Dr. E.H asks, “What are the most common emergencies with tracheostomies?”
Answer: The two most common emergencies with tracheostomies are mucus plugs and inadvertent decannulation/displacement. Mucus plugs occur because of inadequate hydration and inactivity, resulting in thickening and stasis of secretions. Initial presenting symptoms of mucus plugs are respiratory distress and/or desaturation. Treatment involves removing/cleaning inner cannula, vigorous suctioning, and/or changing the entire tracheostomy tube. Occasionally none of these measure will relieve the obstruction. In that case, the mature tracheostomy tube may be removed and the stoma suctioned directly, or bronchoscopy may be necessary to relieve obstruction.
Inadvertent decannulation or dislodgement can result from inadequate security of the tube, especially when it is combined with patient movement or a tube that is too short. Decannulation is easy to observe, in that the tube is completely absent from the stoma; however, dislodgement is not so obvious. Sometimes, the tube is still within the stoma, and so, appears in place; however, it is removed from the tracheal lumen. In an immature tracheostomy, this situation is an emergency. The tube should be removed, the stoma covered, and the patient intubated from above. A tracheal revision can then be performed under more controlled circumstances.
In a mature tracheostomy, dislodgement is recognized by a “high-riding tube” (one that cannot be pushed in as far as the neck flange), inability to pass a suction catheter, and the alert patient may be able to phonate clearly. In this case, the tube may be withdrawn and reinserted, taking care to assess the location and orientation of the tracheal stoma.
L.L.M.