Dislodged Tracheostomy Positioning Technique

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.

Tracheostomy tube dislodgement has a high rate of mortality if occuring in the early post-operative period due to the immaturity of the tracheostoma. The risk of pseudotract formation due to forceful attempts at reinsertion is greater and loss of the airway can have devastating effects. Quick identification of the complication, in addition to readily available supplies and personnel with adequate experience, is critical to ensuring good outcomes.

Elements of Informed Consent

Informed consent may not always be possible to obtain immediately prior to tube reinsertion or repositioning, as the patient may be in distress, requiring quick action. However, the possibility of tube dislodgement and possible loss of airway both during and after the surgical insertion of the tube should be explained to the patient or their legal representative prior to performing the tracheotomy.

Equipment

A dislodged tracheostomy tube often requires emergent replacement. Therefore, it is important to have all of the necessary equipment readily available (see Table 1).

Table 1. Devices to Have Available During Replacement of a Dislodged Tracheostomy Tube (Open Table in a new window)

Anesthesia

No anesthesia is required for replacement of a dislodged tracheostomy tube. If a large amount of manipulation of the tracheostoma is necessary, such as with dilators, 4% topical lidocaine may be sprayed at the site to decrease irritation. Injection of local anesthesia around the stoma should be avoided, as it may cause a temporary narrowing of the opening as it infiltrates surrounding tissue, although a judicious amount may alleviate discomfort from dilation, if needed.

Positioning

The patient should be placed in the supine position with the neck gently extended by placement of a shoulder roll.

After the dislodged tracheostomy tube has been replaced, a suction catheter should pass easily past the distal end of the tracheostomy tube and airway secretions suctioned for confirmation. Tube positioning can be confirmed by passing a fiberoptic endoscope through the tube to visualize tracheal rings and carina or by obtaining a chest radiograph.

A stethoscope should immediately be used to auscultate bilateral breath sounds. A tube that was difficult to reinsert should be tightly secured with consideration to placing string ties and/or stitches. The tube should be treated as a freshly placed tracheostomy tube, and 5-7 days should pass prior to its next change. If the tube was very difficult to insert, the next tube change should be performed in a monitored setting. Changing it in the operating room should be considered, as a variety of airway equipment is available.

Some dislodged tracheostomy tubes are replaced using standard tube-change steps. At times, the dislodged tube is difficult to reinsert, which can quickly become an emergency. (See the videos below.)

Importantly, orotracheal intubation should be considered in patients in respiratory distress when the tracheostomy tube cannot be quickly reinserted. A stoma will narrow over time as a tube is out of position, making tube reinsertion more difficult.

Various techniques, including placing the tube over a scope, suction catheter, or Cook catheter, may be used to reinsert a tube. Tubes with a smaller outer diameter or a longer length should be used in some cases. Various dilation techniques may be used to help reopen a stoma that has stenosed. Patients and their caregivers should always be prepared for potential tracheostomy tube dislodgement.

Well-healed tract

When a tracheostomy tube has become dislodged, it is important to follow all of the steps for a routine tracheostomy change, including having all of the proper equipment available. Good lubrication of the tracheostomy tube is necessary to minimize any trauma with reinsertion. A headlamp and good overhead lighting provide the best visualization of the tract.

For the proper technique to perform a routine tube change, see the article Tracheostomy Tube Change.

Tract that is difficult to visualize

When it is difficult to follow the tract, certain measures should be taken to ensure the tube is not placed into a false passage. A suction catheter can be placed through the tract and its proper positioning confirmed by suctioning secretions from the airway. The suction catheter should be either a red rubber or nonlatex soft catheter or a nonlatex rigid catheter so that a tracheostomy tube can be placed over it and guided into the airway via a Seldinger technique. If a Cook catheter is available, it could also be used as a “guidewire.” Both techniques allow for temporary jet ventilation through the catheter if tube replacement is difficult.

A flexible fiberoptic endoscope can be the most useful tool for replacement of a dislodged tracheostomy tube. It can be passed directly through the stoma to find a passage into the trachea. A false tract is seen as a dead-end. Any granulation tissue present in the trachea is also visible. The tracheostomy tube may be placed over the scope, which can be used as a guide for reinsertion of the tube once the proper tract is found. Proper placement is immediately confirmed by visualization of tracheal rings and the carina.

Tight stoma

The size of the tracheostomy tube being inserted is also important. Tubes are measured by their inner and outer diameters and length. The outer diameter and the length of the tube are most important in determining if the tube will fit in the stoma and sit in the proper position in the trachea. If a tube is difficult to insert, a tube with one size smaller outer diameter should be attempted. In patients who have a goiter, neck mass, or an obese neck, a longer tracheostomy tube may be necessary. This could be an extra long tube, usually in the proximal dimension; a flexible tracheostomy tube template with an adjustable flange; or, in an emergency situation, an endotracheal tube.

In patients who have had a tracheostomy tube that is dislodged or malpositioned for some time, the tract may have started to narrow or even close. If the tract is just narrowed, an attempt can be made to dilate it. Tracheostomy dilators are graduated in size and have a lumen through which air can pass. They should be well lubricated and passed serially to dilate the stoma to a diameter that can accommodate a properly sized tracheostomy tube.

In children, urethral dilators, which are much smaller, can be used to dilate the stoma. Dilators should not be used in fresh tracheotomies but reserved for patients with already well-healed tracts. A nasal speculum can also be used to slowly dilate a well-healed tract. In patients with small tracheotomies, a well-lubricated obturator can be passed first to confirm a patent tract and then the tracheostomy tube with the obturator inside may be more easily inserted.

All manipulation of the tracheostoma can cause bleeding or swelling, which may worsen the clinical situation. Prior to attempting these steps, a staff member who could orally intubate the patient should be available, as well as all airway emergency equipment.

Inability to reinsert the tube

If the tract is no longer patent and the patient is in distress, orotracheal intubation is necessary. After securing the airway in this manner and placing the patient on mechanical ventilation, the tracheostomy tube is replaced. If the patient has an upper airway that precludes a safe intubation, emergent surgical revision of the stoma should be performed in the operating room.

Special circumstances

Reinsertion of dislodged tubes in patients with head and neck cancer may be complicated and difficult. Radiation can increase friability of the stoma, resulting in bleeding with manipulation or wound breakdown, which may cause separation between the trachea and skin. In patients who have not completed treatment or in whom treatment has failed, tumor may surround the stoma, involve the trachea, or obstruct the upper airway, making orotracheal intubation impossible. All resources for difficult airway management should be used.

At times, laryngectomy patients wear a tracheostomy tube in their laryngectomy stomas, which may be confusing to health care practitioners. Replacement of the tube should be easy unless there is stomal stenosis, mucous plugging of the trachea, or tumor recurrence. The risk of false-tract formation is not the same as it is in tracheotomy patients. Practitioners should be aware that laryngectomy patients cannot be orotracheally intubated.