Dislodged Tracheostomy Positioning Technique

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Tracheostomy tube placement has long been used to prolong ventilation and to treat upper airway obstruction and obstructive sleep apnea. Traditionally, tracheostomy tubes were placed via an open technique in the operating room; however, they are now also being performed in intensive care units via either open or percutaneous techniques.

It is estimated that 15%-20% of patients in intensive care units will require a tracheostomy. ^[1] Of these, approximately 20% will not survive until hospital discharge, in most cases because of underlying medical problems and not typically because of tracheostomy-related complications.

Shah et al (2012) performed a retrospective cohort study of over 113,000 tracheostomy patients and cited an overall 3.2% rate of complications. ^[2]

The following are among the many potential complications of a tracheostomy:

Bleeding

Early decannulation or tube dislodgement

Mucous plugging

Tracheoesophageal fistula

Persistent tracheocutaneous fistula

Tracheitis

Tracheal stenosis

Tracheoinnominate fistula

This topic focuses on tracheostomy tube dislodgement, which can happen in any patient. Factors that increase the risk for dislodgment, a potentially catastrophic problem, include the following:

Morbid obesity

Short or thick neck

Goiter

Prior radiation or surgery of the neck

Device connected to ventilator tubing

Patient movement or turning

Frequent coughing

Immediate postoperative period

Inadequately secured tubes

A multi-institutional study by Halum et al (2011) found a 0.8% accidental decannulation rate within the first postoperative week and a 1.2% accidental decannulation rate after one week. ^[3] Falimirski (2003) reported a higher displacement rate (7%), stating that these incidents usually occur within 72 hours of surgery. ^[4]

Quick recognition of a dislodged tracheostomy tube is extremely important, as it can be life threatening owing to inadequate ventilation. Complications of a dislodged tube include the following: ^{[5, 6]}

Loss of airway

Pneumothorax

Subcutaneous emphysema

Pseudotract formation

Stomal stenosis

Tracheoinnominate fistula

Sternoclavicular osteomyelitis

Signs of tracheostomy tube dislodgement include the following:

Increased work of breathing

Noisy breathing

Respiratory failure

Voice changes (if able to phonate, not being mechanically ventilated)

Subcutaneous emphysema

Obvious malposition of the flange/tube

Visible cuff in the tracheostoma

Change in respiratory dynamics of ventilated patient (increased peak pressures, decreased tidal volumes, or loss of end-tidal CO₂ measurements)

Inability to pass a suction catheter

Inability to hear breath sounds on auscultation

An inability to pass a suction catheter through the tube is a clear indication of (1) tube blockage by mucous plugging or granulation tissue or (2) improper position. A tracheostomy tube through which air cannot pass needs to be replaced as quickly as possible, especially in patients with upper airway obstruction or ventilator dependence.

A dislodged tracheostomy tube may be demonstrated on chest radiography as a radiopaque tube that is not positioned in the lumen of the trachea. However, the logistics required to obtain this test are often too burdensome for it to be practically helpful, especially in unstable settings. Tube malposition can also be confirmed with flexible fiberoptic endoscopy, but this requires specialized equipment and suffers from similar logistical issues. Hence, especially in urgent settings, this problem is recognized clinically.

Some patients with dislodgment may be able to pass air around the tube. In these situations, there is more time to prepare for a tracheostomy tube change. The best success in replacing a dislodged tracheostomy tube is achieved by always being prepared with the proper equipment. Every patient with a tracheotomy should carry a replacement tube of the appropriate size and one size smaller with them at all times (eg, an 8 and a 6) and have portable suction available. The smaller tube is used if there is difficulty inserting the normal tube. When a tube is removed from the tracheostoma, even a well-healed tract can significantly narrow over several hours, so efficient replacement of the tube is important.

A dislodged tracheostomy tube (see the video below) needs to be replaced expeditiously. At the same time, if the patient has a stable respiratory status, all appropriate equipment should be made available prior to the tracheostomy tube change. A partially dislodged tube may still provide the patient with an airway, and its removal could worsen the patient’s condition.

Only personnel properly trained in tracheostomy tube replacement should change a dislodged tube, especially when the tract is new. However, the procedure is straightforward and can be attempted by many medical personnel. Tracheostomy tube changes prior to 7 days postoperatively are potentially more dangerous. In general, the operating surgeon should perform the first tube change, as he/she can assess if the tract is well healed and that future tube changes can be performed with ease. In emergent situations, the most experienced person available should replace the tracheostomy tube. Physicians, nurses, and respiratory therapists may be trained how to perform standard tracheostomy tube changes.

