What is the best course of action for a patient experiencing post tracheostomy stridor?

Post-Tracheostomy Stridor Management

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 continues to deteriorate, remove the tube without delay and establish emergency oxygenation via the upper airway. 1

Immediate Assessment Steps

Primary Patency Assessment

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

Critical Safety Point

Never use gum-elastic bougies or stiff introducers for initial patency assessment, as these can create false passages if the tube is partially displaced, potentially causing catastrophic complications including pneumothorax or pneumomediastinum 1, 2, 3

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
• Stridor persists or worsens 1
• There is suspected tube displacement or blockage 1, 2

A blocked or displaced tracheostomy tube acts as a foreign body and must be removed to prevent life-threatening complications—when faced with a deteriorating patient and an obstructed airway, the non-functioning tube offers no benefit with considerable potential for harm 2

Post-Removal Emergency Oxygenation

Primary Oxygenation Options

After removing the tracheostomy tube, reassess both the upper airway and stoma 1, 2:

• Apply bag-valve-mask ventilation to the face while occluding the stoma with a gloved finger or gauze to prevent air leak 1
• Consider using supraglottic airway devices or oral/nasal airway adjuncts as needed 1
• If the upper airway is obstructed or uncertain, apply a pediatric facemask or laryngeal mask airway directly over the stoma 1, 3

Secondary Emergency Oxygenation (If Primary Measures Fail)

If effective oxygenation cannot be achieved with primary measures 1, 2:

• Perform oral intubation using a long, uncut endotracheal tube advanced beyond the stoma to bypass the anterior tracheal wall opening 1
• Alternatively, insert a smaller tracheostomy or endotracheal tube through the stoma using fiberoptic guidance when available 1
• Confirm all tube placements using waveform capnography 1, 2

Special Considerations Based on Tracheostomy Age

Recent Tracheostomy (< 7 Days)

• The stoma tract is immature and tissues will have recoiled significantly, making blind replacement through the stoma dangerous 1
• Orotracheal intubation under direct laryngoscopy is the preferred approach for patients with recent tracheostomy, as blind insertion through a fresh stoma carries substantial risk of creating a false passage anterior to the trachea 1
• The technique of using a long, uncut endotracheal tube advanced beyond the stoma opening provides definitive airway control and allows the stoma to be managed electively once the airway is secured 1

Established Tracheostomy

• Even in established tracheostomies, a size 6 tracheostomy is relatively small and the stoma may be difficult to re-cannulate 1
• Fiberoptic guidance through the stoma is ideal but requires immediate availability of equipment and expertise 1, 3

Critical Pitfalls to Avoid

• Never delay tube removal in a deteriorating patient to attempt fiberoptic inspection unless the patient is stable and equipment/expertise is immediately available 1, 3
• Never ventilate vigorously through an unconfirmed or potentially displaced airway, as this is the primary mechanism for worsening complications and can force air into tissue planes 2, 3
• Only use gentle hand ventilation after confirming tube patency with a suction catheter 2, 3

Ongoing Monitoring Requirements

Patients with post-tracheostomy stridor require 2:

• Close monitoring in a high-dependency or critical care setting with trained staff continuously present until physiologically stable
• An appropriately skilled anesthetist or airway specialist immediately available
• A written emergency airway management plan communicated to all staff