Tracheostomy Emergencies

Tracheostomy Emergencies

Classification 

“DOPES Approach”

Management

The National Tracheostomy Safety Project (NTSP) developed the “Green Algorithm”(also read this)

1. Call for Help

• Call for help (ENT surgeon, anesthesiologist, airway team).2.
• Assess ABCs
• Looking for chest movement
• Listening for airflow
• Feeling for air movement at both the mouth and the tracheostomy

2. Give Oxygen

• Via tracheostomy
• Via face mask simultaneously (especially if upper airway remains patent)

3: Use Waveform Capnography Early

• Continuous waveform capnography is one of the most valuable tools during a tracheostomy emergency.
• Capnography helps:Confirm ventilation,Identify tube displacement.Detect airway obstruction,Monitor the effectiveness of resuscitation

4: Evaluate the Tracheostomy Tube

Before assuming that the tube is functional, assess its patency.

Remove External Attachments

Disconnect any components that could contribute to obstruction, including:

• Speaking valves
• Heat and moisture exchangers (HMEs)
• Inner cannulas
• Humidification devices

If on Ventilator then 

• Immediately disconnect the ventilator and ventilate with a self-inflating bag (Ambu bag).
• Question: Is the patient easy or difficult to bag?
• Easy to Bag—Equipment problem likely
• Difficult to Bag Think:—Tube displacement,Tube obstruction

Pass a Suction Catheter

Attempt to advance a suction catheter through the tracheostomy tube.

If the catheter passes easily beyond the tube tip:

• The lumen is likely patent.
• Suction secretions to remove mucus or debris.

If the catheter cannot be advanced:

• Suspect tube obstruction, displacement, or false passage.

5: Deflate the Cuff

If a cuffed tracheostomy tube is present and obstruction is suspected, deflate the cuff.

Following cuff deflation:

• Reassess airflow from the mouth and stoma.
• Re-evaluate capnography.
• Monitor oxygen saturation and clinical improvement.

Improvement after cuff deflation suggests that air is passing around the tube, indicating possible tube obstruction or malposition.

6: Remove the Tracheostomy Tube if Necessary

If the patient remains unstable and the tube is suspected to be blocked or displaced, remove the tracheostomy tube.

Following removal:

• Reassess breathing from both the upper airway and the stoma.
• Continue oxygen administration.
• Re-evaluate capnography and chest movement.

Important Precaution

7: Emergency Oxygenation

If the patient is deteriorating, immediate oxygenation becomes the priority.

Ventilation Through the Upper Airway

Standard airway techniques may be used:

• Oropharyngeal airway
• Bag-mask ventilation
• Supraglottic airway devices

When ventilating through the mouth and nose, gentle occlusion of the stoma may reduce air leakage and improve ventilation.

Ventilation Through the Stoma

In selected patients, oxygenation may be achieved through the tracheostomy stoma using:

• A bag-valve device with an appropriately sized mask
• Specialized airway equipment designed for stoma ventilation

 8: Advanced Airway Management

If oxygenation remains inadequate, proceed to definitive airway control.

Potential options include:

• Oral endotracheal intubation
• Intubation through the tracheostomy stoma
• Bronchoscope-guided airway placement
• Placement of a new tracheostomy tube under direct visualization

Management in Laryngectomy Patients: The Red Approach

Why Laryngectomy Patients Are Different

A patient who has undergone a total laryngectomy has complete separation of the upper and lower airways. The trachea is permanently brought to the skin surface as a stoma, and there is no connection between the mouth, nose, and lungs.

As a result:

• Bag-mask ventilation via the mouth is ineffective.
• Oral or nasal intubation cannot establish an airway.
• The stoma is the patient’s only airway.

Call for Expert Help

Immediately summon:Airway team/Anesthesiologist/Intensivist/ENT surgeon.

Deliver Oxygen to the Stoma

Since the stoma is the only route to the lungs:

• Apply high-flow oxygen directly over the stoma.
• Do not rely solely on oxygen delivered to the face.

A pediatric face mask, tracheostomy mask, or standard oxygen tubing positioned over the stoma may be used.If there is any uncertainty as to whether the patient has had a laryngectomy, oxygen should be delivered to the face and stoma or tracheostomy tube until this can be determined.

Assess Airway Patency

Use a systematic approach:

Look

• Chest movement
• Respiratory effort
• Stoma patency
• Presence of secretions, blood, or foreign material

Listen

• Air movement through the stoma
• Breath sounds

Feel

• Airflow exiting the stoma
• Chest expansion

Apply Waveform Capnography

Capnography should be used as early as possible.

Benefits include:

• Confirmation of ventilation
• Detection of airway obstruction
• Continuous monitoring during resuscitation

Absence of a capnographic waveform suggests severe airway compromise or ineffective ventilation.

Remove External Attachments

Remove any removable components attached to the airway device, including:

• Speaking valves
• Heat-moisture exchangers
• Inner cannulas
• Humidification devices

These components may occasionally become obstructed and impair airflow.