In patients who have a tracheostomy for upper airway obstruction, tracheal stenosis, head and neck cancer, or facial trauma, the change should be performed when someone who is trained in difficult airway management is available. Orotracheal intubation may not be possible to perform in some cases; however, one should always be prepared to attempt it, if needed.

Because most tracheostomy tubes become dislodged in the immediate postoperative period, some intraoperative steps can be taken to decrease the risk.

The tracheostomy tube should be secured in place with both sutures and string ties. The ties should fit snugly around the neck so as not to allow the tube to move in and out of the newly created tracheal opening. Stay-sutures are also helpful in open procedures to pull the trachea more superficially if the tube falls out, making replacement easier. ^[7] These should clearly be labeled up/down or left/right depending on where they are placed in relation to the hold created in the trachea.

A Björk flap may also help to create a more defined tract in the immediate postoperative period. ^[8] This, however, cannot be performed in pediatric tracheotomies. ^[9]

In morbidly obese patients, it is important to use an appropriately sized tracheostomy tube. This may mean using a soft flexible tube with an adjustable flange, such as a Bivona template (which can then provide measurements for a customized tracheostomy tube) or a tube with an extra-long proximal portion.

Appleby I. Tracheostomy. Anesthesia and intensive care medicine 6. 2005. 220-2.

Shah RK, Lander L, Berry JG, Nussenbaum B, Merati A, Roberson DW. Tracheotomy outcomes and complications: A national perspective. Laryngoscope. 2012 Jan. 122(1):25-9. [Medline].

Halum SL, et al. A multi-institutional analysis of tracheotomy complications. Laryngoscope. 2011 Dec. 122(1):38-45.

Falimirski ME. Tracheostomy. Operative techniques in general surgery. 2003. 134:

Singhal P, et al. Tracheostomy pseudotract. J Bronchol. 2005. 12(1):37-8.

Hashmi A, Zerfas D, Baciewicz FA Jr. Sternoclavicular osteomyelitis: a new complication of misplaced tracheostomy tube. Ann Thorac Surg. 2011 Dec. 92(6):2240-1. [Medline].

Burke A. The advantages of stay sutures with tracheostomy. Ann R Coll Surg Engl. 1981 Nov. 63(6):426-8. [Medline].

Price DG. Techniques of tracheostomy for intensive care unit patients. Anaesthesia. 1983 Sep. 38(9):902-4. [Medline].

Lyons MJ, Cooke J, Cochrane LA, Albert DM. Safe reliable atraumatic replacement of misplaced paediatric tracheostomy tubes. Int J Pediatr Otorhinolaryngol. 2007 Nov. 71(11):1743-6. [Medline].

Device

Use

Ambu-bag with face mask

Allows ventilation via nose/mouth if stoma covered until tube can be replaced

Obturator

Replace current tube with graduated, smooth tip instead of blunt end; decreased risk of false passage creation

Tracheostomy tube (current size and one size smaller)

Replace a plugged tube; replace a tube with broken cuff; replace tube into narrowed stoma

Suction catheter

Suction through tube to confirm placement and can help identify tract; can be used as guide for replacement of tube

Water-based lubricant

Allows gentle reinsertion of tube or other devices to manipulate stoma

Endotracheal tube (cuffed)

Variety of sizes available to place through narrowed tract; can also provide increased length to bypass stenosis, granulation tissue, tumor; can be used if orotracheal intubation is necessary

Flexible fiberoptic endoscope

Can be used to identify tract versus false passage; can be used to confirm proper positioning of tube after replacement; can be used to identify presence of granulation tissue or tumor in trachea; tube can be replaced over endoscope via Seldinger technique

Cook catheter

Can be used as guide for replacement of tube; lumen of catheter allows jet ventilation

Cricoid hook

Elevates trachea toward skin in new tracheotomies

Army-Navy retractors

Can pull soft tissue away from tracheostoma, improving visualization

Trousseau dilator or nasal speculum

Use to dilate tracheostoma

Tracheostoma dilators

Graduated dilators can be passed to increase size of stoma; a lumen allows jet ventilation

Mayo scissors

Cut ties, sutures, or obstructing soft tissue

Scalpel

May be necessary for re-entry into a closed stoma

Headlamp

Improves visualization of stoma

Victoria E Varga-Huettner, MD Resident Physician in Otolaryngology-Head and Neck Surgery, University of Chicago Hospitals

Victoria E Varga-Huettner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association

Disclosure: Nothing to disclose.

Jayant M Pinto, MD Assistant Professor, Section of Otolaryngology-Head and Neck Surgery, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Jayant M Pinto, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Geriatrics Society, American Rhinologic Society, American Society of Human Genetics, Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Nothing to disclose.

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.

Dislodged Tracheostomy Positioning Technique

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