Airway Management in the Trached Patient: Not an Oxymoron!

Tracheostomies (trachs) are often encountered in intensive care units. They are usually placed in patients who are expected to require long-term mechanical ventilation, or to maintain the airway patent such as in patients with laryngeal or neck cancers that are obstructing the airway or compressing the trachea. The majority of these patients will eventually be decannulated (have their tracheostomy removed). Some however will be discharged to a ventilator rehab, or will go home with a permanent tracheostomy. These patients will sometimes present to the emergency department because of complications from their tracheostomy, and will need to have their airway managed. Certain rules and principles regarding the use of the tracheostomy tract and the characteristics of the tracheostomy in place should be understood in order to avoid damaging or losing the airway.


Tracheostomy tubes come in many different sizes and shapes. Please see the extensive review by Dr. Hess. We would also encourage readers interested in further reviewing the indications for placement of tracheostomies, techniques of insertion, and complications, to read the article by De Leyn et al. For the purpose of this post, we will assume that the patients have a tracheostomy in place and are presenting in acute respiratory distress requiring an immediate intervention. We will include a step-by-step description of how to assess the adequacy of the tracheostomy that is in place, as well as indications, contraindications, and techniques for replacement of the tube. A diagram summarizing the approach to the trached patient in respiratory distress is also provided.

Figure 1 in Hess DR., 2005: Components of a standard tracheostomy tube.

De Leyn P, Bedert L, Delcroix M, et al. Tracheotomy: clinical review and guidelines. Eur J Cardiothorac Surg. 2007;32(3):412-21.

Hess DR. Tracheostomy tubes and related appliances. Respir Care. 2005;50(4):497-510.

1. Is the tracheostomy tube displaced or obstructed?

In the patient presenting with a tracheostomy tube and in respiratory distress, it is always important to determine if the problem is primarily from the tracheostomy tube itself. Mucus plugs and blood clots can obstruct tubes that have been present for a long time. Alternatively, the tube could have been displaced and no longer be present in the trachea, or be abutting against the tracheal wall.

A suction catheter can be inserted through the tube to confirm tube patency. If the tube contains an inner cannula, the latter can be removed and replaced. The position of the tracheostomy tube can be confirmed the same way an endotrcheal tube placement would be verified after intubation. This includes using capnometry and listening for bilateral breath sounds. A chest x-ray could also help visualize the tube in the trachea. In departments that have access to them, a fiber-optic scope can be used to directly visualize tracheal rings through the tracheostomy tube.

A damaged or leaking cuff in patients who require positive pressure ventilation can result in low airway pressure and hypoxia. Tubes with leaking cuffs will need to be replaced as well as obstructed tubes whose patency cannot be restored.

Tracheostomy in trachea (image courtesy of lifeinthefastlane.com).

View of tracheal rings with fiber-optic scope.

2. Is the tube cuffed or uncuffed?

Patients with a tracheostomy placed to maintain airway patency, and a subset of patients with minimal ventilator requirements, can arrive with cuffless tubes. These devices will be sufficient to provide adequate ventilation, but will need to be replaced by cuffed tubes should the patient need to receive positive pressure ventilation for hypoxia. Uncuffed tubes should also be replaced in the patient that is no longer able to protect his or her airway as a cuffless tube will not prevent a patient from aspirating. Determining if a tube is cuffed or uncured can be easily done by looking for the presence of an inflation line and a pilot balloon on the proximal aspect of the tube.

Cuffed tubes.

Uncuffed tube. Notice the "Uncuffed" sign on the bottom right of the neck flange.

3. How old is the tract?

The tracheostomy tract usually matures by the 7th day after placement. Attempting to cannulate an immature tract (before day 7) can result in a false passage, or lumen, and is usually done by the surgical service that initially placed the tracheostomy (usually ENT). They should be informed at once that a patient with an immature tract needs to have his tracheostomy replaced. The emergency physician should favor placing an orotracheal tube in patients with an immature tract that need intubation. If the patient with an immature tract already has an uncuffed tube in place, the latter could be changed over a feeding tube. This technique will be detailed later.

Tracheostomy tube in false lumen.

4. What is the size of the Outer Diameter (OD) of the tracheostomy tube?

A replacement tracheostomy tube should be the same size or a smaller size than the tube that was initially used by the patient. Using a larger tube could make it harder to insert or even damage the tract. Since different brands use different sizing classifications the physician should determine the outer diameter of the patient's tracheostomy and not just look at the tube number(#). The provided table will illustrate this and can be downloaded to use as reference while working in the ED. 

Tracheostomy Markings: ID = Inner Diameter, OD = Outer Diameter

Trach Size Table

5. Why was the tracheostomy tube placed?

While the patient in extremis will not be able to provide this information, it should be available in the patient chart or from the emergency medical technicians. The indication for tracheostomy placement is important as it can dictate the next step in management of the trached patient in respiratory distress. A patient that is ventilator dependent whose tracheostomy tube came out of place could be endotracheally intubated in the emergency department. On the other hand, a patient with laryngeal cancer would have to have his tracheostomy replaced emergently by a specialist if the tract is not mature (see next section).

Laryngeal cancer causing airway obstruction.

• The approach to the trached patient is summarized below:

• Changing a tracheostomy tube over a feeding tube:

This technique is similar to the Seldinger technique for the placement of central lines. 16F or 18F feeding tubes are usually used because they are stiff enough to guide the passage of the tracheostomy tube in the trachea. Alternatively, a bougie can be used instead of a feeding tube. If available, an airway exchange catheter (aka tube exchanger) offers the ability to oxygenate the patient during the procedure. More on tube exchangers can be found in this review by Dr. Udomtecha.

1) Cut the feeding tube near the port that would be used for infusion/suction. You should keep it long enough (at least 60cm) that it will not accidentally slip into the patient's trachea. 
2) Insert the blunt end of the tube into the tracheostomy. 
3) If a cuff is present, deflate it then remove the patient's tracheostomy tube over the feeding tube.
4) Lubricate the balloon of the new tracheostomy tube to facilitate passage through the stoma.
5) Insert the new tracheostomy over the feeding tube. Make sure you are using a tube that has an OD of equal size or smaller than the previous one.
5) Retract the feeding tube. 
6) Confirm placement of the new tracheostomy tube.

Nasogastric tube cut at the proximal end

Tracheostomy tube passed over nasogastric tube.

Udomtecha D. Airway tube exchanger techniques in morbidly obese patients. Anesthesiol Res Pract. 2012;2012:968642.

• Temporizing a tracheostomy tube or endotracheal tube with a damaged pilot balloon or inflation line:

A damaged pilot balloon or inflation line will result in a cuff leak. In the patient with respiratory distress this can be temporarily fixed using a 10ml syringe with a luer lock, and a 20 gauge catheter.


1) Cut the pilot line proximal to the defect. 
2) The 20 gauge catheter will fit nicely into the pilot line. 
3) Using a three-way stopcock (A) or a one-way valve (B) will prevent the air from escaping.

If you're in luck, your respiratory therapist might be able to get you a pilot balloon replacement device. These nifty devices have a metal tip that fits into the inflation line and are equipped with their own pilot balloon.

Additional techniques for the replacement of damaged pilot balloons are presented in this review article by Kovatsis et al.

Kovatsis PG, Fiadjoe JE, Stricker PA. Simple, reliable replacement of pilot balloons for a variety of clinical situations. Paediatr Anaesth. 2010;20(6):490-4.