This skill station covers:
Tracheostomy and laryngectomy – the essentials
Management of emergencies
Patients with a tracheostomy or laryngectomy tube represent a uniquely vulnerable population in critical care, facing a significantly elevated risk of death from airway emergencies. A comprehensive analysis by the Fourth National Audit Project (NAP4) revealed that 70% of intensive care unit (ICU) airway incidents were related to tracheostomy tubes, accounting for a staggering 60% of the ICU deaths observed in the study.
Similarly, the NSW Agency for Clinical Innovation (ACI) identified 18 tracheostomy-related deaths over a five-year period, with critical deficiencies in skills, knowledge, and equipment being the main contributing factors.
Analysis of adverse events from around the world has highlighted recurring themes, including the unique challenges posed by obese patients for whom standard tube lengths are often inadequate, and the inherent difficulty in rapidly and accurately distinguishing between a displaced tube, a blocked tube, or other causes of respiratory distress. This section synthesises contemporary best practices and emergency algorithms to equip clinicians with the knowledge and strategies required to navigate these time-critical, high-risk scenarios and improve patient safety.
Standard length tracheostomy tubes are not long enough, and tubes become displaced
It can be difficult to distinguish between a displaced tube, a blocked tube, cuff leak or rupture, airway haemorrhage, pulmonary or neuromuscular problems
The most immediate life-threatening emergencies occur with blocked or displaced tubes, with most adverse events occurring with a failure to assess tube patency, inadequate attempts to clear the airway and delay in removing the tube
Continuous waveform capnography increases safety in patients with a tracheostomy and laryngectomy, allowing for earlier detection of accidental decannulation, tube displacement and blockages.
Its lack of use has been implicated in many adverse events.
Tube comes out, Tube is displaced, Tube gets blocked
While the causes of respiratory distress in these patients can be varied, the most immediate and life-threatening emergencies typically stem from three primary scenarios
The Tube Comes Out (Accidental decannulation)
When a tube comes out completely, the risk of death or neurological injury is paradoxically lower compared to other scenarios. This is likely because the overt absence of the tube prompts clinicians to more quickly initiate standard upper airway manoeuvres, treating the patient as they would any other individual without a tracheostomy.
The Tube is Displaced
This is a more insidious and dangerous emergency. The tube appears to be in its correct position, yet its distal end has moved, often creating a false tissue tract that obstructs the airway. This is a life-threatening situation where the clinician may be misled into thinking the tube is correctly placed while a critical obstruction persists.
Patients are particularly vulnerable to tube displacement:
- When they are moved
- When there are attachments to the tube (e.g. suction, oxygen, ventilator tubing)
- When they have a newly formed stoma
- When they are confused or delirious
A crucial principle of all tracheostomy algorithms is that a displaced tube should never be simply pushed back in due to the high risk of creating a false tissue tract.
The Tube is Blocked
A partially or completely blocked tube is a common and serious cause of patient harm, often resulting from a combination of factors, including inadequate humidification, patient dehydration leading to thick sputum, or infrequent cleaning of the inner cannula.
Tracheostomy tubes with an inner cannula are preferred because their removal can often resolve the blockage. For tubes without an inner cannula, suctioning or complete tube removal are the only available options.
Unlike a displaced tube, cuff deflation in the case of a blocked tube (as directed by emergency algorithms) is more likely to result in gas flow around the tube.
Emergency Algorithms Explained
The NSW ACI recommends the UK National Tracheostomy Safety Project algorithms, which are used widely around the world, including most hospitals in Australia and New Zealand. These must always be kept with the patient.
The algorithms are designed as decision trees, which are best used by a team leader offering prompts to the airway clinician(s).
Oxygenation of the patient should be prioritised at every step.
Manoeuvres to assess tube patency are combined with manoeuvres to clear the airway, including timely removal of a tube as soon as it is deemed to be displaced out of the trachea or irretrievably blocked.
Assessing Gas Flow and Tube Patency
Look, Listen and Feel
Look, Listen and Feel
- First responders should use the BLS manoeuvre, Look, Listen and Feel, but at the mouth AND tracheostomy.
- Look at the respiratory pattern – is it obstructed (see-saw or paradoxical movement)?
Resuscitator with flow-inflating bag
Resuscitator with flow-inflating bag
- Use breathing system with flow-inflating bag (e.g. Mapleson C, F) rather than a self-inflating bag
- Can assess tube / stoma patency, ventilation (spontaneous breathing), lung compliance (manual ventilation)
Waveform Capnography
Waveform Capnography
- Waveform capnography (not number-only or colour-change) is paramount
- Mandatory for all ventilated patients
- Must be easily accessible for all other patients to assess tube patency and gas flow in emergencies.
