Written by: Nina Kouprina, MD. Edited by: Akshay (Sunny) Elagandhala, MD

We’ve all been there. You’re running a shift as the critical care doctor in the ER, and you get a call from the triage nurse. “We’ve got an unstable vent coming in, the patient has a tracheostomy and is on the vent but is now hypoxic!” What do you do next? Read on to learn all you need to know to manage this particular type of critically ill patient!

What is a tracheostomy?

A tracheostomy is a surgically created passage into the trachea, which is then kept open with placement of a tracheostomy tube. The purpose of a tracheostomy is to ensure a patent airway in patients prone to obstruction and sometimes to provide positive pressure or mechanical ventilation. Patients with tracheostomies are often chronically ill and require prolonged mechanical ventilation. [1, 2, 3, 4, 5, 6, 7]

The location of a tracheostomy is inferior to the cricothyroid membrane, typically at the level of the 2nd or 3rd tracheal cartilage (see figure below). [1, 3, 4, 6, 7]

Types of tracheostomy tubes

There are many types of tracheostomy tubes available, varying in diameter, length, shape, and presence / absence of a cuff. Components of a standard tracheostomy tube are depicted in the two figures below. Of note, sizing is not standardized between models or manufacturers. [4, 5, 6, 7, 8]

Tracheostomy tubes may be single cannula (top figure) or dual cannula (bottom figure). Dual cannula tubes contain both an outer and an inner cannula. The outer cannula holds the tracheostomy stoma open and connects to a flange, which is secured in place via Velcro straps around the neck. The inner cannula is removable and fits inside the outer cannula. The advantage of having an inner cannula is that it allows for cleaning of the lumen of the tube without having to remove the entire tracheostomy tube from its stoma. It’s important to note that in many dual cannula models, the 15 mm connector is located on the inner cannula. Therefore, a ventilator (or bag valve mask) cannot be attached unless the inner cannula is in place. [4, 5, 6, 7, 8]

Another major distinction is the presence or absence of a cuff. Uncuffed tubes allow airway clearance, but provide no protection from aspiration. They may be preferable in patients who are potential candidates for decannulation. Cuffed tubes allow secretion clearance and do offer protection from aspiration by creating a seal between the trachea and the tracheostomy tube. In addition, positive pressure ventilation can be applied when the cuff is inflated. Patients who require mechanical ventilation will have cuffed tubes [4, 5, 6, 7, 8]

Some tracheostomy tubes also have fenestrations, which allow for the passage of air through the tube to the vocal cords to allow the patient to speak (see figure below). Fenestrated tubes also allow for the assessment of a patient’s ability to breathe normally. For example, when preparing for decannulation, the tracheostomy tube is capped and the cuff deflated to allow the patient to breathe around the tube and through the fenestrations. Fenestrated tubes have their own unique complications. For instance, they have a risk of becoming obstructed by granulation tissue that may extend through the fenestration, which may also lead to bleeding and difficulty with removing the tube. [4, 5, 6, 7, 8]

An additional point is the importance of differentiating between a tracheostomy and a laryngectomy in a patient (see figure below). It’s imperative to know that the 2 terms are not synonymous. Patients with a total laryngectomy have a stoma that appears similar to a tracheostomy. However, these patients have no anatomical connection between the upper airway (e.g., the oropharynx) and the trachea. As a result, these patients cannot be oxygenated with a nasal cannula, face mask, or bag valve mask. Furthermore, orotracheal or nasotracheal intubation of these patients is impossible. The laryngectomy stoma is the only accessible airway in these patients. Placing end tidal CO2 monitoring on the patient’s nose and looking for a characteristic waveform is a method that can be used to see whether or not there is communication with the trachea in patients who are unable to provide a history [4, 5, 6, 7, 8, 10]

Complications

Tracheostomy complications can be immediate (perioperative), short term, or long-term following initial placement. Short term complications (<7 days) include obstruction, bleeding, infection, and decannulation. Long term complications (>7 days) include obstruction, bleeding, infection, fistula formation, stenosis, and delayed stoma closure. [1, 3, 4, 6, 7, 11]

Let’s review the approach to the most common complications in tracheostomy patients.

