What are the treatment options for a patient with a widening tracheostomy (trach) hole?

Management of Widening Tracheostomy Stoma

A widening tracheostomy stoma requires immediate assessment for tube displacement, infection, or tissue breakdown, followed by upsizing the tracheostomy tube to match the enlarged stoma diameter while addressing the underlying cause. 1

Immediate Assessment Protocol

Rule Out Emergency Conditions First

• Check for active bleeding - moderate bleeding with tube pulsation suggests tracheo-arterial fistula requiring immediate cuff hyperinflation and emergency surgical intervention 1
• Assess tube position - a widening stoma often indicates chronic tube displacement or malposition causing mechanical irritation and tissue erosion 1
• Verify airway patency - pass a soft suction catheter through the tracheostomy to ensure it passes freely; if it doesn't, the tube must be removed immediately 2
• Look for "red flag" signs - increased discomfort, blood-stained secretions, or physiological deterioration (respiratory rate changes, altered consciousness) indicate urgent complications beyond simple stoma widening 1

Common Pitfall to Avoid

Never dismiss a widening stoma as benign without systematic assessment - this can be the first sign of serious complications including granulation tissue, tracheal wall erosion, or impending tube displacement 1, 3

Treatment Algorithm

Step 1: Stabilize the Current Situation

• Apply high-flow oxygen to both the face and tracheostomy using two separate oxygen sources to maximize oxygenation 2, 4
• Position the patient optimally - place a pillow or rolled towel under the shoulders to extend the neck, bringing the trachea anteriorly and improving stoma access 2
• Use waveform capnography immediately to confirm tube patency and proper positioning 2, 1

Step 2: Determine the Underlying Cause

• Mechanical causes - verify the tube extends at least 2 cm beyond the stoma and remains 1-2 cm above the carina; improper positioning causes chronic irritation leading to stoma widening 5
• Granulation tissue - examine for friable tissue at the stoma site causing bleeding and progressive enlargement, which requires cauterization or surgical management 1, 3
• Infection - assess for purulent drainage, erythema beyond the immediate stoma margin, and systemic signs requiring antimicrobial therapy 1
• Tracheomalacia - consider if the stoma has been present long-term, as cartilage weakening can cause progressive enlargement 3, 6

Step 3: Definitive Management

For a stable patient with a widening stoma:

• Upsize the tracheostomy tube - use a tube one half-size larger to fill the widened stoma and prevent air leak, ensuring proper seal and ventilation 2
• Consider a cuffed tube if not already in place - this provides better seal in an enlarged stoma and prevents aspiration 3
• Address tissue breakdown - optimize local wound care, ensure proper tube positioning, and minimize movement at the stoma site 1

For granulation tissue:

• Bronchoscopic cauterization or surgical excision is required for significant granulation tissue causing progressive stoma enlargement 1, 3

For suspected tracheomalacia:

• Multidisciplinary evaluation with bronchoscopy to assess tracheal wall integrity and consider surgical revision if conservative measures fail 3

Step 4: Emergency Tube Replacement Technique (If Required)

If the current tube is displaced or inadequate:

• First attempt - use a tube one half-size larger than currently in place to match the widened stoma 2
• Use stay sutures if present (in new tracheostomies) - pull these sutures to elevate the trachea and widen the stoma, facilitating tube insertion 2
• Second attempt if unsuccessful - try the original tube size with optimal positioning (neck extended, shoulders elevated) 2
• Third attempt if needed - use a soft suction catheter as a guide (Seldinger technique) with a smaller tube 2

Critical: After each insertion attempt, confirm patency by passing a suction catheter to the depth indicated on the bedhead sign before attempting ventilation - ventilating through a displaced tube causes life-threatening subcutaneous emphysema 2, 4

Step 5: Prevent Recurrence

• Ensure proper initial tube placement - tracheostomy should be placed between the second and third tracheal rings to minimize complications including stomal breakdown 5
• Avoid prolonged cuff overinflation - this causes tracheal ischemia and progressive tissue damage leading to stoma widening 5
• Secure the tube properly - minimize movement at the stoma site which causes chronic irritation and enlargement 6
• Regular stoma care - maintain clean, dry environment and assess daily for early signs of breakdown 6

When to Summon Emergency Assistance

• Immediate multidisciplinary team if widening stoma is accompanied by respiratory distress, active bleeding beyond minimal secretions, sudden increase in pain, or any physiological deterioration 1
• Emergency assistance required if the tube appears displaced, suction catheter won't pass, or patient is deteriorating despite oxygen administration 1, 4

Long-Term Considerations

• Surgical revision may be required for persistent stoma widening despite conservative measures, particularly if associated with tracheal stenosis or significant tracheomalacia 3, 7
• Consider decannulation evaluation if the underlying indication for tracheostomy has resolved, as this eliminates the chronic irritation causing stoma widening 8