstructed upper airway AND is clinically stable AND fiberoptic equipment with expertise is immediately available, consider fiberoptic inspection before removal 1, 4
• This should NEVER delay removal in a deteriorating patient 1, 2

Post-Removal Emergency Oxygenation

After removing the tube, reassess BOTH airways (mouth and trachea) and ensure oxygen is reapplied to face and stoma 1, 2

Primary Emergency Oxygenation Options:

Via the 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 2, 3
• Use supraglottic airway devices or oral/nasal airway adjuncts as needed 2

Via the tracheostomy stoma:

• Apply a pediatric facemask or laryngeal mask airway directly over the stoma 1, 2, 3
• If there is a large leak, occlude the nose and mouth 3

Key Point on Timing:

Definitive airway management (re-insertion of a tracheostomy or oral tube) is not necessarily required immediately if the patient is not hypoxic—harm has resulted from inappropriate attempts to manipulate the stoma blindly when not required 1

Secondary Emergency Oxygenation (If Primary Measures Fail)

If the patient fails to improve after removing the tracheostomy tube and applying primary oxygenation measures, advanced airway techniques are required:

Oral Intubation (Preferred for Recent Tracheostomies):

• Use a long, uncut endotracheal tube advanced beyond the stoma opening to bypass the anterior tracheal wall defect 2, 3
• This technique is particularly important for tracheostomies less than 7 days old, as the stoma tract tissues will have recoiled, making direct stoma replacement dangerous 1, 2
• Confirm placement with waveform capnography 2, 3

Stoma Intubation (If Oral Route Fails):

• Insert a smaller tracheostomy tube or endotracheal tube through the stoma 2, 3
• Use fiberoptic guidance when available to ensure correct placement and avoid creating false passages 2, 3
• Confirm placement with waveform capnography 2, 3

Special Considerations Based on Tracheostomy Age

Surgical vs. Percutaneous Tracheostomy:

• A 4-day old surgical tracheostomy tube can reasonably be expected to be replaced, as the stoma tract is likely to remain initially patent 1
• A 4-day old percutaneous tracheostomy replacement will likely prove much more difficult, as the dilated stoma tract tissues recoil 1

Tracheostomy Less Than 7 Days Old:

• The stoma tract is immature and prone to recoil 2
• Blind replacement through the stoma is dangerous—oral intubation is safer to avoid creating false passages 2

Critical Pitfalls to Avoid

• Never ventilate vigorously through an unconfirmed airway—only use gentle hand ventilation after confirming tube patency with a suction catheter 1, 4, 3
• Never use stiff introducers or bougies for initial patency assessment 1, 2, 3
• Never delay tube removal in a deteriorating patient to attempt fiberoptic inspection unless the patient is stable and equipment/expertise is immediately available 1, 2
• Never attempt blind manipulation of the stoma when not required—this has caused harm 1

Equipment That Should Be at Bedside

Every tracheostomy patient's bedside should have: 5

• Functional suctioning system 5
• Oxygen source 5
• Manual resuscitation bag 5
• Complete tracheostomy kit 5

Call for Help Early

Seek the best assistance early—ideally including anesthetists, intensivists, head and neck surgeons, or specialist practitioners trained in tracheostomy emergencies 1, 3