Management of Surgical Emphysema Post-Tracheostomy

Initial Assessment and Immediate Actions

The priority is determining whether the tracheostomy tube is patent and properly positioned, as surgical emphysema often indicates tube displacement or tracheal wall injury, according to Praxis Medical Insights 1, 2
Apply high-flow oxygen simultaneously to both the face and tracheostomy stoma using two separate oxygen sources, as recommended by Praxis Medical Insights 1, 2
Remove any attached ventilation devices from the tracheostomy tube, as suggested by Praxis Medical Insights 2
Pass a soft suction catheter only through the tracheostomy tube to assess patency—the catheter must pass easily beyond the tube tip and into the trachea, according to Praxis Medical Insights 1, 2
Apply waveform capnography immediately to confirm airway patency and guide interventions, as recommended by Praxis Medical Insights 1, 2
Monitor pulse oximetry continuously, as suggested by Praxis Medical Insights 2

Never use stiff introducers or gum-elastic bougies for initial assessment, as these can create false passages if the tube is partially displaced, worsening the surgical emphysema, according to Praxis Medical Insights 1, 2

Remove the tracheostomy tube immediately if the suction catheter will not pass through the tube, as recommended by Praxis Medical Insights 2
Remove the tracheostomy tube immediately if the patient continues to deteriorate despite oxygen administration, according to Praxis Medical Insights 2
Remove the tracheostomy tube immediately if subcutaneous emphysema is present or worsening, as suggested by Praxis Medical Insights 1
Remove the tracheostomy tube immediately if there is suspected tube displacement or blockage, according to Praxis Medical Insights 2

After removing the tracheostomy tube, reassess both the upper airway (mouth) and the tracheostomy stoma, applying oxygen to both sites, as recommended by Anaesthesia and Praxis Medical Insights 3, 1
Apply bag-valve-mask ventilation to the face while occluding the stoma with a gloved finger or gauze to prevent air leak, according to Praxis Medical Insights 1, 2
Apply a pediatric facemask or laryngeal mask airway directly over the stoma, occluding the nose and mouth if there is a large leak, as suggested by Anaesthesia and Praxis Medical Insights 3, 1

If effective oxygenation cannot be achieved with primary measures, advanced airway techniques are required, such as oral intubation using a long, uncut endotracheal tube advanced beyond the stoma to bypass the anterior tracheal wall opening, according to Anaesthesia and Praxis Medical Insights 3, 1, 2
Insert a smaller tracheostomy tube or endotracheal tube through the stoma, using fiberoptic guidance when available to ensure correct placement and avoid creating false passages, as recommended by Anaesthesia and Praxis Medical Insights 3, 1, 2
Confirm all tube placements using waveform capnography, according to Anaesthesia and Praxis Medical Insights 3, 1, 2

Avoid vigorous attempts at ventilation via a potentially displaced tracheostomy tube, as this is a primary mechanism for worsening surgical emphysema and can cause pneumothorax or pneumomediastinum, according to Praxis Medical Insights 1
Only use gentle hand ventilation after confirming tube patency with a suction catheter, as recommended by Praxis Medical Insights 1
High airway pressures through a malpositioned tube can force air into the mediastinum and subcutaneous tissues, according to Anaesthesia 4

False passage creation during insertion can lead to surgical emphysema, according to Praxis Medical Insights 2
High ventilation pressures forcing air through injured tissue planes can contribute to surgical emphysema, as suggested by Anaesthesia 4

Patients with surgical emphysema post-tracheostomy require close monitoring in a high-dependency or critical care setting, with trained staff continuously monitoring the patient until physiologically stable, according to Anaesthesia 5, 4
An appropriately skilled anesthetist or airway specialist must be immediately available, as recommended by Anaesthesia 5, 4
A written emergency airway management plan should be in place and communicated to all staff, according to Anaesthesia 5, 4