A standard adult tracheostomy is a surgical procedure in which
an opening is created between cartilaginous rings in the trachea,
and the skin of the neck is frequently sutured to the anterior tracheal
wall (Figure 242-1). In pediatric and some
adult tracheotomies, a vertical incision is made through two or
three tracheal rings, and the lateral edges are tagged with temporary
stay sutures. These sutures are usually removed before the patient
leaves the hospital.
Skills needed for tracheostomy management in the ED include replacement
of an uncuffed with a cuffed tracheostomy tube for mechanical ventilation,
replacement after accidental decannulation, correction of tube obstruction,
and control of bleeding or infection at the tracheostomy site (Figure 242-2). Key information in managing
a tracheostomy includes why and when the procedure was performed
and what type of tracheostomy tube is currently being used. Determine
if the patient can be orally intubated if needed. Patients
who have undergone a laryngectomy or who have tumors or scarring
that occlude the upper airway cannot be orally intubated.
There are many types of tracheostomy tubes available, including
tubes made of plastic, silicone, nylon, and metal. Most hospitals
stock only a few types of tracheostomy tubes, and emergency physicians
should be familiar with the types available at their institution.
Tracheostomy tubes can vary in diameter, total length, and the length
before and after the curve and the presence or absence of a cuff
(Figure 242-3). The tracheostomy tube cuff
is similar to that of an endotracheal tube. The size of the tracheostomy
tube is usually defined by the inner diameter, ranging in adults
from 5 to 10 mm, and in pediatric tubes from 2.5 to 6.5 mm. Most pediatric
and adult tracheostomy tubes have a 15-mm standard respiratory connection
that may be used with ventilator tubing and a bag-valve device.
Common components of most tracheostomy tube sets.
Fenestrated tracheostomy tubes have an opening along the dorsal
surface of the body of the tube. The fenestration allows the passage
of air through the tracheostomy tube to the vocal cords so the patient
can speak. Tubes must be carefully fitted to provide alignment of
the fenestration within the trachea, so there is no contact of the
fenestration with the anterior neck tract or the posterior tracheal
wall. When the fenestration contacts these structures, slight respiratory
movement of the tube will lead to granulation tissue formation.
The granulation tissue can extend into the fenestration, leading
to bleeding, obstruction, and difficulty removing the tracheostomy
tube. If any difficulty is encountered removing a fenestrated tracheostomy
tube, otolaryngologic consultation is needed.
Most adult tracheostomy tubes have a removable inner cannula,
which allows secretions to be cleared from the lumen without removing
the entire tube from the trachea. In assessing an adult tracheostomy
patient, remove and examine the inner cannula for crusting or obstruction.
Both disposable and reusable inner cannulas can be cleaned by using
a small brush dipped in a solution of hydrogen peroxide, and then
rinsing the cannula with warm tap water. If the correct size of
disposable inner cannula is not available in the ED, use the existing
inner cannula temporarily, or change the entire tracheostomy tube. Pediatric
tracheostomy tubes never have an inner cannula because of the small
inner diameter, so the entire tube must be removed for cleaning.
Changing a Tracheostomy
The amount of difficulty encountered when changing a tracheostomy tube
depends on when the procedure was performed and on patient anatomy. If
the tracheostomy is <7 days old, the tract will not be mature
and manipulation may easily create a false passage within the soft tissue
of the neck. In addition, a tract may easily collapse at any time in
patients with obese necks or neck masses. If the situation
is not emergent, and the tracheostomy is <7 days old, tracheostomy
tubes should be changed by a surgeon familiar with the procedure.
An uneventful tracheostomy change depends on adequate preparation and
is best accomplished with an assistant. The spontaneously breathing, stable
patient can easily breathe through a patent stoma without the tube in
place, so there is no reason to rush through
this procedure. The needed equipment is listed in Table
242-1. If a cuffed tube is used, test the balloon before use
and make sure the balloon is completely deflated before insertion.
A cricoid hook can be inserted just under the cricoid and used to
lift and stabilize the trachea. The dilator is particularly useful
if a larger tube is to be inserted, but if dilation is needed and
time permits, obtain otolaryngologic consultation. Dilation may
require injection of local anesthesia. Become familiar with the cricoid
hook and tracheal dilator before using them. To minimize soft tissue
damage, use an obturator whenever a tracheostomy tube is replaced.
