Tracheostomy Quick Guide

Red Flags

  • Air escaping from mouth (cuffed trach)
  • Respiratory distress/accessory muscle use
  • Displaced tube or blood-stained secretions
  • Physiological deterioration

Emergency Algorithm

1. Call for help - Get airway specialist immediately

2. Assess breathing - CPR if apneic, high-flow O₂ if breathing

3. Check patency - Remove inner tube, attempt suction

4. If obstructed - Deflate cuff → Remove tube if needed

Oxygenation Methods

Primary:

  • Oral airway + BVM (cover stoma)
  • Stoma mask ventilation

Secondary:

  • Oral intubation (uncut tube)
  • Stoma intubation (6.0 ETT)

Critical Notes

  • Laryngectomy patients can ONLY be oxygenated via stoma
  • Always check for tracheostomy type/indication
  • Have emergency equipment at bedside

Emergency Tracheostomy Management

Tracheostomy Red Flags

Airway flags

  • No gas should escape through mouth with cuffed tracheostomy
  • Audible air leaks or bubbles at mouth/nose suggest cuff damage or malposition
  • Grunting, snoring or stridor indicate airway problems

Breathing flags

  • Apnoea (capnographic or clinical)
  • Respiratory distress:
    • Accessory muscle use
    • Tachypnea
    • High airway pressures
    • Low tidal volumes
  • Hypoxia
  • Noisy breathing

Specific tracheostomy flags

  • Visibly displaced tube
  • Blood-stained secretions
  • Increased pain/discomfort
  • Cuff requiring excessive inflation:
    • Possible cuff damage
    • Tube displacement

General flags

  • Physiological changes:
    • Respiratory rate
    • Heart rate
    • Blood pressure
    • Consciousness level
  • Anxiety/agitation/confusion

Emergency Algorithm

  1. Call for expert airway help immediately
  2. Assess breathing:
    • If not breathing → Call crash team, start CPR if needed
    • If breathing → Apply high-flow O₂ to face and tracheostomy
  3. Assess patency:
    • Remove speaking valve/cap
    • Remove inner tube if present
    • Attempt suction catheter passage

If unable to pass suction catheter:

  1. Deflate cuff
  2. Reassess:
    • If improved → Continue monitoring
    • If no improvement → Remove tracheostomy tube
  3. After removal:
    • If breathing → Monitor and await expert help
    • If not breathing → Crash call, emergency oxygenation

Emergency Oxygenation

When tracheostomy tube removal doesn't improve oxygenation, use these approaches:

Primary Methods:

  • Standard oral airway maneuvers:
    • Cover stoma with swabs/hand
    • Use BVM with oral/nasal airway or LMA
  • Stoma ventilation:
    • Pediatric mask to stoma (may need to occlude nose/mouth)
    • LMA applied to stoma

Secondary Methods (if primary fails):

  • Oral intubation:
    • Prepare for difficult intubation
    • Use uncut tube advanced beyond stoma
  • Stoma intubation:
    • Small tracheostomy tube/6.0 cuffed ETT
    • Consider Aintree catheter with fiberoptic guidance

Critical Note: Laryngectomy patients can ONLY be oxygenated via the stoma - their upper airways are completely disconnected from the lungs.

Equipment Checklist

  • Spare tracheostomy tubes (same size and one size smaller)
  • Suction equipment
  • 10ml syringe (for cuff deflation)
  • Tracheostomy dilators
  • ET tubes (various sizes)
  • BVM and masks

Special Considerations

Pediatric Patients

  • Smaller airway diameter → higher risk of obstruction
  • More prone to tube displacement
  • Consider uncuffed tubes in young children

Laryngectomy Patients

  • No connection between upper airway and lungs
  • Cannot be intubated orally
  • Stoma is only access to lungs
  • Always check for laryngectomy status

Home Care Patients

  • May have non-standard tubes
  • Caregivers may have valuable information
  • Check for patient-specific instructions