Dislodgement

The most important question to ask in this scenario is how long ago was the tracheostomy placed. If the tract is immature (<7 days), blind replacement is contraindicated because of the risk of creating a false tract. The patient should be intubated from above (see section “Intubating patient with a tracheostomy” below). [2, 3, 4, 5, 6, 7, 11]

If the tract is mature, you may proceed by removing the entire tracheostomy tube and replacing with a new tube (see section “Replacing the tracheostomy tube” below). A bougie catheter may be inserted to keep the path open. Of note, a mature stoma can become stenosed by more than 50% within 12 hours of decannulation. If placement attempts are unsuccessful, the patient may need to undergo dilation of the stoma by ENT. [2, 3, 4, 5, 6, 7, 11]

Obstruction

Obstruction is the most common complication seen in tracheostomy patients. Because the moistening and warming effects of the nasopharynx are lost, secretions become thickened and may lead to mucous plugging. [2, 3, 4, 5, 6, 7, 11]

The first step is to apply oxygen to both the face and stoma. If present, remove the inner cannula and deflate the cuff. Sometimes, deflating the cuff may provide extra room to allow the patient to ventilate on their own. Deflating the cuff also allows you to oxygenate from above. The inner cannula may be cleaned with warm tap water. Suction the patient and reassess. If there is no improvement or if unable to pass suction, the tracheostomy tube must be replaced (see section “Replacing the tracheostomy tube” below). [2, 3, 4, 5, 6, 7, 11]

At this point, it is crucial to know the timing of when the tracheostomy was created. As mentioned above, the stoma tract is considered mature after 7 days. If it was placed more recently, the patient should be intubated from above. [2, 3, 4, 5, 6, 7, 11]

Infection

Stomal skin infections, tracheitis, and bronchitis can be recurring problems in tracheostomy patients. These infections are typically polymicrobial and require broad spectrum antibiotics. You should have a low threshold for obtaining a chest x-ray in these patients because of the higher risk of associated pneumonia and progression to severe infections such as mediastinitis. [5, 6, 7, 11]

Bleeding

Bleeding can occur at ANY time after tracheostomy placement. There are many causes: local irritation, infection, granulation tissue, trauma from suctioning, and tracheoinnominate fistula formation, which is a life-threatening emergency (see section “Approach to patient with bleeding” below). Tracheoinnominate fistula should always be suspected in any patient presenting with bleeding from the tracheostomy site, even if the bleeding is small and self-resolved. [3, 4, 5, 6, 7, 11]

If bleeding is slow and originating from the stoma, the site can be packed with saline soaked gauze or hemostatic product. If this not effective, you will need to remove the entire tracheostomy tube to fully examine the stoma site. Once the area of bleeding is identified, it can be cauterized with silver nitrate. If there is doubt, CT angiography may be helpful, but it should not be utilized during an episode of active bleeding. [3, 4, 5, 6, 7, 11]

If bleeding appears brisk, the tube should be replaced with a cuffed tracheostomy or endotracheal tube, with the cuff below the bleeding site. During active bleeding, direct visualization should occur in the OR setting. Immediate surgical consultation is warranted (see section “Approach to patient with bleeding” below). [3, 4, 5, 6, 7, 11]

Stenosis

Stenosis refers to narrowing of the tracheal lumen due to scar tissue. This can occur above, below, or at the level of the stoma. A concerning scenario is a patient presenting with stridor. Diagnosis can be made by CT scan or flexible fiberoscopy. Bronchodilators and racemic epinephrine may be useful to decrease airway edema. As expected, intubation from above will be difficult. Call for backup and prepare for a difficult airway. [5, 6, 7]

Replacing the tracheostomy tube

A tracheostomy tube may need to be replaced in the case of obstruction or accidental decannulation, or when an uncuffed tube needs to be exchanged for a cuffed tube in a patient who requires mechanical ventilation.

