A tracheostomy involves a surgically created opening (stoma) in the neck into the windpipe (trachea), allowing a tube to aid breathing. Accidental dislodgement of this tube is a serious event, as it can rapidly compromise a person’s ability to breathe. Understanding the correct immediate actions is paramount for maintaining airway patency and ensuring safety.
Immediate Steps After Dislodgement
First, remain calm and quickly assess the individual’s breathing and distress. Observe for signs such as gasping for air, noisy breathing, or a blue discoloration (cyanosis), which indicate compromised airflow. Prompt assessment guides the immediate response.
Focus on maintaining an open airway. If the individual can breathe through their mouth and nose, encourage them to do so calmly while you prepare for reinsertion. In cases where breathing is severely compromised, gently extend the neck slightly (unless a cervical spine injury is suspected) to help open the airway and facilitate air passage.
If you are trained in tracheostomy care and reinsertion, gather equipment without delay. This includes a spare tracheostomy tube of the same size or one size smaller, a tracheal dilator or obturator, and water-soluble lubricant. Ensure good lighting to visualize the stoma. Having these items accessible minimizes critical time delays during an emergency.
To reinsert, lubricate the tip of the replacement tube or its obturator. Gently insert the obturator into the tube, or use a dilator to open the stoma slightly. With the stoma open, carefully guide the lubricated tube into the opening, aiming downwards and slightly inwards towards the lungs. Once the tube is fully inserted, promptly remove the obturator or dilator and secure the tube with ties or a tube holder.
After reinsertion, confirm proper tube placement by observing the individual’s breathing patterns and listening for clear air movement through the tube. Look for bilateral chest rise and fall, indicating effective ventilation. If the individual is able to speak, ask them to do so. Monitor their color, respiratory rate, and overall distress level closely.
If reinsertion is difficult or impossible after one or two attempts, or if the individual continues to show signs of severe respiratory distress, do not force the tube. The stoma can close rapidly, especially in newly formed tracheostomies. In such scenarios, covering the stoma with a sterile dressing and providing oxygen through the mouth and nose via a mask, if available, while awaiting professional medical help. Position the individual to maximize airflow, such as sitting upright.
When to Call for Emergency Assistance
Emergency medical services (EMS) should be contacted immediately if you are unable to successfully reinsert the tracheostomy tube after one or two attempts. Persistent difficulty may indicate an obstruction, a closed stoma, or an incorrect angle of approach that requires specialized medical intervention.
Call for emergency assistance if the individual continues to exhibit significant signs of respiratory distress despite attempts at reinsertion or airway management. These signs include rapid, shallow breathing, gasping, nasal flaring, retractions of the chest or neck, or a bluish tint to the skin or lips. These symptoms indicate insufficient oxygenation and require urgent professional medical attention.
Seek immediate medical help if there is significant bleeding from the stoma site or if you suspect an injury occurred during the dislodgement or reinsertion attempt. While minor spots of blood might be common, profuse or continuous bleeding can be a sign of a more serious issue. Any signs of trauma around the stoma require immediate medical assessment.
Contact EMS if the individual becomes unresponsive, drowsy, confused, or experiences a change in mental status after dislodgement. Altered consciousness can be a symptom of severe oxygen deprivation to the brain and is a medical emergency. Even if the tube is reinserted, a change in consciousness warrants immediate medical assessment to determine the cause and provide appropriate care.
Essential Supplies and Prevention
Maintaining a readily accessible emergency kit is a proactive measure for any tracheostomy user. This kit should include at least two spare tracheostomy tubes: one of the current size and one a size smaller. A tracheal dilator or obturator, suction catheters appropriate for the tube size, a portable suction machine or bulb syringe, and sterile water-soluble lubricant are also necessary components for managing the airway.
Further essential items include clean tracheostomy ties or a securement device, sterile gauze pads, and saline solution or sterile water for stoma care and cleaning. Having a working flashlight or headlamp can be invaluable for clear visibility during reinsertion. These critical supplies should be stored together in a designated, easily accessible location known to all primary caregivers and family members.
Prevention of accidental dislodgement begins with the meticulous and proper securement of the tracheostomy tube. Ensure that the tracheostomy ties or tube holder are snug but not overly tight, allowing for approximately one finger to fit comfortably underneath to avoid pressure injuries. Regular daily checks of the securement device for any signs of wear, tear, or loosening are also important to maintain continuous tube stability.
Individuals with tracheostomies and their caregivers should be continuously mindful of activities that could lead to accidental pulling on the tube, such as vigorous coughing, sudden head movements, or engaging in rough play. Consistent and gentle routine tracheostomy care, including appropriate suctioning and meticulous stoma cleaning, helps prevent complications like secretions buildup or infection that might necessitate tube manipulation and potentially lead to dislodgement. Educating all individuals interacting with the patient about the importance of tube security further contributes to prevention.