Accidental decannulation, the unplanned removal of a tracheostomy tube, is a medical emergency that demands immediate, decisive action. A tracheostomy is a surgically created opening, or stoma, in the neck that provides a direct airway into the trachea, allowing a person to breathe without using the nose or mouth. When the tube comes out, the airway is compromised, and the situation can quickly become life-threatening. Preparation and a calm response are necessary to ensure the patient’s airway is restored quickly.
Immediate Response and Airway Assessment
The immediate priority is to assess the patient’s breathing and call for emergency assistance. The local emergency number, such as 911, or the specialized medical team’s emergency line should be activated immediately. While awaiting help, positioning the patient can optimize the environment for reinsertion or rescue breathing.
The patient should be placed in a supine position if their condition allows. Placing a rolled towel or blanket under the shoulders can gently extend the neck, which helps align the airway tract. Quickly assess if the patient is moving air adequately through the stoma or upper airway. Look for signs of respiratory distress, such as noisy breathing, a blue or gray color change in the skin, or rapid, shallow breaths. If the patient is struggling to breathe, the focus must shift to maintaining an open passage for air.
Understanding Stoma Maturity
The next step is determining the maturity of the tracheostomy stoma, which informs the decision to attempt tube reinsertion. The stoma is the tract between the skin and the trachea. It must be at least 7 to 10 days old to be considered mature, allowing the tract walls to stabilize and the inner lining to form.
An immature stoma (less than seven days old) carries a significant risk if reinsertion is attempted. Since the neck tissues have not fully healed, forcing a tube could create a “false passage” outside the trachea, causing air to leak into the neck instead of the lungs. For an immature stoma, the safest course is to maintain the opening and wait for trained medical personnel. If the stoma is mature, the risk of a false passage is significantly lower, and a trained caregiver can attempt reinsertion.
Step-by-Step Guide for Reinsertion
If the stoma is mature and a trained caregiver is present, attempt reinsertion immediately using the available emergency equipment.
Preparing for Insertion
First, locate the spare tracheostomy tube of the same size and attach the obturator. The obturator is a smooth, rounded guide that makes insertion safer and easier. It must be in place to prevent the tube’s tip from causing trauma to the tracheal wall. Lubricate the tip of the spare tube with a water-soluble gel to ensure it slides easily through the stoma.
Insertion Technique
Gently guide the tube with the obturator into the stoma, following the natural curve of the airway toward the chest. If the tube meets resistance, do not force it, as this can cause injury or create a false passage. If the tube of the same size cannot be inserted easily, immediately remove it and attempt insertion with the spare tube that is one size smaller.
Securing the Tube
Once the tube is successfully in place, the obturator must be removed immediately, as the patient cannot breathe with it blocking the lumen. Secure the tube quickly with the tracheostomy ties or holder. Ensure one finger can fit snugly between the tie and the neck to prevent it from being too tight.
Rescue Breathing
If reinsertion is unsuccessful after two gentle attempts, or if the stoma is immature, the priority shifts to providing rescue breaths through the upper airway. Cover the stoma opening securely with gauze to prevent air from escaping through the neck. The patient should then receive ventilation using a bag-valve-mask (BVM) over the nose and mouth, directing air into the lungs through the natural upper airway.
After the Emergency: Follow-Up and Prevention
Once the immediate crisis has passed and the tube is successfully reinserted, the patient requires a complete medical review. Even if the reinsertion was successful and the patient appears stable, a physician must assess the tube’s position to rule out displacement or trauma to the tracheal lining. This assessment involves listening to the chest to confirm equal air entry into both lungs and checking vital signs, which should be monitored frequently for at least two hours following the event.
Maintaining a well-stocked emergency kit is essential for prevention. The kit must contain:
- Two sterile tracheostomy tubes: one of the same size currently in use and one tube that is one size smaller, both with obturators.
- A bag-valve-mask (BVM).
- Water-soluble lubricant.
- A syringe to inflate the cuff of a cuffed tube.
To prevent recurrence, manage all tubing carefully to avoid tension on the tracheostomy site. Regularly check the security of the tube ties or holder, ensuring they are snug but not restrictive. Adhering to a regular schedule for tube changes, as recommended by a physician, helps maintain a healthy stoma and reduces the risk of emergency decannulation.