A surgical tracheostomy was performed (adjustable flange) on an ITU patient. Back in ITU a post operative chest x-ray showed the tip of tube to be at the carina. When the flange of tracheostomy was withdrawn 2 cm, ventilation became impossible and could not be restored when the tube was returned to its original position.

The inner cannula was removed but a suction catheter could not be passed, the patient still could not be ventilated and the oxygen saturations dropped to 40%. Bronchoscopy via the tracheostomy showed the tube against tracheal wall but attempts to reposition it in the trachea caused further desaturation. The ICU consultant inserted a bougie and tube orally using a videolaryngoscope but could not pass either beyond the vocal cords, even after the tracheostomy tube was removed.

Another trial of intubation was unsuccessful, and ventilation was impossible with either a 2^nd gen supraglottic airway or a face mask. Jet ventilation via a cannula through the tracheostomy stoma also failed. The duty anaesthetist from theatres was called. In total the patient experienced around 10 minutes with minimal or no ventilation. There was loss of cardiac output and chest compressions were started. After several further attempts the trachea was intubated with a size 8 tube using a videolaryngoscope.  The patient received 14 minutes CPR before return of spontaneous circulation.

Commentary:

This case highlights how tracheostomy emergencies can rapidly become life threatening. The National Tracheostomy Safety Project website^1,2 contains resources/ information that all staff should be aware of (for both patients with tracheostomies and laryngectomies).

Waveform capnography should always be used to access a patent/partially not patent airway.

Unfamiliarity with different types of tracheostomy tubes can lead to morbidity and mortality; standardization is key. With respect to adjustable flange or variable length tracheostomy tubes, SALG has previously commented on the issues that can arise (PSU, April-June 2021: page 3). We are again reminded that correct positioning should always be confirmed before any withdrawal, by bronchoscopy and direct vision rather than imaging/CXR.

References:

1. National Tracheostomy Safety Project website [Accessed, September 2025]
2. McGrath, BA, Bates, L., Atkinson, D., Moore, JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaes. 2012; 67(9): 1025-41