Tracheostomy assessment (ED focus)
A functioning tracheostomy is lifesaving but can be the source of sudden deterioration. The emergency approach must be rapid, structured and pragmatic: use an ABTG (Airway - Breathing - Tracheostomy - General) rapid assessment integrated into ABCDE; perform immediate simple interventions (suction → pass catheter → change tube if needed) and escalate early to senior/airway specialists (ENT, anaesthetics, ICU) per local policy (Resuscitation Council UK; NICE).
This section summarises mechanisms, key clinical features, immediate actions for the ED, practical guidance for emergency tube change/ventilation via the stoma, and equipment / escalation considerations.
Why problems occur
- Obstruction: secretions, blood clot, mucus plug, blocked inner cannula.
- Malposition/displacement: partial or complete dislodgement, cuff sitting above the stoma or tube abutting the tracheal wall.
- Cuff failure or leak: damaged cuff, underinflation, or malposition allowing gas to escape proximally.
- Upper airway pathology: supraglottic oedema or secretions causing stridor despite a patent stoma.
- Tracheal injury or stomal bleeding: recent procedure, erosion into vessels (rare but catastrophic).
- Circuit/equipment faults: disconnection, obstructing HME, faulty ventilator.
Presentation - what to look for
- Increased work of breathing, accessory muscle use, tachypnoea; noisy breathing (gurgling, stridor, snoring).
- Sudden difficulty ventilating: rising airway pressures, falling tidal volumes, ventilator alarms.
- Hypoxia, hypercapnia (agitation, reduced consciousness).