Field Notes on Tracheostomy Part 2: The Problems

So you’ve got a patient with a tracheostomy tube. And Houston, we’ve got a problem. What do we do? Here are some common problems and basic troubleshooting actions:

Tube dislodgment

This is often a problem in the first few days of tracheostomy when the wound is still fresh and the tracheostomy tract is still not mature or patent. Risk factors: thick neck, big neck, no neck, short tube, insecure tube (not in a sense of low self esteem, but tubes which are not well stitched to skin or well tied), emergency insertion (higher chance of poor technique), patient movement (frequent rolling or bed transfers for procedures, delirium, etc), high ventilation pressures (higher chance of tube migration), frequent coughing. It is always better to watch out for these red flags and do all you can to prevent tube dislodgement. Stitching in and tying down the tube may look uncomfortable but your patient will thank you for preventing an accidental decannulation. What happens if the tube gets dislodged though? Either a complete decannulation or creation of a false passage with the tip of the tracheostomy sitting in the soft tissues of the neck. If the patient is still machine-ventilated, you’ll get the immediate and obvious subcutaneous emphysema from the creation of the false passage. Pull the tube out altogether. Do not attempt to blindly reinsert as further false passage may be created. We’ve lost the airway.

So relax. Take a deep breath. You have some time.

Call for help.

Gently open up the wound or tracheostoma with your thumb and index finger. This is often enough to create a patent passage all the way into the trachea where you can pass a sucker or feed an oxygen cannula. You will need a light to be able to see down the hole, though.

With a tracheal dilator (or a pair of haemostat, artery, mosquito, scissors, nasal speculum, anything available in the trach tray which should be next to the patient), insert the tip into the trachea between the tracheal rings which had been previously cut and open the instrument up to open the airway.

Take another breath.

Suction the area around it and the track into the trachea.

Re-insert a new tracheostomy tube, or insert a flexible sucker or flexible scope into the airway and use it as a guidewire to insert the new tracheostomy tube.

Confirm the position visually with a scope, or with capnography.

If all the above maneuvers fail, and in a true airway emergency, simply put your index finger down the stoma hole until you can feel tracheal rings. Put the tip of your finger into the lumen of the trachea. Then either feed a tracheal dilator by feel into the airway, or feed the new tracheostomy into the airway alongside your finger. That’s the quickest way of re-establishing the airway.

If the tracheostomy tract is old (more than 2 weeks) and mature, usually the stoma is patent and you can reinsert a new tracheostomy tube under direct vision without much trouble.

Tube occlusion

This is probably the most common problem. Tracheostomy tubes can be occluded by blood, or frequently dried mucous and sputum. The use of humidification will reduce the chances. Regular cleaning of inner cannula helps. Regular suctioning with a flexible suction catheter down the lumen of the tube into the trachea also helps to prevent and relieve the tube of obstruction. A small amount of normal saline can be put down the tube to dislodge these crusts. In some cases, granulation tissue may be the obstructing lesion. This can be identified with the use of a flexible scope. Repositioning of the tube and some systemic steroids may help reduce the granulation tissue. Sometimes surgical removal of the offending tissue may be required.


The most fearsome complication is a fistula between the trachea and the innominate artery or any of the great vessels in the superior mediastinum. Note that a tracheostomy tube is only centimetres away from the arch of aorta, brachiocephalic and carotid arteries. Pathologies, surgical interventions, and radiation therapy may distort the anatomy and increase the chance of a fistula. If this was to occur, it could be fatal, and an emergency surgical intervention by ENT, vascular and/or thoracic surgeons is necessary. Tamponading the bleed by inflating the tracheostomy cuff and putting pressure around the stoma is the only temporizing method. The definitive treatment is by surgical exploration, ligation or endoluminal stenting of the artery.

