Dislodged Tracheostomy Positioning Technique Technique

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.