When the obturator is placed within the outer cannula, the tube presents
a solid, rounded end that is less likely to damage the neck soft tissue
during tube insertion (Figure 242-3). But
after placement, quickly remove the obturator and place the inner
cannula, because the patient cannot breathe through the tracheostomy
tube when the obturator is in place.
242-1 Equipment Needed to Change a Tracheostomy Tube |Favorite Table|Download (.pdf)
242-1 Equipment Needed to Change a Tracheostomy Tube
|Suction device with both a Yankauer tip and suction catheters
that fit inside the tracheostomy tube|
|Good lighting directed into the tracheostoma|
|An appropriate size tracheostomy tube with obturator in place|
|Another tracheostomy tube one size smaller than planned|
|Tracheostomy tube tie|
|Cricoid hook and tracheal dilator (if physician is familiar
with their use)|
After all of the equipment is in place, place the patient supine
with a shoulder roll to extend the neck. Remove the old tube and
gently suction and examine the stoma. In most cases, the opening
in the trachea and the posterior tracheal wall can be seen. Gently
direct the fresh tube into the opening, curving it downward into
the trachea (Figure 242-4). The movement
should be smooth and gentle. If resistance is met, the tube
is likely caught on the cartilaginous tracheal wall. Remove the
tube and reexamine the stoma, and again place the tube directly
into the tracheal opening. If the tube still cannot be placed, consider
placing a smaller tracheostomy tube. However, a smaller tube
will also be shorter, and may not be long enough for the patient’s
neck. Another helpful method is to place a small suction
catheter or nasogastric tube into the trachea and thread the tracheostomy
tube over it.
Insertion (A) and placement (B)
of the tracheostomy tube. Cuffed tubes should be inserted with the
Once the tube is in place, verify correct tube position by inserting
a suction catheter into the tube. It should easily pass beyond the
length of the tracheostomy tube without resistance. If there is
a question about placement, a nasopharyngoscope or flexible bronchoscope
can be passed through the tube for direct visualization of placement,
or an x-ray obtained.
Patients with accidental decannulation but no distress can have
the tracheostomy tube replaced as described above in Changing a
Tracheostomy Tube. If the tube has been out for several hours,
the stoma may begin to close and dilation may be needed before tube
insertion. If this is the case, and if the stoma is small
and/or the tracheostomy is the patient’s only
airway, otolaryngologic consultation is needed for tube replacement.
Although problems with the tracheostomy may be the cause of respiratory
distress, all other causes of distress should be considered, and
if the tracheostomy is found to be patent and in the airway, leave
it in place. Tracheostomy tube obstruction with mucous plugging
is common. Secretions may act by a ball-valve mechanism, allowing
air in but restricting exhalation. Suctioning may relieve the obstruction
(Figure 242-2). Preoxygenation and placement
of sterile saline solution into the trachea will aid in suctioning.
Prolonged use of large suction catheters without preoxygenation
will cause hypoxemia. If mucous plugging cannot be relieved by suctioning,
the inner cannula of the tracheostomy tube and, sometimes, the entire
tracheostomy tube may need to be removed and cleaned.
with a Tracheostomy Tube
If the patient requires mechanical ventilation, an uncuffed tracheostomy tube will
result in a large air leak. If the patient cannot be effectively
ventilated with an uncuffed tube, replace with a cuffed tube. If
a tracheostomy tube is not readily available, an endotracheal tube
may be inserted into the stoma to maintain airway security. If the
stoma cannot be cannulated, the patient may be orotracheally intubated
to secure the airway—unless the patient has a laryngectomy
(see following section).
Laryngectomy patients cannot be orally intubated. The
only access to the tracheo-bronchial tree in laryngectomy patients
is through the tracheostoma in the neck. Occasionally, laryngectomy
patients will have a laryngectomy tube in the stoma, similar in
appearance to a tracheostomy tube. Laryngectomy patients can
be distinguished from tracheostomy patients by history and physical
examination, and by the fact that laryngectomy patients are unable
to vocalize (or breathe) when the laryngectomy tube is occluded.
