Tracheostomy Emergencies

Tracheostomy emergencies hinge on a few high-stakes distinctions: when and why the trach was placed, whether the tube is obstructed or dislodged, and whether the patient can still be oxygenated from above. Bleeding from a trach site raises a different threat profile, including the rare but catastrophic tracheoinnominate fistula.

Respiratory Distress With a Tracheostomy

• Critical first history: The most important questions are when and why the tracheostomy was placed, because a fresh stoma, prior difficult intubation, or laryngectomy can completely change your rescue options.
• Three-part troubleshooting frame: Start by asking whether the trach is dislodged, obstructed, or functioning normally while the real problem is primary lung disease; that framing keeps the evaluation fast and organized.
• Inner cannula obstruction: A blocked inner cannula is the most common trach problem and is often fixed immediately by removing and clearing it. We walk through the bedside sequence in the episode.
• Suction catheter check: Passing a suction catheter to the level of the manubrium is a practical patency test; failure to pass suggests either tube obstruction or false passage from dislodgement.
• Guided tube replacement: Do not blindly replace a dislodged trach, especially before tract maturation at about 7 to 10 days; fiberoptic guidance or a bougie with ETCO2 confirmation is the safer approach.
• Dual-route oxygenation: In the crashing patient, temporize by oxygenating through both the mouth and the stoma, often with two operators, before choosing between trach troubleshooting and oral intubation.

Bleeding From the Tracheostomy

• Most feared bleeding cause: Tracheoinnominate artery fistula is rare with modern low-pressure cuffs but remains the diagnosis you cannot miss when significant bleeding appears at a trach site.
• High-risk time window: The danger period for tracheoinnominate fistula is roughly 3 days to 6 weeks after placement, making recent tracheostomy bleeding especially concerning.
• Herald bleed warning: About 50% of tracheoinnominate fistulas announce themselves with a small sentinel bleed before catastrophic hemorrhage, so minor bleeding should not reassure you.
• Early source assessment: If the patient is stable enough, slightly withdrawing the tube or using a fiberoptic scope may localize bleeding near the stoma, while ENT evaluation remains the key next step.
• Temporizing hemorrhage control: Emergency control starts with overinflating the trach cuff to tamponade bleeding; if that fails, intubation from above plus digital compression against the manubrium can be lifesaving. We get into the rescue mechanics in the episode.

References:

1. Common Tracheostomy Issues. Core EM. Accessed February 23, 2024. https://coreem.net/core/common-tracheostomy-issues/
2. Weingart S. EMCrit 195 - Management of Tracheostomy (Trach) and Laryngectomy Emergencies. EMCrit Project. Published March 20, 2017. Accessed February 23, 2024. https://emcrit.org/emcrit/tracheostomy-emergencies/
3. Morgenstern J. Respiratory distress in the patient with a tracheostomy (update). First10EM. Published July 25, 2018. Accessed February 23, 2024. https://first10em.com/tracheostomy/
4. Nickson C. Respiratory distress in Tracheostomy Patient. Life in the Fast Lane LITFL. Published January 1, 2019. Accessed February 23, 2024. https://litfl.com/respiratory-distress-in-tracheostomy-patient/
5. Nickson C. Tracheostomy. Life in the Fast Lane • LITFL. Published February 4, 2019. Accessed February 23, 2024. https://litfl.com/tracheostomy/
6. Nickson C. Tracheostomy Complications. Life in the Fast Lane • LITFL. Published January 1, 2019. Accessed February 23, 2024. https://litfl.com/tracheostomy-complications/
7. Bontempo LJ, Manning SL. Tracheostomy Emergencies. Emerg Med Clin North Am. 2019;37(1):109-119. PMID: 30454773
8. McGrath BA, Bates L, Atkinson D, and Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia 2012; 67: 1025-41.  PMID: 22731935