Key Principles
Do no harm – don’t squeeze the bag
Life-threatening surgical emphysema can result from manual ventilation via a displaced tracheostomy tube.
All tracheostomy emergency algorithms therefore suggest that tube patency must be checked before manual ventilation is performed.
If there’s no flow, it has to go
Differentiating between blocked and displaced tracheostomy tubes can be difficult or impossible, so the algorithms advocate two simple methods to assess tube patency and continuity with the trachea: detection of gas flow and passage of a suction catheter.
If there is no gas flow through or around the tube, and the suction catheter cannot be passed, the tube should be removed, whatever the cause. Delays in removing blocked or displaced tracheostomy tubes have been implicated in many deaths.
Do no harm – don’t re-insert the tube
If the tube is removed, the stoma should be covered with a gloved hand and standard upper airway management performed as for any other patient.
Replacing displaced or dislodged tracheostomy tubes in an emergency can cause formation of false tracts, bleeding, surgical emphysema, loss of airway and death. These attempts also divert attention away from simple oral or stomal airway manoeuvres which are often neglected in reported incidents.
The age of the stoma is not a reliable indicator of ease of re-insertion of tracheostomy tubes, especially in obese patients.
Stoma oxygenation can be attempted if oral airway manoeuvres fail.
If all else fails
Reintubation of the stoma should only be attempted when all other methods of oxygenation have failed.
A bougie, exchange catheter, or bronchoscope may help to identify the trachea and replace the tracheostomy tube.
This video gives guidance on how to manage tracheostomy emergencies using the Intensive Care NSW (Agency for Clinical Innovation) Tracheostomy Emergency algorithm.
Acknowledgements:
Health Education & Training (HETI) NSW
Agency for Clinical Innovation NSW
UK National Tracheostomy Safety Project
A box or bag of equipment for the management of respiratory emergencies should always be kept with patients with tracheostomy or laryngectomy.
A flexible bronchoscope should be readily available to check the position of tracheostomy tubes and assist with bronchoscopic oral, nasal or stoma intubation.
Tracheostomy Kit
Laryngectomy Kit
The most effective approach to tracheostomy emergencies is proactive prevention through meticulous care, clear communication, and ongoing education.
Is this a tracheostomy or a laryngectomy?
Confusion about whether a patient has a tracheostomy or a laryngectomy still causes adverse incidents worldwide.
The distinction is vital: a laryngectomy is a permanent, surgical separation of the upper and lower airways, meaning the patient cannot be ventilated from the mouth or nose.
Conversely, a tracheostomy offers access to the trachea whilst leaving the upper airway intact.
From the end of the bed, differentiating between these patients might not be easy, and the algorithms for rescue are profoundly different, underscoring the necessity of bedside signage that clearly identifies the patient’s specific condition.
A bedhead sign should be considered a non-negotiable component of care for these patients.
It should include essential information such as the patient’s name, the date and method of stoma formation (e.g., percutaneous or surgical), the size and type of tube in place, the presence of sutures, and the contact details of clinicians to be called in an emergency.
Why does the patient have a tracheostomy?
To help risk-stratify our patients, it is helpful to consider the reason for the tracheostomy. Patients undergo the formation of a tracheostomy for four main reasons:
- To relieve upper-airway obstruction due to tumour, surgery, trauma, foreign body, or infection. These patients are more likely to have a surgical tracheostomy.
- To prevent laryngeal and upper airway damage due to prolonged trans-laryngeal intubation.
- To allow easy or frequent access to the lower airway for suctioning and secretion removal. These patients are more likely to have a blocked tracheostomy.
- To provide a stable airway in a patient who requires prolonged mechanical ventilation or oxygenation support.
Was the tracheostomy percutaneous or surgical?
In the ICU, most patients undergo percutaneous dilatational tracheostomy (PDT). Apart from the obvious time and cost savings, there may be other advantages, such as a lower incidence of wound infection.
However, compared to surgical stomas (where the tissue layers have been sutured together), new PDT stomas are less likely to stay open if the tube becomes dislodged:
This reinforces the importance of the bedhead signage.
Are there stay sutures?
Stay sutures are sometimes placed at the time of surgical tracheostomy. These are placed through opposite edges of the incised trachea and taped to the skin. Pulling on them during an emergency brings the tracheal stoma forward and can help with tube re-insertion
In an emergency, it is worth knowing what type of tube you are dealing with. Some of the considerations are outlined in the images and table below.
