Management of a Desaturating Patient with Tracheostomy

Initial Assessment and Immediate Actions

The American Society of Anesthesiologists recommends immediately assessing tracheostomy patency by removing any attached devices and passing a soft suction catheter through the tube 1, 2, 3
Deliver high-flow oxygen to both the face and the tracheostomy stoma simultaneously using two separate oxygen sources 3
Apply waveform capnography immediately to assess ventilation and guide interventions 3
Check pulse oximetry to monitor response to interventions 3

Use only a soft suction catheter to test patency, as gum-elastic bougies or stiff introducers can create false passages if the tube is partially displaced 3, 4
The catheter must pass easily beyond the tube tip and into the trachea 3

Remove the tracheostomy tube without delay if the suction catheter will not pass, the patient continues to deteriorate, or there is suspected tube displacement or blockage 2, 3, 4

Apply bag-valve-mask ventilation to the face, occluding the stoma with a gloved finger or gauze to prevent air leak 2, 5
Consider using a supraglottic airway device or oral/nasal airway adjuncts as needed 5
If the upper airway is obstructed or uncertain, apply a pediatric facemask or laryngeal mask airway directly over the stoma 2, 5

Use a long, uncut endotracheal tube advanced beyond the stoma to bypass the anterior tracheal wall opening for oral intubation 2
Insert a smaller tracheostomy or endotracheal tube through the stoma, using fiberoptic guidance when available to ensure correct placement 2, 5
Confirm tube placement using waveform capnography 2

A size 6 tracheostomy is relatively small, and the stoma may be difficult to re-cannulate, especially if the tract is not mature 1
If the tracheostomy is recent (less than 7 days old), the stoma tract tissues will have recoiled, making replacement significantly more difficult 1

Never delay tube removal in a deteriorating patient to attempt fiberoptic inspection unless the patient is stable and equipment/expertise is immediately available 2
Never use stiff introducers or bougies for initial patency assessment, and never ventilate vigorously through an unconfirmed airway 3, 4

The American Society of Anesthesiologists recommends orotracheal intubation under direct laryngoscopy for patients with a recent tracheostomy, as the stoma tract is immature and prone to recoil, making blind replacement through the stoma dangerous 6
Patients with a fresh tracheostomy (< 7 days) have significantly recoiled tissues, making oral intubation a safer option to avoid creating false passages 6, 7

The use of a long, uncut endotracheal tube advanced beyond the stoma opening is recommended to bypass the anterior tracheal wall defect and establish a secure airway below the tracheostomy site, providing definitive airway control with confirmation via waveform capnography 6
This technique allows the stoma to be managed electively once the airway is secured, reducing the risk of complications 6

Blind insertion of an endotracheal tube directly through a fresh stoma carries substantial risk, including creating a false passage anterior to the trachea, which can be catastrophic 8, 6
Fiberoptic guidance through the stoma is ideal but requires immediate availability of equipment and expertise, which may not be present in the emergency department 6