Ventilating a patient with a stoma depends entirely on whether the stoma is from a tracheostomy or a total laryngectomy, because the two have fundamentally different anatomy. Getting this distinction wrong can waste critical seconds. In a tracheostomy, the mouth, nose, and upper airway are still connected to the lungs. In a total laryngectomy, that connection no longer exists: the stoma is the only airway.
Why the Type of Stoma Changes Everything
A tracheostomy is a surgically created opening in the trachea, usually with a tube in place. The patient’s upper airway (mouth, nose, throat) still connects to the lungs. That means you have two potential routes for ventilation: through the stoma or through the mouth and nose.
A total laryngectomy is different. The larynx has been completely removed, and the trachea is permanently rerouted to the stoma in the neck. The mouth and nose are disconnected from the lungs entirely. Trying to ventilate through the mouth is useless in these patients. One study found that 32% of nurses initially believed oral ventilation was sometimes or always appropriate for laryngectomy patients, and nearly one in five healthcare professionals across disciplines didn’t understand that the oral airway no longer exists after this surgery.
Look for a medical alert bracelet or necklace that says “total neck breather.” Many laryngectomy patients wear one specifically so first responders know to direct oxygen and ventilation to the stoma, not the face. If you can’t confirm the type of stoma, treat it as the only airway and ventilate through it first.
Ventilating a Laryngectomy Stoma
For a patient with a total laryngectomy, the stoma is your only option. No air you push through the mouth or nose will reach the lungs.
If the patient needs supplemental oxygen, place an oxygen mask directly over the stoma site on the neck. If they need active ventilation (they aren’t breathing adequately on their own), use a pediatric face mask over the stoma to create a seal, then connect it to a bag-valve device and deliver breaths. A pediatric mask works well here because an adult mask is too large to seal against the neck. Press the mask firmly around the stoma to prevent air leaks, and watch for chest rise with each breath to confirm air is reaching the lungs.
Before ventilating, remove any stoma covers, heat and moisture exchange (HME) filters, or other devices sitting over the opening. These are designed for normal breathing and will block or restrict airflow from a bag-valve device.
Ventilating a Tracheostomy Patient
With a tracheostomy, your primary route is through the tracheostomy tube itself. Attach the bag-valve device directly to the 15mm connector on the tracheostomy tube and ventilate. If the tube has a cuff, inflate it to seal the trachea and prevent air from escaping upward through the mouth and nose.
If the tracheostomy tube has been removed or you can’t ventilate through it, you have two options. First, try placing a pediatric mask over the bare stoma, just as you would for a laryngectomy patient. A second person may need to close the patient’s mouth and nose to prevent gas from escaping through the upper airway, since that connection still exists. Second, because the upper airway is intact, you can attempt standard oral ventilation with a face mask while someone else occludes the stoma with a gloved hand or gauze to prevent air leaking out the neck.
Clearing a Blocked Tracheostomy Tube
If you’re meeting resistance when trying to ventilate through a tracheostomy tube, work through these steps in order. Each one targets a different cause of obstruction, and you move to the next only if the previous step doesn’t fix the problem.
- Remove any speaking valve or cap. These devices redirect airflow for speech and will block ventilation if left in place.
- Remove the inner cannula. Many tracheostomy tubes have a removable inner sleeve. Mucus and secretions accumulate on this part. Pulling it out can instantly open a blocked airway.
- Pass a suction catheter. Thread a suction catheter through the tube to clear mucus plugs that may be partially or completely blocking the airway deeper in.
- Deflate the cuff. In some cases, an overinflated or herniated cuff can itself cause obstruction. Deflating it may relieve the blockage.
- Remove the tracheostomy tube entirely. If none of the above steps work, take the tube out. You can then attempt to ventilate through the stoma directly using a pediatric mask, or intubate through the mouth since the upper airway is still connected to the lungs.
This sequence moves from least invasive to most invasive. Each step takes only seconds, so moving through them quickly is realistic even in an emergency.
Getting a Seal on a Bare Stoma
When there’s no tube in the stoma and you need to ventilate, creating an airtight seal against the neck is the main challenge. A pediatric face mask is the most commonly recommended tool. Press it firmly over the stoma, forming a ring of contact with the skin around the opening. Some clinicians also use a laryngeal mask airway placed directly against the stoma, which can conform well to the neck surface.
Watch for two signs that your seal is working: visible chest rise with each squeeze of the bag, and the absence of air hissing from around the mask edges. If you see the chest rise but it’s inadequate, check whether air is escaping through the mouth and nose. In a tracheostomy patient, this is expected since the upper airway is open. Have a second person pinch the nose shut and close the mouth, or pack the oropharynx if needed. In a laryngectomy patient, air should not escape from the mouth or nose at all. If it does, you may be dealing with a tracheostomy rather than a laryngectomy, and should adjust accordingly.
Key Differences at a Glance
- Laryngectomy: Ventilate only through the stoma. Mouth and nose ventilation will not work. No need to occlude the mouth and nose.
- Tracheostomy with tube in place: Ventilate through the tracheostomy tube. Inflate the cuff to prevent air leak.
- Tracheostomy without tube: Ventilate through the stoma using a pediatric mask, and have someone seal the mouth and nose. Alternatively, ventilate through the mouth while occluding the stoma.
In all cases, remove stoma covers, HME filters, speaking valves, and caps before attempting ventilation. Confirm chest rise with each breath. If resistance is encountered with a tracheostomy tube in place, work through the obstruction algorithm: remove the valve, remove the inner cannula, suction, deflate the cuff, and if all else fails, remove the tube.