Tracheostomy care and emergencies: SAQ

This infant has a tracheostomy emergency: a child with a tracheostomy who is distressed and desaturating has a blocked or displaced tube until proven otherwise. Two features raise the stakes. A speaking valve is in place, which completely occludes the tube on expiration and can itself cause the obstruction, and the tracheostomy is only 3 days old, so the stoma tract is immature and reinsertion after any displacement carries a high risk of a false passage. [1]

Question 1 (10 marks)

Describe your immediate emergency management of this infant, in the correct order. [1]

Call for help and immediately give high-flow oxygen to both the face and the tracheostomy stoma, because you do not yet know which route is patent and covering both loses nothing. Remove the speaking valve at once, since a valve occludes the tube and is a common and instantly reversible cause of obstruction, and remove the inner cannula if the tube has one, then reassess breathing. [2]

Pass a suction catheter down the tube to test patency and clear secretions. If the catheter passes, the tube is patent, so suction, ventilate, and reassess. If the catheter will not pass, the tube is blocked or displaced, so deflate the cuff if present and remove the tracheostomy tube, because a tube that cannot be cleared only occupies the airway. [1]

After the tube is removed, reassess breathing and oxygenate. Because this infant has a normal upper airway, cover the stoma and give oxygen or bag-mask ventilation via the face in the usual way, or alternatively deliver oxygen or ventilation directly to the stoma with a small mask or supraglottic airway. Only once the infant is oxygenated should a controlled attempt at re-cannulation be made. [1]

Question 2 (10 marks)

The tracheostomy tube comes out completely during your assessment. Explain why the age of the tracheostomy changes your approach to reinsertion, and outline how you would proceed. [1]

The tracheostomy was formed only 3 days ago, so the stoma tract is immature and has not yet healed into a stable, epithelialised channel from skin to trachea. In an immature tract the tissue planes collapse when the tube is out, and blind reinsertion can drive the tube into the pretracheal space, creating a false passage that ventilates nothing while appearing to be correctly placed. A fresh tracheostomy is therefore a fundamentally more dangerous device than a mature one. [3]

Because of this, the priority after decannulation of a fresh stoma is to oxygenate the infant rather than to force a tube back in. Use the intact upper airway: cover the stoma and provide bag-mask ventilation or oxygen via the face, and be prepared to secure the airway by oral endotracheal intubation if ventilation is inadequate. Call the surgical team urgently, because stay sutures placed on the trachea at operation can be used to pull the trachea forward and reopen the tract under direct vision for a safe reinsertion. [1]

If reinsertion is attempted, it should be gentle and guided, using the same size tube and then a smaller one, and railroading over a suction catheter to guide the tube along the tract. Correct placement must be confirmed by air movement, chest rise, and a capnography trace rather than assumed from the tube being in the neck, and if there is any doubt the tube should be removed and the child oxygenated from above while surgical help is obtained. [1]