Thankfully however, such a massive bleeding complication is rare. The more common is a small to moderate amount of bleeding that is non life-threatening. Most common cause of bleeding is at the subcutaneous level. Small vessels around the wound site may bleed. With a light source, suction and a little skin retraction, most clinicians will be able to identify a bleeding spot under the flange around the stoma. Several options: inject with local (eg xylocaine) and adrenaline which vasoconstricts the vessels, cauterize with bipolar or silver nitrate sticks, pack with surgicell or kaltostat. Another possible source of bleeding is the thyroid gland a little deeper. Injections don’t work too well here, but cauterization and packing still works.

Cuff leak

Not too uncommonly, the cuff pressure may be difficult to maintain. This can be due to a perforation in the cuff or the inflation line. If this is the problem, then unfortunately the cuff will always leak and a tracheostomy tube change is warranted in a safe elective setting. However, I have found many occasions when the one-way valve of the pilot balloon is faulty. Placing an IV bung on the end of that valve seem to sort that problem quite easily.

Tracheostomy tube change

Often done about day 7 and every few weeks after that as necessary. You will need 3 essential things: a light source (head light or procedural light), aflexible & rigid sucker, and a trache dilator. The older the tracheostomy tract is, the easier the tube change will be, as the tract is often mature, patent and epithelialized. In new tracheostomies, the tissue layers are still soft and may slide and herniate into the tract easily. The bigger the neck, the longer is the distance between skin and trachea, and therefore the more challenging it would be. Always have on standby an oxymetry, an airway exchange catheter (or a flexible suction catheter to guidewire slide tube in and out if necessary), a new stitch and stitch cutter, a trache tape, a new trache tube of the same size and one size smaller (in case there’s significant resistance putting in the same size, put a smaller one in).

Suction the airway, pull out the tube, retract the skin, suck around the stoma, inspect the track, put another one in with an introducer.

Bedside tray

Tracheostomy tube care is reliant on specific instruments. On the trache patient’s bedside there should be a box of tools that would help in routine management and the emergency care should an urgent problem arise. This should include: trache dilators, flexible and rigid suckers, torchlight, new trache tubes of same size or smaller, inner cannulas, gauze, normal saline, pickup forceps, tapes, stitch cutter, scissors.

Tracheostomy patients

Our beloved patients need to be empowered through education. The tracheostomy tube is a marker of severe life threatening illness. The tracheostomy tube is a safe airway but the only airway that the patient has. This is often in the context of patients who need multi-systemic and multi-disciplinary care. Meticulous care is required. Educating the patient in aspects of tracheostomy tube care will go a long way in alleviating their anxieties.

Thank you for looking after the patient with tracheostomy tube.

Field Notes on Tracheostomy Part 1: The Basics

Hello! This is not a comprehensive textbook on how to manage patients with tracheostomies. This is a humble collection of practical brief notes, as requested by a twitter friend. This is a primer. For more extensive information, feel free to consult the big texts.


Someone once said that a tracheostomy tube is a piece of plastic that sits between 12 specialties. I can only count 9 (ENT, ICU, Anaesthesiology, Respirology, Thoracic, Nursing, Speech Pathology, Physiotherapy, Emergency), but I get the drift. Many of us will manage patients with tracheostomy tubes and find it a little uncomfortable. I hope to give you some practical basics to hang on to. There would certainly be tracheostomy protocols in most of the hospital you work with. Do read them.

Tracheostomy is a tracheo-cutaneous airway fistula surgically created to provide direct cannulation of the trachea and therefore direct ventilation of the lower airway. The opening on the skin is called a tracheostoma. (I know, some purists would say that tracheostoma refers only to the permanent stomal opening of the trachea after a laryngectomy- removal of the larynx and separation of the digestive and upper airway tracts – another topic altogether.)

How is it inserted?

Two main ways. Open surgical tracheostomy via skin incision and dissection of anterior neck tissues down to tracheal cartilages. Secondly, percutaneously through needle insertion and guidewire directed dilatation. This is usually assisted by a flexible scope to confirm position intraluminally. There are many percutaneous tracheostomy kits available. As you can imagine, there are advantages and disadvantages to both methods and complications associated with them.