Portex Blue Line Ultra
Portex Blue Line Ultra
- Standard length – may be too short in obese patients
- Can attach breathing circuit without inner cannula in place
- Subglottic suction version available
Tracoe Twist Plus Extract
Tracoe Twist Plus Extract
- “Extended length” but fits almost all adult patients
- Need inner cannula in place to attach breathing circuit
- Suction port can be used for vocalisation
Bivona Single Cannula
Bivona Single Cannula
- No inner cannula
- Blockage options: suction until cleared or remove
- More commonly used in paediatric patients
Tracoe Twist Cuffless
Tracoe Twist Cuffless
- Cuffless: positive pressure ventilation may be ineffective, may require change to cuffed tube for anaesthesia or when sick
- Cuffless tubes are often also fenestrated
- Commonly used in weaning phase or in long-term tracheostomy patients
Tracoe Twist Fenestrated
Tracoe Twist Fenestrated
- Comes with fenestrated and non-fenestrated inner cannulas
- Positive pressure ventilation may be ineffective with fenestrated inner cannula
- In some models, suction catheter may pass through fenestration
Shiley XLT Proximal and Distal
Shiley XLT Proximal and Distal
- Extended proximal length: patients with thick necks
- Extended distal length: patients with long trachea, stenosis, or malacia
- Need inner cannula in place to attach breathing circuit
Portex Uniperc
Portex Uniperc
- Adjustable flange, extended length
- May slip in or out – check length in an emergency
- Can attach breathing circuit without inner cannula in place
Laryngectomy Tube
Laryngectomy Tube
- Soft silicone tube, cannot attach breathing circuit
- No inner cannula
- Blockage options: suction until cleared or remove
One-Way Valves
One-Way Valves
- Open in inspiration, closed in expiration
- Air through upper airway allows speech
- Cuff must be deflated before use
Getting the Size Right
Incident monitoring shows that undersized tracheostomy tubes are regularly responsible for serious complications including death.
Studies show that standard length tubes are often too short, even for non-obese ICU patients.
The Tracoe Twist Plus™ range was designed to overcome these problems. These tubes, which are approximately 1-2cm longer (depending on the size) are now used as standard in many hospitals internationally.
The outer diameter (OD) of a tracheostomy tube should be 2/3 to 3/4 of the diameter of the trachea:
10mm OD tube is appropriate for most adult females (ID 6.0-7.0), 11mm OD for most males (ID 7.0-8.0)
Choosing the correct diameter tube allows a good seal to be achieved with cuff pressures of 20-25mmHg, decreasing the likelihood of pressure injury, while also allowing for air flow around the tube during the weaning phase.
The tip of the tube should sit at the mid-point of trachea or lower (at least 3cm from the carina)
In obese patients, extended length or adjustable flange tubes should be used and extra care taken in securing them, especially before and during turning or moving the patient
The position of the tube tip should be checked with a bronchoscope at the time of insertion for all patients.
Regular care
Tracheostomy tapes should be secure, and tight enough that one or two fingers can be placed beneath them.
Inner cannulas should be removed, inspected and cleaned regularly to ensure patency, and a spare cannula should always be at the bedside.
Training Requirements
At least 50% of staff working in clinical areas caring for tracheostomy and laryngectomy patients should have passed a competency assessment in the management of the relevant emergency situations.
All staff should be aware of the Tracheostomy Red Flags – the early warning signs that may indicate tracheostomy is blocked or displaced
Staff should feel empowered to escalate care in patients displaying any of these signs.
Regular simulation-based training should occur, using the emergency algorithms and equipment.
The ACI suggests that all hospitals should have a multidisciplinary tracheostomy team to coordinate training and quality improvement, and facilitate the care of these patients.
There are several studies showing the benefit of tracheostomy teams.
The management of tracheostomy and laryngectomy emergencies is a high-stakes clinical challenge, where a lack of preparation can have catastrophic consequences. The NAP4 audit and ACI findings unequivocally highlight that these are not rare occurrences but significant contributors to patient morbidity and mortality in the ICU setting.
The cornerstone of patient safety in these scenarios is the systematic application of a well-defined emergency algorithm, prioritising oxygenation while strictly adhering to the “do no harm” principles of not re-inserting a displaced tube or performing ventilation before confirming the patency and position of the tube. The fundamental lesson is that in a time-critical crisis, the inability to pass a suction catheter or detect gas flow after troubleshooting mandates immediate tube removal.
Furthermore, proactive prevention is paramount; this includes rigorous staff training, the use of continuous waveform capnography for early warning, meticulous attention to tube sizing, and the critical distinction between a tracheostomy and a laryngectomy via clear bedside signage.
By replacing reactive confusion with a planned, systematic approach, clinicians can significantly enhance patient safety and outcomes.