During cardiopulmonary resuscitation (CPR) on a patient with a tracheostomy, should breaths be delivered by blowing through the tracheostomy stoma?

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CPR in Tracheostomy Patients: Ventilation Through the Stoma

Yes, during CPR on a patient with a tracheostomy, breaths should be delivered through the tracheostomy stoma, not through the mouth/nose, as this is the direct route to the lungs. 1

Primary Approach: Ventilate Via the Stoma

Emergency oxygenation in tracheostomy patients can be achieved through the stoma using several techniques: 1

  • Apply a pediatric facemask or laryngeal mask airway (LMA) directly to the skin over the stoma to deliver ventilation 1
  • If attempting oral/nasal ventilation, you must occlude the tracheal stoma to maximize effective ventilation, otherwise air will escape through the stoma 1
  • Conversely, if ventilating through the stoma, occlude the nose and mouth if there is a large air leak preventing effective ventilation 1

Critical Distinction: Tracheostomy vs. Laryngectomy

The approach differs fundamentally based on whether the upper airway is connected to the lungs: 1

  • Tracheostomy patients retain upper airway continuity - ventilation can theoretically occur via mouth/nose OR stoma, but the stoma must be occluded if using the oral route 1
  • Laryngectomy patients have NO upper airway connection to lungs - ALL ventilation must occur through the neck stoma; mouth-to-mouth is completely ineffective 1
  • Default emergency action: apply oxygen to BOTH the face and stoma when uncertain about the anatomy, as tracheostomies are 20-30 times more common than laryngectomies 1

Stepwise Algorithm for CPR Ventilation

If Tracheostomy Tube is In Place and Patent:

  • Confirm patency by passing a suction catheter beyond the tube tip into the trachea 1
  • Ventilate through the tracheostomy tube using a bag-valve device connected to the 15mm adapter 1
  • Inflate the cuff (if present) to seal the trachea and allow effective positive pressure ventilation 1
  • Use gentle hand ventilation only - vigorous attempts can cause fatal surgical emphysema if the tube is displaced 1

If Tracheostomy Tube is Blocked or Displaced:

  • Remove the tracheostomy tube immediately if suction catheter cannot pass and cuff deflation fails to improve the situation 1
  • Apply oxygen to both face and stoma after tube removal 1
  • Attempt ventilation via the stoma using a pediatric mask applied to the skin 1
  • Occlude the stoma if attempting oral ventilation to prevent air leak 1

Key Technical Points

Once an advanced airway is established during cardiac arrest, deliver continuous chest compressions at 100-120/minute with asynchronous ventilation at 10 breaths/minute (1 breath every 6 seconds): 1

Avoid excessive ventilation as this compromises venous return, cardiac output, and cerebral blood flow 1

Use waveform capnography to confirm and monitor correct placement and effective ventilation 1

Common Pitfalls to Avoid

  • Never attempt vigorous ventilation through a potentially displaced tube - this causes life-threatening surgical emphysema 1
  • Do not use stiff bougies or introducers if the tube is partially displaced, as these create false passages; use soft suction catheters only 1
  • Do not forget to occlude the stoma when ventilating via mouth/nose - this is the most common error in tracheostomy resuscitation 1
  • Do not assume all neck stomas are the same - laryngectomy patients cannot be ventilated orally at all 1

Special Considerations for Pediatric Patients

In pediatric tracheostomy emergencies, deliver 5 rescue breaths before starting chest compressions if the child is not breathing 1

Mouth-to-tracheostomy ventilation has been successfully described in pediatric patients when equipment is unavailable 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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