Why tracheostomies?

In the emergency situation: to secure the airway in the context of upper airway pathology (eg. Laryngeal tumours, epiglottitis, Ludwig’s angina, base of tongue cancer, facial fractures, etc.)

In the elective situation: for prolonged intubation and ventilation (ICU patients, long term ventilation and toileting in neuromuscular disorders, etc), as adjunct to other procedures (eg. Major head and neck maxillofacial resection and reconstruction), and congenital airway pathologies (vocal fold palsies, craniofacial syndromes, etc.)

Tube choices

This can be quite confusing, but it’s actually quite logical. There are many options available, and we choose them on the basis of the indications.

First, choose the size in the same way you would choose an endotracheal tube size. Therefore most adult would be a size 7 or 8.

Secondly, do you need a cuff (balloon)? Usually the answer is yes. Having a cuff would provide a seal around the tube for ventilation, and prevent secretions or blood from going down into the lower airway. When would you choose an uncuffed tube? When the patient is able to breathe on their own and maintain their own secretions by swallowing. This is usually when the patient is expected to be tracheostomy tube dependent for a prolonged period.

Thirdly, do you need longer tubes? Depending on the anatomy of the neck, sometimes you need to choose a longer tube. The extension can be on the proximal or distal segment. In an obese neck, we need a proximal extension. In a long thin neck and high tracheostomy, we need distal extension. Some tubes have a flange that can be moved so the proximal extension length can be modified to the patient’s neck thickness.

Easy enough?

Other special features:

Inner cannula: an inner tube or cannula allows the lumen to be easily cleaned regularly. This is important as blood, mucous, and sputum can occlude the lumen easily. Pull it out, wash it out, put it back in. Easy. Note also though that an inner cannula narrows the internal diameter of the tube. The smaller you go, the harder the airflow.

Suction: Some tubes have suction-aid: a small suction hole just above the cuff so that secretions above the cuff can be suctioned. Very useful.

Fenestration: some uncuffed tube provide fenestration opening on the superior surface of the tube. This is useful for vocalization in patients who are tracheostomy dependent. Patients can breathe around and through the tube fenestration to project air into the larynx and oral cavity, and therefore speak.

Materials: most tubes are made of hard plastic. Some are made of flexible silicone to reduce pressure around the neck and trachea. There are even those made of metal for long term tracheostomy dependent patients. Note that different materials will result in different sizes of internal and external diameter of the tube. So a size 8 tube may have different outer diameters based on the materials, which means it may be a little wider and harder to insert.

Tracheostomy care in the first few days

I tell my residents that there are 3 significant potential complications within the first few days of tracheostomy: tube dislodgement, tube occlusion and bleeding. Tracheostomy tube care is critical in the first few days. Positioning of the neck and the tube is important, particularly as patients are being rolled or moved in bed. If the tube is not stitched to skin, a firm tape around the neck is essential. Sometimes firm padding around the flange is helpful. Humidification is important as the humidifying properties of the nose is bypassed in patients with tracheostomy. Humidification prevents dried mucous to become an obstructing plug in and around the tube. The use of inner cannula is recommended and the inner cannula should be washed and cleaned several times a day to prevent crusting and occlusion. Regular suctioning transorally above the cuff and through the tube under the cuff is necessary to prevent excessive secretions from seeping down into the lower airway and interfering with ventilation. Most newly tracheostomised patients are not able to swallow well or clear secretions with the tube in situ. Remember that patients are not able to produce an effective cough with tracheostomy tube in situ. Suctioning takes over the toileting properties of a cough. It is normal for small amounts of blood and mucous to be expressed around the stoma and during suctioning. Simple packing with gauze and suctioning usually resolve most problems.

What about tube dislodgement or excessive bleeding? What about change of tracheostomies? We’ll talk about that in Part 2: Problems.