The COVID-19 era has forced many healthcare workers with no prior experience regarding tracheostomy tubes (“trachs”) to learn how to handle them. These airways can be placed surgically or percutaneously at the bedside. In either case, the tubes are secured using ties and/or sutures at least for the first week (“fresh trach precautions”); however, they can inadvertently become dislodged and fall out. So what do you do?
If the patient has a chronic trach, it’s likely that the tract has granulated well enough to simply replace the tube. I usually use a bougie/Cook catheter, manually open the stoma with my finger tip, pass the airway catheter, and then thread the trach tube over. I have the curved portion face posteriorly and rotate it anteriorly as soon as it’s pushed into the airway.
If the trach is fresh and the patient is rapidly decompensating after dislodgment, I’ll cover the tracheostomy stoma with a large Tegaderm, mask ventilate the patient with an AMBU-bag, and proceed to orally/nasally intubate the trachea. If I’m fortunate to have a bronchoscope around, I’ll thread a trach tube onto the scope, visualize tracheal rings as I enter the stoma, and advance the trach tube into the airway UNDER DIRECT VISUALIZATION. This is the key! Blindly replacing a trach with a fresh tract can lead to the creation of a false lumen (ie, the trach tube is really between fascial/muscle layers instead of the airway) which can complicate securing the actual airway, massive crepitus, and ultimately death. Call for help!
Drop me a comment below with your experiences regarding dislodged tracheostomy tubes!