Pass a Suction Catheter

Attempt to advance a suction catheter through the laryngectomy tube or stoma.

If the Catheter Passes Easily

• The airway is likely patent.
• Suction retained secretions.
• Continue reassessment.

If the Catheter Does Not Pass

Consider:Mucus plug/Blood clot/Tube obstruction/Airway narrowing

Remove the Laryngectomy Tube if Necessary

If obstruction is suspected:

• Remove the tube.
• Reassess airflow through the stoma.
• Continue oxygen administration directly over the stoma.

Many laryngectomy patients can breathe adequately through the stoma once an obstructed tube is removed.

Emergency Ventilation Through the Stoma

If the patient is not breathing adequately:

Bag-Valve Ventilation

Ventilate directly through the stoma using:

• Pediatric face mask
• Laryngeal mask applied to the stoma
• Appropriate tracheostomy interface

Observe:

• Chest rise
• Oxygen saturation
• Capnography

Definitive Airway Management

If oxygenation remains inadequate:

Intubate the Stoma

Preferred technique:

• Insert a cuffed endotracheal tube through the stoma.

Commonly used sizes:

• 6.0 mm cuffed endotracheal tube
• Smaller tube if resistance is encountered

Confirm placement with:

• Waveform capnography
• Bilateral chest expansion
• Breath sounds

Reference: Adapted from the principles of the National Tracheostomy Safety Project (NTSP) Red Algorithm for emergency management of laryngectomy patients.

Accidental Decannulation

Complete tube displacement from trachea.

Risk Factors

• Agitation
• Obesity
• Short neck
• Fresh tracheostomy
• Excessive coughing

Clinical Features

• Sudden distress
• Desaturation
• Air leak
• Inability to ventilate

Management

Step 1: Oxygenate

MANAGEMENT DEPENDS ON AGE OF TRACHEOSTOMY

A. Fresh Tracheostomy (<7–10 Days)

Golden Rule:DO NOT blindly reinsert the tracheostomy tube

Reason:

• Tract not mature
• High risk of creating a false passage
• May completely lose airway access
• Can worsen hypoxia

Management

B. Mature Tracheostomy (>7–10 Days)

A mature tract allows cautious reinsertion.

Management

If Reinsertion Fails

False Passage

Tube enters: Soft tissues of neck instead of Tracheal lumen

Risk Factors

• Fresh tracheostomy
• Difficult reinsertion
• Obesity
• Neck edema

Clinical Features—

• Severe distress
• Neck swelling
• Crepitus-subcutaneous emphysema
• High airway pressure
• No ETCO₂
• Difficulty passing suction catheter
• Absent or reduced breath sounds

Management

Can a Suction Catheter Be Passed?

If NO

This should be considered a false passage until proven otherwise.

If YES

Passage of a suction catheter does not completely exclude malposition.

Proceed with:

If Patient Is Stable

Bronchoscopic Confirmation

The quickest definitive test is bronchoscopy.

Correct findings:

• Tracheal rings visible
• Carina visible
• Tube tip within tracheal lumen

False passage findings:

• Soft tissue
• Blood clot
• No tracheal rings
• Blind-ending tract

If Patient Is Unstable-Difficult Airway Strategy

Tracheo-Innominate Fistula (TIF)

Most lethal tracheostomy complication.

Incidence ~0.1–1%

Mortality >70–90%

Pathophysiology-Pressure necrosis Anterior tracheal wall

Timing Usually:3 days–6 weeks

Peak:7–14 days

Sentinel Bleed

• Occurs in 30–50%.
• Small self-limited bleed before catastrophic hemorrhage.
• Never ignore.

Clinical Features

• Massive pulsatile bleeding
• Bright red blood
• Hemodynamic collapse
• Airway flooding

Clinical Pearl: Any sentinel bleed or massive hemorrhage from a tracheostomy should be considered a Tracheo-Innominate Artery Fistula (TIF) until proven otherwise, as mortality is extremely high without immediate intervention.

Granulation Tissue

Most common late complication.

Clinical Features

• Difficult tube changes
• Bleeding
• Obstruction
• Stridor

Diagnosis—Bronchoscopy

Treatment

• Laser
• Cautery
• Surgical excision

References

1. National Tracheostomy Safety Project (NTSP). Emergency Algorithm – Tracheostomy [Internet]. Manchester: NTSP; cited 2026 Jul 8. Available from: National Tracheostomy Safety Project – Tracheostomy Algorithm
2. National Tracheostomy Safety Project (NTSP). Emergency Algorithm – Laryngectomy [Internet]. Manchester: NTSP; cited 2026 Jul 8. Available from: National Tracheostomy Safety Project – Laryngectomy Algorithm
3. McGrath BA, Wallace S, Goswamy J. Laryngeal and tracheostomy emergencies. In: Oh’s Intensive Care Manual. 9th ed. Philadelphia: Elsevier; 2024.
4. Paulich S, Layer A, Hodzovic I. Two new algorithms for managing tracheostomy and laryngectomy airway emergencies. Br J Anaesth. 2020;125(2):e151-e153.