What are the steps to stabilize a patient with a recently placed tracheostomy (less than 7 days) that has become dislodged and is exhibiting signs of respiratory distress?

From the Guidelines

If a tracheostomy tube placed less than 7 days ago becomes dislodged and the patient is showing respiratory distress, you should immediately call for help, position the patient with the neck extended, administer supplemental oxygen via face mask, and prepare for emergency airway management, as attempting to reinsert the tube blindly can be harmful and the priority is to maintain oxygenation and ventilation. The most recent and highest quality study 1 recommends a graded response to managing the airway, starting with the least invasive techniques that have the highest likelihood of success, such as standard oral airway maneuvers, bag-valve masks, oral or nasal airway adjuncts, and supraglottic airway devices (SAD).

Key Considerations

• The patient's airway should be managed with caution, as a tracheostomy tract takes 7-10 days to mature, and premature dislodgement means the tract may collapse, making reinsertion difficult and potentially creating a false passage 1.
• If ventilation via the upper airways is not possible or inadequate, ventilation may be attempted via the stoma, using a pediatric facemask or SAD applied over the stoma attached to a bag-valve mask 1.
• The surgical team who performed the tracheostomy should be notified immediately, and the patient should be continuously monitored for oxygen saturation, respiratory rate, and signs of increasing distress while definitive airway management is arranged.

Emergency Airway Management

• If the patient's condition deteriorates, initiate bag-mask ventilation while maintaining neck extension to optimize the partially formed tract.
• Prepare for possible emergency orotracheal intubation if the tracheostomy cannot be reestablished.
• Consider attempting intubation of the tracheostomy stoma itself using a tracheal tube one half-size smaller than the original tracheostomy tube, as a simple, temporary, yet life-saving alternative 1.

Prioritizing Patient Safety

• The priority is to maintain oxygenation and ventilation, and to avoid causing further harm to the patient.
• The approach should be guided by the most recent and highest quality evidence, and should take into account the individual patient's needs and circumstances.

From the Research

Stabilizing a Patient with a Dislodged Tracheostomy Tube

If a tracheostomy tube becomes dislodged less than 7 days after placement and the patient is showing signs of respiratory distress, the following steps can be taken:

• Stay calm and call for help immediately 2
• Check the patient's airway, breathing, and circulation (ABCs) and provide oxygen if necessary
• Attempt to replace the tracheostomy tube or insert a new one if available
• If the patient has a partial airway, they may not show immediate signs of distress, but it is still crucial to address the situation promptly 2
• Consider the patient's overall condition, including their weight and neck size, as these factors can affect the stability of the tracheostomy tube 2

Key Considerations

• A dislodged tracheostomy tube can lead to respiratory distress and potentially life-threatening complications 2
• Patients with a full neck or who are overweight may be more prone to tracheostomy tube displacement due to the increased amount of soft tissue the tube must pass through 2
• The use of sedation and analgesia may be necessary in some cases, but it is essential to carefully monitor the patient's respiratory status and adjust medication as needed 3, 4, 5, 6

Additional Measures

• Continuous monitoring of the patient's vital signs and oxygen saturation is crucial in this situation
• Having a plan in place for emergency situations, such as a dislodged tracheostomy tube, can help ensure prompt and effective treatment
• Healthcare professionals should be aware of the potential complications associated with tracheostomy tubes and take steps to prevent them whenever possible 2, 3