Diagnostics & Procedures · Topic 10 of 16

Tracheostomy Management

Procedures · tracheostomy care

Tracheostomy Management

A fresh trach that falls out is managed from above; a sentinel bleed weeks after placement is a tracheoinnominate fistula until proven otherwise.

Key numbers

Trach out < 7 days: intubate orally< 7 days

Trach bleed: think tracheoinnominate fistula3 days – 6 weeks

Cuff pressure 20–30 cm H₂O20–30 cm H₂O

01 · DoTrach out < 7 days: intubate orally

In the first 7 days the tract is immature: do not blindly reinsert a dislodged tube (false passage) — cover the stoma, oxygenate by bag-mask, intubate orally, and call the team that placed it.

02 · Don't confuseLaryngectomy: the stoma is the only airway

First establish whether the patient has a tracheostomy (upper airway intact, can be oxygenated and intubated from above) or a total laryngectomy, where the neck stoma is the only airway and oral intubation is impossible.

03 · Watch forTrach bleed: think tracheoinnominate fistula

Bleeding 3 days to 6 weeks after tracheostomy, often after a brief sentinel bleed, suggests a tracheoinnominate artery fistula: hyperinflate the cuff, then compress through the stoma (Utley maneuver) and call surgery.

Presentation

What you'll see

Signs of dislodgement: lost ETCO₂, can't suctionSuspect displacement with hypoxemia or distress, loss of ETCO₂ waveform or exhaled volume, a suction catheter that will not pass, speech around an inflated cuff, subcutaneous emphysema, or a raised flange.

Diagnosis & monitoring

Work-up

Cuff pressure 20–30 cm H₂OMeasure cuff pressure with a manometer at least every shift and keep it at 20–30 cm H₂O: over-inflation causes tracheal necrosis, stenosis and tracheoesophageal fistula; under-inflation allows microaspiration and lost tidal volume.

Decannulate: off vent, cough, secretions, swallowDecannulation candidates are off the ventilator on minimal oxygen, alert, with an effective cough, manageable secretions and a safe swallow, and tolerate capping (typically 24–48 hours) or a speaking valve for most of the day.

Do right now

In this order

First moves

Blocked trach: inner cannula, suction, deflate, remove

→

Laryngectomy: the stoma is the only airway

→

Trach out < 7 days: intubate orally< 7 days

→

Mature tract: reinsert through the stoma

Why each step

Blocked trach: inner cannula, suction, deflate, removeBlocked trach: give oxygen to face and stoma; remove any cap, speaking valve and inner cannula; pass a suction catheter. If it will not pass, deflate the cuff; if still failing, remove the tube.

Laryngectomy: the stoma is the only airwayFirst establish whether the patient has a tracheostomy (upper airway intact, can be oxygenated and intubated from above) or a total laryngectomy, where the neck stoma is the only airway and oral intubation is impossible.

Trach out < 7 days: intubate orallyIn the first 7 days the tract is immature: do not blindly reinsert a dislodged tube (false passage) — cover the stoma, oxygenate by bag-mask, intubate orally, and call the team that placed it.

Mature tract: reinsert through the stomaWith a mature tract (beyond about 7 days), reinsert a same-size or smaller tracheostomy tube (or a 6.0 cuffed endotracheal tube) through the stoma, ideally over a bougie or scope; confirm with ETCO₂.

Management

Orders

Deflate the cuff before cappingBefore capping, fully deflate the cuff or downsize to a smaller, often cuffless tube — a cap or speaking valve on a tube with an inflated cuff blocks all airflow and has caused deaths.

Red flags & don'ts

Avoid harm

Speaking valve only with the cuff deflated avoidA one-way speaking valve (Passy-Muir) is used only with the cuff fully deflated or a cuffless tube; remove it at once if the patient develops airway obstruction or cannot speak.

Any trach bleeding needs urgent review complicationEarly bleeding (first 4 days) is usually skin, thyroid or anticoagulant-related and settles with pressure or packing; later bleeding, or more than 10 mL, needs urgent senior review — it may herald an arterial fistula.

Late stridor: tracheal stenosis complicationTracheal stenosis — at the stoma, the cuff site or subglottis — is the main late complication, presenting with dyspnea or stridor weeks to months after decannulation; high cuff pressure and obesity raise the risk.

The rules

Know these

Early tube changes by the placing teamThe placing team makes tube changes in the first 10 days — in daytime, with light, suction and a spare tube ready — and the tube stays sutured to the skin for 7 days.

Early trach does not improve survivalTracheostomy suits patients expected to need prolonged ventilation, but early placement does not lower mortality: in TracMan, 30-day mortality was 30.8% with tracheostomy within 4 days vs 31.5% after 10 days.

Dislodged trach: fresh or mature tract?

Commonly confused

Tract	Immature — closes fast, false passage likely
First move	Cover the stoma; bag-mask and intubate orally
Confirm	ETCO₂ after orotracheal intubation
Call	Surgeon or airway team who placed it

More detail

Reference

Show 5 reference facts

Dislodgement risks: the first 7 days, obesity or a short thick neck, goiter, delirium, coughing, ventilator tubing traction and a tube too short for the neck — extended-length tubes suit deep tracheas.

A tracheoesophageal fistula (under 1%) from cuff or feeding-tube erosion presents with copious secretions, aspiration of feeds, a persistent cuff leak or gastric distension.

In an emergency, cricothyrotomy is faster and safer than tracheostomy; tracheostomy is preferred for long-term ventilation, often percutaneously at the bedside under bronchoscopic guidance.

Routine care: clean or change the inner cannula regularly (it prevents tube occlusion), humidify inspired gas, and keep a same-size and a smaller spare tube, suction and a bedhead airway sign at the bedside.

In TIF bleeding unresponsive to cuff hyperinflation, slowly withdraw the tube, place a finger through the stoma and compress the innominate artery anteriorly against the sternum, keeping pressure until the operating room.

Pearl

Fresh trach out? Don't fight the stoma — cover it and intubate from above.

Sources · Cheatham ML, Brown J. Tracheostomy Dislodgement — Surgical Critical Care Evidence-Based Guideline, Orlando Regional Medical Center (2020) · Cipriano A et al. An overview of complications associated with open and percutaneous tracheostomy procedures. Int J Crit Illn Inj Sci 2015;5:179–188 (PMC4613417) · Singh RK, Saran S, Baronia AK. The practice of tracheostomy decannulation — a systematic review. J Intensive Care 2017;5:38 (PMC5477679) · Merck Manual Professional — Hemoptysis (Dezube R, rev. Nov 2025; tracheal-innominate artery fistula 3 days to 6 weeks after tracheostomy) · Tarver EM et al. Tracheoinnominate Artery Fistula (simulation case). J Educ Teach Emerg Med 2021;6:S62–S86 (PMC10332689) · Young D et al. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA 2013;309:2121–2129 (abstract via Europe PMC) · Merck Manual Professional — Surgical Airway (rev. Jun 2026) · Tintinalli's Emergency Medicine — Complications of Airway Devices (chapter summary, Prince of Wales Hospital ED, SESLHD) · National Tracheostomy Safety Project — Emergency tracheostomy management (patent upper airway algorithm), from McGrath BA et al. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia 2012;67:1025–1041 · National Tracheostomy Safety Project — Tracheostomy emergencies: bleeding (based on TRAMS, Austin Health) · National Tracheostomy Safety Project — Basic care (adults): inner cannula care; kit checklist and daily checks · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).