A. Any patient with an established tracheostomy is likely to develop mucus plugs due to drying of secretions within the lumen of the tube.

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.

A. It usually takes 5-7 days for a mature tract to establish.

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.

A. If the patient has a mature stoma, the easiest first step to check obstruction is to check the inner cannula.

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 may be a mucus plug further down in the airway.

A. If the cause of the obstruction has been relieved, the patient should be assessed frequently to ensure that no further problems develop.

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.

A. If a suction catheter cannot be easily passed, secretions may be clogging the inner lumen of the tracheostomy tube.

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.

A. If the tracheostomy tube was dislodged from the tracheal lumen, one should explore the cause of this dislodgement.

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.

A. If the suction catheter cannot be easily passed, the lumen may be partially or completely obstructed with secretions.

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.

A. If unable to suction secretions from the tube, ensure that the secretions remain thin and mobile.

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.

A. If obstruction has been relieved, the goal should be to prevent a future obstruction from occuring.

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.

C. Tube may be defective or damaged. In case of continued respiratory distress, remove tube provide mask ventilation and orotracheal intubation.

A. If the patient is still obstructed after all of the previous maneuvers, one should change the entire tracheostomy tube. Many times, a mucus plug will be removed when the entire tube is removed.

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.

A. If there are signs of obstruction in an immature tracheostomy, the approach is completely different from that of a mature tracheostomy.

B. First step is to check the inner cannula for visible obstruction.

A. If the patient experiences immediate relief with removal of the inner cannula, it should be cleaned and replaced.

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.

A. When a patient with an immature tracheostomy has signs of obstruction, one must determine whether the cause is inadvertent decannulation or obstruction due to mucus plug.

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).

A. A patient in distress with an immature tracheostomy requires immediate ventilation.

B. Ventilate patient via face mask, using bag-valve-mask technique. Cover open stoma to avoid leak of air. Observe chest rise with ventilations.

C. The patient may require intubation with an endotracheal tube.

A. When an inadvertent decannulation has occurred, one must always examine the possible causes: tracheostomy tube that is too short, too much traction or torque against the tube, including closed suction systems, inline filters, etc.

B. Remove sources of traction and torque if present.

A. If the patient is having respiratory distress, one must always consider the ABC’s: airway first. If the patient is unstable, consider oro-tracheal intubation and planned tracheostomy revision in a more controlled environment.

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.

A. After tracheostomy dislodgement occurs and the patient stabilized, there should be efforts to prevent further dislodgement.

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