It’s worth reiterating that the most important thing to know before proceeding with tube replacement is when the tracheostomy was placed. As mentioned above, blind replacement is contraindicated when the tract is less than 7 days old. In this case, manipulation may create a false passage. So, if a tracheostomy is new, it should be replaced by ENT under direct visualization. Otherwise, the patient would need orotracheal intubation (see section “Intubating patient with a tracheostomy” below). [4, 5, 11]

In a stable patient, the procedure for replacing a tracheostomy tube is relatively simple (see figure below). The first step is to make sure you have the proper equipment: tracheostomy tube (same size and one size smaller), 6-0 cuffed endotracheal tube, suctioning, BVM, bougie, and laryngoscope. The patient should be placed supine with a rolled towel underneath their shoulders in order to extend the neck. Next, preoxygenation should be performed by applying oxygen to both the mouth and tracheostomy. In a less stable patient, consider replacement with a cuffed tube even if the original tube is uncuffed; it may be helpful if the patient needs more aggressive resuscitation. [4, 5, 11]

If present, an obturator should be used to guide tube placement and minimize soft tissue damage. For a dual cannula tube, remove the inner cannula and place the obturator inside. Apply water soluble lubricant onto the new tracheostomy tube. Remove the old tube by releasing the tracheostomy ties and deflating the cuff. The new tube should be inserted at a 90 degree angle, then curved downward into the trachea. Make sure to insert no more than 1 cm past the cuff (the carina may only be 4-6 cm from the tracheostomy). Remove the obturator and insert the inner cannula. Inflate the cuff. Secure in place with new tracheostomy ties. [4, 5, 11]

Confirm placement by the presence of bilateral breath sounds during positive pressure ventilation (or air flow through the tube if the patient is breathing spontaneously). Attempt to pass suction catheter; it should easily pass without resistance. You may also attach an end tidal CO2 detector to confirm placement. [4, 5]

If you encounter difficulty during placement of the new tracheostomy tube, consider using a smaller size tube. Another option would be to use a tube exchanger or a bougie catheter. If you don’t have a tracheostomy tube available, you can use a 6-0 endotracheal tube instead. As with a tracheostomy tube, make sure to insert the endotracheal tube no more than 1 cm past the cuff. The tube can be cut down to 12 cm for convenience. [4, 5]

If you are unable to replace the tracheostomy tube by using the above techniques and the patient is becoming unstable (or if the patient has a brand new tracheostomy that has become dislodged), you will need to proceed with oral intubation (see section “Intubating patient with a tracheostomy” below).

Intubating patient with a tracheostomy

Call for help. Apply high flow oxygen to both the tracheostomy and mouth. If the tracheostomy tube is still in place, deflate the cuff so that you can oxygenate from above. If the tracheostomy tube has been removed, perform standard oral airway maneuvers while covering the stoma. Stoma ventilation can be performed by using a pediatric facemask or a size 2 LMA while covering the nose and mouth (see figure below). This allows for the generation of an adequate seal to deliver ventilation breaths if the patient is not breathing spontaneously. [11, 12, 13]

As always, in an airway emergency, oxygenation is a priority. The goal is to optimize the patient prior to intubation. When performing the intubation, the endotracheal tube should be inserted 2 cm past the stoma site. If the tracheostomy is still in place, it may be removed by an assistant during the intubation procedure. [11, 12, 13]

Approach to patient with bleeding

As mentioned above, any patient presenting with bleeding from the tracheostomy site should be suspected to have a tracheoinnominate fistula until proven otherwise. A tracheoinnominate fistula occurs secondary to vessel erosion due to direct pressure from either the tip of the tracheostomy tube or an overinflated cuff against the innominate artery. The majority of patients will present within the first 3 weeks of tracheostomy placement. [3, 6, 7, 11]

