Management of Subcutaneous Emphysema Post-Tracheostomy
Immediately assess tracheostomy tube patency by passing a soft suction catheter through the tube—if the catheter will not pass easily or subcutaneous emphysema is present and worsening, remove the tracheostomy tube without delay, as a blocked or displaced tube acts as a foreign body forcing air into tissue planes and must be removed to prevent life-threatening complications. 1, 2
Initial Assessment and Immediate Actions
The priority is determining whether the tracheostomy tube is patent and properly positioned, as subcutaneous emphysema typically indicates tube displacement, tracheal wall injury, or creation of a false passage during insertion. 1
Perform these steps simultaneously:
- Apply high-flow oxygen to both the face and tracheostomy stoma using two separate oxygen sources to maximize oxygenation regardless of which airway route is functional. 1, 2
- Remove any attached ventilation devices from the tracheostomy tube to allow direct assessment. 1
- Pass a soft suction catheter through the tracheostomy tube—the catheter must pass easily beyond the tube tip and into the trachea to confirm patency. 1, 2
- Apply waveform capnography immediately to confirm airway patency and guide subsequent interventions. 1, 2
- Monitor pulse oximetry continuously to assess response to interventions. 1
Critical Pitfall: Never Use Stiff Introducers
Never use gum-elastic bougies or stiff introducers for initial assessment, as these can create false passages if the tube is partially displaced, dramatically worsening subcutaneous emphysema and potentially causing pneumothorax or pneumomediastinum. 1, 2 Only soft suction catheters should be used for patency testing. 1
Indications for Immediate Tube Removal
Remove the tracheostomy tube immediately if any of the following are present:
- The suction catheter will not pass through the tube 1, 2
- The patient continues to deteriorate despite oxygen administration 1, 2
- Subcutaneous emphysema is present or worsening 1, 2
- There is suspected tube displacement or blockage 1, 2
When faced with a deteriorating patient and an obstructed airway, a non-functioning tracheostomy tube offers no benefit with considerable potential for harm—the blocked or displaced tube must be considered a foreign body in the trachea that must be removed. 3 Do not delay removal even in patients with known difficult or obstructed upper airways, as continued attempts at ventilation through a malpositioned tube will worsen subcutaneous emphysema. 3, 1
Post-Removal Emergency Oxygenation
After removing the tracheostomy tube, reassess both the upper airway (mouth) and the tracheostomy stoma, applying oxygen to both sites simultaneously. 3, 1
Primary oxygenation options:
- Apply bag-valve-mask ventilation to the face while occluding the stoma with a gloved finger or gauze to prevent air leak and maximize ventilation effectiveness. 1, 2
- Apply a pediatric facemask or laryngeal mask airway directly over the stoma, occluding the nose and mouth if there is a large leak through the upper airway. 3, 1, 2
Most responders will correctly attempt to manage the airway via the oro-nasal route but must remember to occlude the tracheal stoma to maximize effective ventilation. 3
Secondary Emergency Oxygenation (If Primary Measures Fail)
If effective oxygenation cannot be achieved with primary measures, advanced airway techniques are required:
- Perform oral intubation using a long, uncut endotracheal tube advanced beyond the stoma to bypass the anterior tracheal wall opening—this is particularly important in recent tracheostomies (less than 7 days old) where the stoma tract is immature and prone to recoil. 3, 1, 2
- Insert a smaller tracheostomy tube or endotracheal tube through the stoma, using fiberoptic guidance when immediately available to ensure correct placement and avoid creating false passages. 3, 1, 2
- Confirm all tube placements using waveform capnography to verify correct positioning. 1, 2
Separate airway teams may be appropriate in dire situations—one working at the head/face and one working on the neck. 3
Prevention of Worsening Emphysema
Avoid vigorous attempts at ventilation via a potentially displaced tracheostomy tube, as this is the primary mechanism for worsening subcutaneous emphysema and can cause pneumothorax or pneumomediastinum. 1, 2, 4, 5
- Only use gentle hand ventilation after confirming tube patency with a suction catheter. 1, 2
- High airway pressures through a malpositioned tube force air into the mediastinum and subcutaneous tissues, creating the pathophysiology of extensive surgical emphysema. 3, 4, 5
- False passage creation during insertion or tube displacement allows air to track into tissue planes rather than the tracheal lumen. 1, 4, 5, 6
Special Considerations for Fiberoptic Inspection
Fiberoptic inspection of the tube while it remains in situ should only be considered if the patient is clinically stable and appropriate equipment and expertise are immediately available. 3, 2 This should never delay removal of a blocked or displaced tube when faced with a deteriorating patient. 3
Monitoring and Ongoing Care
Patients with subcutaneous emphysema post-tracheostomy require close monitoring in a high-dependency or critical care setting with trained staff continuously monitoring until physiologically stable. 1
- An appropriately skilled anesthetist or airway specialist must be immediately available. 1
- A written emergency airway management plan should be in place and communicated to all staff. 1
Definitive Management of Extensive Emphysema
If subcutaneous emphysema becomes massive and causes respiratory compromise despite airway management, insertion of large-bore subcutaneous drains maintained on low negative pressure (-5 cm H₂O) can provide effective decompression. 7 In rare cases of acute ventilatory failure from massive subcutaneous emphysema causing thoracic restriction, emergency tracheostomy or surgical decompression may be life-saving. 8