In the algorithm below simply click on the area in the flow chart to bring up the procedure for each step.
Additional algorithms are available in the book Tracheostomies: The Complete Guide:
- Downsizing Algorithm
- Cuff Leak Algorithm
- Phonation Algorithm
B. Assess patient for signs and symptoms of distress: stridor, use of accessory muscles, retractions, anxiety, other signs of air hunger, desaturation, change in level of consciousness.
Is Tracheostomy Mature or Immature?
B. If the tracheostomy is immature (< 5 days), the tube could be dislodged from the tracheal lumen. C. Depending on the maturity of the stoma, the situation will be handled differently.
- If the stoma is immature, the likely cause of distress is dislodgement from the tracheal stoma.
- If the stoma is mature, the likely cause of distress is mucus plug causing obstruction of the airway.
Check Inner Cannula for Obstruction
B. If the obstruction is in the inner cannula, it should be cleaned or replaced with a new disposable inner cannula.
C. If the inner cannula is clear, there is still probably a mucus plug further down in the airway.
B. Fluids should be optimized to ensure that secretions are thin and mobile.
C. The patient should be started on an aggressive program of physical mobility.
Can Suction Catheter of Appropriate Size be Passed Easily With Return of Tracheal Secretions?
B. If a suction catheter of appropriate size cannot be passed; one should not automatically use a smaller suction catheter. One should explore the cause of the apparent obstruction.
C. If the suction catheter can only be passed a few inches into the tracheostomy tube, the tube is likely dislodged from the tracheal lumen. In this case, one should use the obturator to guide the tube into place—or remove and replace the tracheostomy tube.
B. Monitor pulse oximetry greater than 92%, ABGs PaO2 of 60 or PaCO2 of 50 (or greater than 8 mm Hg of baseline).
C. Likely causes of a dislodged tracheostomy tube are a tube that is too short or not properly secured.
Lumen May be Partially or Completely Obstructed
B. If the tracheostomy tube has an inner cannula, it should be cleaned and/or replaced.
C. If the tracheostomy tube does not have an inner cannula, the entire tube should be removed and replaced, preferably to a tracheostomy tube with an inner cannula.
Is Patient Experiencing Relief of Symptoms?
B. Saline lavage may be used if other measures to suction thick secretions are ineffective.
C. If the tracheostomy tube was dislodged from the tracheal lumen, one should explore the cause of this dislodgement.
B. Ensure that the patient is adequately hydrated, ensure that tracheostomy care and cleaning of the inner cannula is occurring at least every 8 hours.
B. After changing the tube, if difficulty is still encountered, one should remove the tube and suction deeply and vigorously directly through the stoma.
C. If not contraindicated, the Heimlich maneuver can be done to bring a mucus plug into reach of the suction catheter.
Check Inner Cannula for Obstruction
B. First step is to check the inner cannula for visible obstruction.
B. Always ensure security of the tube with an immature tracheostomy tube. Secure ties of tracheostomy tube to ensure that no more than one finger fits under the ties.
Can Suction Catheter be Passed Easily Into Airway?
B. In an immature tracheostomy, one easy test of proper placement is to try to pass a suction catheter.
C. When the suction catheter can only be advanced a few centimeters before resistance is felt, inadvertent dislodgement can be assumed (false passage).
Tube May be in False Passage
B. Ventilate patient via face mask, using bag-valve-mask technique. Cover open stoma to avoid leak of air.
C. The patient may require intubation with an endotracheal tube.
B. Remove sources of traction and torque if present.
B. If stay sutures have been placed, they can be used to pull the stoma open. Traction can be used in an anterior (outward) direction, while also moving the sutures away from each other. This action should open the stoma to the surface of the skin.
C. If the patient is stable, bronchoscopy can be used to guide the tube into place and/or to assess and remove obstructing secretions within the airway.
B. Measures to prevent tracheostomy dislodgement include:
- Place a longer tracheostomy tube
- Check integrity and security of tracheostomy ties prior to any movement of the patient
- Remove traction or torque against the tracheostomy tube