Imagine you’re in resus, juggling your many sepsis patients, when a patient is rushed into the room. All you hear is “trach problem.” Before you jump to the AMAC > ENT pathway, think about this simple outline. There are 3 main trach emergencies and 3 major things you need to know. Read below for an approach to tracheostomy emergencies.

3 Important Questions:

  1. WHEN was the trach placed. This changes management if the trach is dislodged.
    • <7 days, don’t touch the trach  **CALL ENT** the stoma tract is not mature
    • >7 days old, stoma tract should be formed, you can replace the trach if needed
  2. WHAT size/type Sinai stocks Shiley, Elmhurst stocks Portex, they do the same thing but ideally, for an exchange, use the same type and size if possible
  3. WHY the trach was placed. Basically you want to know did the patient have a laryngectomy or a tracheostomy. This also changes management. Tracheostomy is more common with a plethora of indications. Laryngectomy however is usually reserved for patients with laryngeal disease, those airway structures are completely removed and there is no longer a connection between nose/mouth and the trachea/lungs.

3 Main Emergent Complications and Approach:


  • Most common complication, typically secondary to secretions
  • Remove inner cannula
  • Suction trach
  • If unable to pass suction through trach after multiple attempts, remove and replace if safe. Ventilate via oropharynx if airway patent.


  • Extremely difficult to replace if tract has not formed – usually takes 1 week for tract to heal
  • <7 days = BVM and orotracheal intubation, do not attempt to replace trach, ENT needs to evaluate the trach
  • >1 week w mature tract = possible to attempt to replace trach with obturator



  • Most feared complication is tracheoinnominate fistula – innominate artery erodes into the trachea
  • Incidence is 0.7% with mortality rate approaching 100%
  • Causes – pressure necrosis from cuffs with too high of pressures, improper placement of cannula tip, radiation therapy, steroids, hyperextension of head
  • Most commonly 3-4 weeks after surgery
  • MGMT – oxygenate, cuff overinflation (attempt to tamponade bleeding) translaryngeal intubation, direct compression, ENT/SURGERY, possible IR

Here are detailed algorithms for trach management:

for a patent upper airway

for post laryngectomy

Here is the anatomy of the tracheostomy tube! Know your tools:

Listen to this podcast: EMCrit Trach Emergency

Read this article on consensus guidelines: Guidelines Tracheostomy and Laryngectomy Airways




Check out these Sources:

  3. McGrath, B. A., et al. “Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies.” Anaesthesia 67.9 (2012): 1025-1041.
  4. Morris, Linda L., Andrea Whitmer, and Erik McIntosh. “Tracheostomy care and complications in the intensive care unit.” Critical care nurse 33.5 (2013): 18-30.
  5.  – Great site with information about emergent trach care.


June 2024