Management of Post-Tracheostomy Subcutaneous Emphysema

Initial Assessment and Management

The American Society of Anesthesiologists recommends assessing both the upper airway and tracheostomy stoma for patency by looking, listening, and feeling for airflow, and applying high-flow oxygen to both the face and tracheostomy stoma if available, with a strength of evidence level of high 3, 4
The Anaesthesia society suggests using waveform capnography when available to confirm airway patency, with a moderate level of evidence 3, 4
Passing a suction catheter through the tracheostomy tube can help establish if the airway is patent along its length and perform therapeutic suction if needed, with a high level of evidence 2
Avoid using stiff introducers or bougies as these can create false passages if the tube is partially displaced, with a moderate level of evidence 2

If subcutaneous emphysema is present or worsening, the American College of Surgeons recommends removing the tracheostomy tube immediately, even with concerns about difficult airways, with a high level of evidence 1, 2
After tube removal, reassess both airways and apply oxygen to both face and stoma, with a moderate level of evidence 2, 5
Emergency oxygenation options include via oro-nasal route or via tracheostomy stoma using a pediatric facemask or laryngeal mask airway applied to the skin, with a moderate level of evidence 1, 5

If the patient fails to improve after removing the tracheostomy tube, the American Thoracic Society recommends oral intubation may be possible using a long tube advanced beyond the stoma, or attempt intubation of the tracheostomy stoma with a smaller tracheostomy tube or tracheal tube, with a moderate level of evidence 5
For patients with known difficult airways, consider fiberoptic inspection of the tube while it remains in situ, but only if appropriate equipment and expertise are immediately available, with a low level of evidence 5

The American Association for Respiratory Care recommends avoiding vigorous attempts at ventilation via a potentially displaced tracheostomy tube, and only use gentle hand ventilation after confirming tube patency with a suction catheter, with a high level of evidence 2