Approach to Tracheostomy Emergencies - OnePager Summary
COMPONENTS OF A TRACHEOSTOMY TUBE:
 • Obturator - inserted into the inner cannula & used to guide placement; must remove to ventilate
 • Inner Cannula - can be inserted into the outer cannula. Removable. Can be used to clear secretions.
 • Outer Cannula - stays in tracheostomy attached to faceplate/flange.
 • Pilot balloon - indicates if tracheal cuff is inflated
 • Faceplate/flange - holds tracheotomy tube against the neck (usually has holes for sutures)
 • Tracheal cuff - a balloon used to seal the tracheostomy tube against the trachea; inflation enables sustained airway pressure but prevents speech & eating.
TRACHEOSTOMY SIZING:
 • Proper sizing is essential and depends on length, inner diameter, outer diameter, and curvature. Usually the size number refers to the inner diameter (ID) of the outer cannula, measured in mm. This is not consistent for all manufacturers. The ID and OD sizes are always written on the flange.
APPROACH TO TRACHEOSTOMY EMERGENCIES:
 • There are three categories of emergencies involving a tracheostomy: ACCIDENTAL DECANNULA TION, OBSTRUCTION, and BLEEDING. 
 • The timing of the emergency is also important as the approach is different in the 7-14 days after initial tracheostomy placement compared with later. (The tracheotomy tract takes time to mature)
DECANNULATION EMERGENCY
 • Early (<7-14 days):
    - Do NOT attempt re-insertion due to risk of is not mature)
    - Call for help (e.g. airway code)
    - Oxygenate and ventilate from above while preparing to intubate
    - Intubate
 • Late (>7-14 days):
    - Prepare back-up airway
    - Oxygenate and ventilate from above
    - Attempt to replace tracheostomy (can insert obturator) and may need to downsize
    - Confirm proper placement, ideally with bronchoscopy
    - If unable to re-insert, intubate.
OBSTRUCTION EMERGENCY
 • Early (<7-14 days):
    - Prepare back-up airway plan
    - Deflate cuff and oxygenate from above
    - Remove inner cannula
    - Attempt to pass suction catheter and clear
    - Consider bronchoscopy if immediately available
    - In unable to clear, intubate from above
 • Late (>7-14 days):
    - Prepare back-up airway plan
    - Deflate cuff and oxygenate from above
    - Remove inner cannula
    - Attempt to pass suction catheter and clear
    - Consider bronchoscopy if immediately available
    - If still obstructed, attempt to replace and may need to downsize tracheostomy tube
BLEEDING EMERGENCY
 • Early (<7-14 days):
    - Early bleeding may be at the surgical site, from suction trauma, or due to tracheitis
    - Tx: Inflate cuff, apply direct pressure, apply topical silver nitrate
 • Late (>7-14 days):
    - Late bleeding may be due to the above or due to development of a Tracheo-innominate fistula: erosion of the tracheostomy causing a fistula between innominate artery & trachea. Look for ETT pulsations. This can cause life-threatening hemorrhage.
    - Tx: overinflate cuff to tamponade, ventilate from above and remove tracheostomy, Intubate from above, Insert finger into stoma and pull anteriorly to occlude innominate artery. Surgical management of hemorrhage will be required (high mortality w/o surgery)

by Nick Mark MD @nickmmark and Helen D'Couto, MD @hdcouto23

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