The tracheostomy tube may be dislodged from the trachea, but
not from the neck. In this case, a suction catheter cannot be passed
through the tube, and the tracheostomy tube may extrinsically compress
the trachea (Figure 242-5). In this circumstance,
the entire tracheostomy tube should be immediately removed. When
attempting to properly reinsert the tracheostomy tube, it may be
difficult to accurately identify the actual tracheal stoma. A nasopharyngoscope
or flexible bronchoscope should be inserted into the visible stoma
in an attempt to identify the tracheal opening. If the latter still
cannot be identified, otolaryngologic consultation is needed. If
the patient cannot maintain the airway, oral intubation will be
needed while awaiting the otolaryngologist.
A. Patient with a large goiter and a no.
4 Shiley tracheostomy tube with the tip of the tube outside the
trachea and compressing the tracheal wall. B. Same
patient with a longer no. 6 Shiley tracheostomy tube with the tip
of the tube inside the trachea.
Indwelling tracheostomy tubes are contaminated with normal, and sometimes
pathogenic, flora. Stomal skin infection, tracheitis, and bronchitis
can be a recurring problem. Staphylococcus aureus, Pseudomonas, and Candida are
often identified, and broad-spectrum antibiotics are indicated in
the setting of clinical disease. Dressing changes with gauze soaked
in 0.25% acetic acid are effective for local wound infections.
Bleeding can occur immediately after a tracheostomy and in the
late postoperative period.5 Sources of hemorrhage
include granulation tissue in the stoma or trachea, and erosion
of thyroid vessels or the thyroid itself, the tracheal wall (frequently
from suction trauma), or the innominate artery. Slow bleeding originating
from the stoma may be controlled by packing the site with saline-soaked
gauze. If this is ineffective, remove the tube and examine the stoma
and tracheal wall. Local bleeding can be controlled with silver
nitrate. Electrocautery is done by an otolaryngologist. If bleeding
is brisk, replace the tracheostomy tube with a cuffed endotracheal
tube with the cuff below the bleeding site.
Tracheoinnominate artery fistula is a rare,6 but
life-threatening complication of tracheostomy.7 Bleeding
results from vessel erosion caused by either direct pressure of
the tip of the tracheal cannula against the innominate artery (Figure 242-6), or from a cuff with inappropriately
high pressures after being overinflated. Most patients with a tracheoinnominate
fistula present within the first 3 weeks after tracheostomy, with
the peak incidence of presentation between the first and second
week. Approximately 50% of patients may present with
a sentinel arterial bleed or hemoptysis.8 Bleeding
may be mild to severe and should not be taken lightly, because the
potential exists for sudden massive hemorrhage. Immediate otolaryngologic
and thoracic surgery consultation is required, and operative repair
is lifesaving. If
patients present with massive bleeding, the first maneuver to control
brisk bleeding while planning operative intervention is to hyperinflate
the cuff. This technique has been successful in 85% of
cases. If bleeding persists, slowly withdraw the tube while exerting
pressure against the anterior trachea. If these interventional maneuvers
do not control the bleeding, then place a cuffed endotracheal tube
to prevent pulmonary aspiration of blood. Passing the endotracheal
tube past the tracheoinnominate fistula will require direct visualization
with a flexible nasopharyngoscope or bronchoscope through the tube
and an assistant to withdraw the tracheostomy tube as the endotracheal
tube passes.9 Stomal hemorrhage is then controlled
with digital pressure of the innominate artery against the manubrium. Tamponade
of the hemorrhage should be maintained during transport to the operating
The arrow points to the position of the tracheostomy tube
in relation to the innominate artery. This close approximation facilitates
creation of a tracheoinnominate fistula.
Tracheal stenosis can present weeks to months after decannulation
and results from mucosal necrosis and subsequent scarring. Signs
and symptoms include dyspnea, wheezing, stridor, and the inability
to clear secretions. A chest radiograph may demonstrate the narrowed
tracheal airway. Medical treatment includes humidified oxygen, nebulized
racemic epinephrine, and early administration of steroids. Operative
treatment involves rigid bronchoscopy with laser excision of the
scar bands, and stenting or tracheal reconstruction in more severe
cases. Immediate otolaryngologic consultation is warranted.