If a patient is presenting with slow bleeding from the tracheostomy, the stoma should be carefully inspected. Blood or clots should be suctioned. If bleeding is visible from granulation tissue, you may cauterize it with silver nitrate. It’s important to keep in mind that 50% of patients with a tracheoinnominate fistula will initially present with a herald bleed. Therefore, close inspection of the tracheostomy is extremely important. [3, 6, 7, 11]

If there is active bleeding, immediately call for surgical backup. The main priority should be hemorrhage control. Over inflate the cuff to a total of 50 cc of air in an attempt to tamponade the bleeding (this is successful in 85% of cases of tracheoinnominate fistulas) (see figure below). If bleeding persists, gently withdraw the tube while exerting pressure against the anterior trachea. If unsuccessful, prepare to secure the airway with endotracheal intubation (see section above). The cuff of the endotracheal tube should be distal to the source of bleeding. During the intubation, have an assistant simultaneously remove the tracheostomy tube and insert a finger into the stoma. Digitally compress the innominate artery anteriorly against the posterior sternum (see figure below). The patient should be immediately transported to the OR (maintain tamponade during transport). [3, 6, 7, 11]

Approach to crashing patient

The following will be a summary of a general approach to an unstable patient with a tracheostomy (see algorithm below).

As before, the 2 key things to know before proceeding are: 1) is there a connection between the airway and the mouth? 2) how old is the tracheostomy?

Call for back up early (ENT, anesthesia, surgery). The first step is to improve oxygenation. Apply high flow oxygen to both face and tracheostomy. Gather your equipment.

As with ventilated patients, the “DOPES” mnemonic (dislodgment, obstruction, patient problem, equipment, stacked breaths) may be used to help assess tracheostomy patients presenting in respiratory distress. As noted above, in tracheostomy patients, the more common problems are dislodgement and obstruction. Assess tube patency by removing the inner cannula (if present) and suctioning; remember that in many models, the inner cannula has to be replaced in order to connect to a BVM or ventilator. Deflating the cuff (if present) may also be helpful in improving ventilation and will allow for oxygenation from above. [9, 14, 15, 16, 17]

If these maneuvers do not improve the patient’s respiratory status or if you are unable to pass the suction catheter, you will need to remove the tube and replace it. This is where it’s important to again recall what kind of procedure patient underwent (simple tracheostomy or laryngectomy) and how long ago it was performed (greater or less than 7 days). If the tracheostomy is less than 7 days old, you will need to intubate from above. If the patient has had a laryngectomy, intubating from above is not an option. [9, 14, 15, 16, 17]

If you have determined that the tracheostomy is mature, you may proceed with tube replacement. Deflate the cuff on the tracheostomy tube (if you haven’t already done so) and remove the tube. Perform standard oral airway maneuvers (unless patient has had a laryngectomy, of course). Proceed with emergency oxygenation of the stoma using a pediatric face mask or a size 2 LMA to ensure an adequate seal (as described in section “Intubating patient with a tracheostomy” above). [9, 14, 15, 16, 17]

Once you have improved the patient’s oxygenation status, attempt to replace the tracheostomy tube (see section “Replacing the tracheostomy tube” above). Your options are:

1) a tracheostomy tube of the same size

2) a tracheostomy tube one size smaller

3) a 6-0 endotracheal tube.

Ideally, you should have all 3 available. Remember, that sizing is not standardized between models or manufacturers. Also remember that a cuffed tube may be preferable to use in resuscitation even if the original tube is uncuffed. A bougie or a tube exchanger can be used to facilitate placement of the tracheostomy or endotracheal tube. The tube (regardless of type used) should be advanced no more than 1 cm past the cuff. [9, 14, 15, 16, 17]

If the tracheostomy is immature (or if you are unable to replace the tracheostomy tube), you will need to intubate from above (see section “Intubating patient with a tracheostomy”). Again, if the patient has had a laryngectomy, oral intubation will be impossible as their only airway access is through their stoma. These patients will need immediate surgical intervention if their airway access becomes compromised. Otherwise, you can proceed with orotracheal intubation as described earlier. Remember to advance the endotracheal tube about 2 cm beyond the stoma. [9, 14, 15, 16, 17]