Management of Subcutaneous Emphysema Post-Tracheostomy

Initial Assessment and Immediate Actions

The American College of Surgeons and other medical guidelines recommend immediately assessing tracheostomy tube patency by passing a soft suction catheter through the tube, and removing the tube without delay if it is blocked or displaced, as a blocked or displaced tube can act as a foreign body forcing air into tissue planes and must be removed to prevent life-threatening complications 1, 2
The priority is determining whether the tracheostomy tube is patent and properly positioned, as subcutaneous emphysema typically indicates tube displacement, tracheal wall injury, or creation of a false passage during insertion 1
High-flow oxygen should be applied to both the face and tracheostomy stoma using two separate oxygen sources to maximize oxygenation regardless of which airway route is functional 1, 2
Any attached ventilation devices should be removed from the tracheostomy tube to allow direct assessment 1
A soft suction catheter should be passed through the tracheostomy tube to confirm patency, and the catheter must pass easily beyond the tube tip and into the trachea 1, 2
Waveform capnography should be applied immediately to confirm airway patency and guide subsequent interventions 1, 2
Pulse oximetry should be monitored continuously to assess response to interventions 1

The American Society of Anesthesiologists recommends never using gum-elastic bougies or stiff introducers for initial assessment, as these can create false passages if the tube is partially displaced, dramatically worsening subcutaneous emphysema and potentially causing pneumothorax or pneumomediastinum 1, 2

The tracheostomy tube should be removed immediately if the suction catheter will not pass through the tube, the patient continues to deteriorate despite oxygen administration, subcutaneous emphysema is present or worsening, or there is suspected tube displacement or blockage 1, 2
When faced with a deteriorating patient and an obstructed airway, a non-functioning tracheostomy tube offers no benefit with considerable potential for harm, and the blocked or displaced tube must be considered a foreign body in the trachea that must be removed 3, 4, 1

After removing the tracheostomy tube, both the upper airway (mouth) and the tracheostomy stoma should be reassessed, applying oxygen to both sites simultaneously 3, 1
Primary oxygenation options include applying bag-valve-mask ventilation to the face while occluding the stoma, or applying a pediatric facemask or laryngeal mask airway directly over the stoma 1, 2, 3

If effective oxygenation cannot be achieved with primary measures, advanced airway techniques are required, including oral intubation using a long, uncut endotracheal tube advanced beyond the stoma, or inserting a smaller tracheostomy tube or endotracheal tube through the stoma using fiberoptic guidance 3, 1, 2
All tube placements should be confirmed using waveform capnography to verify correct positioning 1, 2

Vigorous attempts at ventilation via a potentially displaced tracheostomy tube should be avoided, as this is the primary mechanism for worsening subcutaneous emphysema and can cause pneumothorax or pneumomediastinum 1, 2
Only gentle hand ventilation should be used after confirming tube patency with a suction catheter 1, 2
High airway pressures through a malpositioned tube can force air into the mediastinum and subcutaneous tissues, creating the pathophysiology of extensive surgical emphysema 3

Fiberoptic inspection of the tube while it remains in situ should only be considered if the patient is clinically stable and appropriate equipment and expertise are immediately available 3, 2

Patients with subcutaneous emphysema post-tracheostomy require close monitoring in a high-dependency or critical care setting with trained staff continuously monitoring until physiologically stable 1
An appropriately skilled anesthetist or airway specialist must be immediately available 1
A written emergency airway management plan should be in place and communicated to all staff 1