How should acute dyspnea in a patient with a recent tracheostomy be evaluated and managed?

Acute Dyspnea in Post-Tracheostomy: Emergency Management

Immediately assess for tube obstruction or displacement—the two most common life-threatening causes of respiratory distress in tracheostomy patients—by attempting to pass a suction catheter through the tube to the predetermined depth; if resistance is met, remove the tube immediately and provide emergency oxygenation. 1, 2

Initial Assessment and Stabilization

Immediate Actions (First 60 Seconds)

• Apply high-flow oxygen simultaneously to both the patient's face/nose AND the tracheostomy stoma using two separate oxygen sources, as both the native upper airway and tracheostomy may contribute to ventilation 1, 2
• Remove all external attachments (heat-moisture exchange filters, speaking valves, inner cannula) to exclude equipment-related obstruction before further assessment 1
• Initiate waveform capnography immediately to verify airway patency and adequate gas exchange 1, 2

Rapid Patency Assessment

• Pass a soft-tipped suction catheter through the tracheostomy tube to the predetermined depth—successful passage confirms the tube is patent and correctly positioned 1, 2
• Never use rigid devices (bougies, stylets) to test patency, as they can create false passages if the tube is partially displaced 1, 2
• If the suction catheter meets resistance and cannot advance to expected depth, assume tube blockage or displacement and perform immediate emergency tube exchange rather than continuing ventilation through a potentially malpositioned tube 1

Emergency Oxygenation Algorithm

Primary Emergency Oxygenation (If Tube Removal Required)

When the tube is removed or non-functional, use a graded approach starting with least invasive techniques:

Via Upper Airway (If Patent)

• Apply standard bag-valve-mask ventilation with oral/nasal airway adjuncts or supraglottic airway devices 3
• Occlude the tracheal stoma with a gloved finger or non-woven gauze to prevent air escape and maximize ventilation effectiveness 3
• Use waveform capnography to confirm effective ventilation 3

Via Stoma (If Upper Airway Obstructed)

• Apply a pediatric facemask or laryngeal mask airway directly over the stoma attached to bag-valve-mask 3
• Close the nose and mouth if there is significant air leak to facilitate effective ventilation via the stoma 3

Secondary Emergency Oxygenation (If Primary Measures Fail)

These are advanced techniques requiring experienced operators:

Oral Intubation Option

• Attempt oral intubation using standard techniques, recognizing that difficult airways are common in tracheostomy patients 3
• Use an uncut tracheal tube that can be advanced beyond the stoma to bypass the hole in the anterior tracheal wall 3, 2
• Use a tube one half-size smaller than the original tracheostomy tube for first attempt 3

Stoma Intubation Option

• Attempt intubation of the tracheostomy stoma itself using a tracheal tube one half-size smaller than the original 3
• Use fiberoptic guidance when available to facilitate placement and ensure correct positioning 3
• Avoid blind or digitally-assisted bougie placement, which risks malposition 3

Critical Monitoring in First 72 Hours

Early Complication Surveillance

• Inspect the neck and chest for subcutaneous emphysema every 3 hours during days 0-4 post-tracheostomy; new emphysema signals possible tube malposition 1
• Observe for clinical signs of respiratory distress: stridor, accessory muscle use, tracheal tug, intercostal recession 1
• Watch for any bleeding, even minor "sentinel" bleeds, as they can precede life-threatening tracheo-innominate fistula, especially when tracheostomy is placed below the third tracheal ring 1, 4

Bedside Equipment Requirements

• Keep emergency equipment immediately available: suction devices with appropriate catheters, spare tracheostomy tubes (same size and one size smaller), waveform capnography monitors, fiberoptic bronchoscope, manual resuscitation bag with mask 1, 2, 5
• Ensure multidisciplinary team (ENT surgeon, anesthesiologist experienced in advanced airway management, intensivist) is on standby 1

Common Pitfalls to Avoid

• Never deliver vigorous hand-bag ventilation through a possibly displaced tracheostomy tube, as this generates massive subcutaneous emphysema and worsens the patient's condition 1
• Do not disregard the native upper airway as a potential route for oxygenation—both pathways may be needed to maintain adequate gas exchange in the immediate post-tracheostomy period 1
• Do not use high-flow nasal cannula or non-invasive ventilation in fresh tracheostomy patients—oxygen must be delivered directly to the stoma 2
• Avoid prolonged cuff over-inflation, which exacerbates tracheal ischemia and increases stenosis risk 1

Special Considerations for Fresh Tracheostomy (≤7 Days)

• Stoma tissue retracts during the first week, making tube exchange extremely difficult; avoid blind re-intubation and consider transport to tertiary center if decannulation occurs in a stable patient 2
• The overall complication rate exceeds 50%, though serious complications are less common; the greatest life threats are decannulation, obstruction, and hemorrhage 6
• Short-term complications include blockage or complete/partial tube displacement, which are the primary causes of acute respiratory distress 3