A tracheostomy is a surgically created opening in the neck, called a stoma, that leads into the trachea. This allows a tube to be inserted, providing an alternative pathway for breathing. Patients may require a tracheostomy due to airway obstruction, prolonged mechanical ventilation, or difficulty clearing respiratory secretions. Dislodgement of a tracheostomy tube is a serious medical emergency, as it can lead to immediate loss of a patient’s airway and oxygen deprivation.
Recognizing Dislodgement and Immediate Response
Signs of dislodgement include sudden respiratory distress, increased effort to breathe, noisy breathing, or the visible absence of the tube from the stoma. The patient may also exhibit signs of hypoxia, such as agitation or a decreased level of consciousness. If the tube has dislodged, the priority is to swiftly re-establish a patent airway.
First, remain calm and call for assistance from a rapid response team or emergency services. While waiting for help, position the patient to optimize their airway; this typically involves placing a roll under the shoulders to extend the neck slightly, which helps align the trachea for potential reinsertion. Assess the patient’s airway and breathing continuously, noting any sounds or efforts to breathe. If the patient is not breathing or is in severe distress, prepare for immediate manual ventilation.
Emergency Reinsertion Steps
Essential items at the bedside include:
A spare tracheostomy tube of the same size
A smaller size tube
An obturator for each tube
Water-soluble lubricant
A 10 mL syringe (for cuffed tubes)
Tracheostomy ties
To begin reinsertion, extend the patient’s neck to align the tracheal opening. If using a cuffed tube, confirm the cuff is fully deflated. Insert the obturator into the outer cannula of the spare tracheostomy tube; the obturator guides the tube and prevents tissue damage during insertion. Apply water-soluble lubricant to the tube’s tip.
Gently insert the lubricated tube with the obturator into the stoma, aiming downward and slightly backward, following the airway’s natural curve. Never force the tube, as this can create a false passage leading to serious complications. Once in place, immediately remove the obturator, as the patient cannot breathe with it in the tube. If it is a cuffed tube, inflate the cuff with 6 to 8 mL of air using the 10 mL syringe. Confirm correct placement by observing chest rise and fall, auscultating for bilateral breath sounds, and checking for misting in the tube. Secure the tube with new tracheostomy ties to prevent further dislodgement.
Addressing Complications and When to Seek Help
If the tracheostomy tube cannot be reinserted, attempt to insert a smaller size tube, as this may pass more easily through a constricted stoma. For a fresh tracheostomy (less than 7 days old), the tract is immature, and reinsertion carries a higher risk of creating a false passage, which can lead to air trapping under the skin (subcutaneous emphysema) or other severe issues. In such cases, or if reinsertion fails, cover the stoma with an occlusive dressing and prepare to ventilate the patient through the mouth and nose using a bag-valve mask.
Complications include continued respiratory distress, bleeding from the stoma site, or the development of subcutaneous emphysema, which feels like crackling under the skin. If these signs appear, or if there is any doubt about proper tube placement, escalate care by notifying the medical team and preparing for alternative airway management. This might involve oral intubation or, if trained, ventilating directly over the stoma with a pediatric face mask attached to a bag-valve mask. Continuous monitoring of the patient’s vital signs, especially oxygen saturation and respiratory rate, is crucial for guiding further interventions.
Post-Incident Care and Prevention
After the immediate crisis is resolved, comprehensive post-incident care is essential. Monitor the patient for delayed complications such as infection at the stoma, continued bleeding, or signs of tracheal injury. Provide comfort and reassurance to the patient, who may be distressed by the event. Document the entire incident thoroughly, including the time of dislodgement, interventions performed, patient response, and the stoma’s condition.
Preventive measures reduce the risk of future dislodgement. Ensure the tracheostomy tube is securely fastened with appropriate ties, checking regularly for tightness and integrity. Proper suctioning techniques help prevent mucus plugs that could lead to tube obstruction and subsequent dislodgement efforts by the patient. Patient and caregiver education on tracheostomy care, including how to recognize dislodgement and perform basic emergency steps, is also a valuable preventive strategy. Utilizing a head-of-bed communication tool outlining key patient information and emergency protocols can further enhance preparedness.