Laryngectomy Emergency

After a laryngectomy there is NO connection between the mouth and the trachea. Oxygen to the face does nothing. Bag-mask ventilation does nothing. Oral intubation is impossible. Everything happens at the stoma. Mistaking a laryngectomy for a…

NTSP Red Algorithm

The pathway

1 · Call for help — say "laryngectomy"

Emergency call, and use the word laryngectomy explicitly
Ask for the airway trolley, suction, waveform capnography and ENT
Say clearly to the team: "this patient has no upper airway"

2 · Oxygen to the STOMA

15L via paediatric face mask over the stoma, or a tracheostomy mask
Also apply oxygen to the face if there is any doubt it is a true laryngectomy
Oxygen at the face alone will not reach the lungs in a laryngectomy

3 · Look, listen, feel — at the stoma

Chest movement, misting, breath sounds at the stoma
Waveform capnography at the stoma
Check the notes, wristband or a laryngectomy alert card if there is time

4 · Remove anything in or over the stoma

Heat-moisture exchanger (HME), stoma button, valve, cover or bib
Crusting at the stoma is common in laryngectomy patients and can occlude it completely

5 · Remove the inner tube if one is present

Many laryngectomy patients have no tube at all — just a stoma
If a tube is present, treat as for tracheostomy: inner tube out first

6 · Pass a suction catheter into the stoma

Passes → patent, so suction and reassess
Will not pass → obstruction below, or a false passage

7 · Deflate the cuff if there is a cuffed tube

Then remove the tube entirely if still not oxygenating
Unlike a tracheostomy, removing it does not lose you the airway — the stoma is the airway

8 · Ventilate via the stoma

Paediatric face mask applied over the stoma and bagged
Or an LMA placed over the stoma — an established rescue technique
Never attempt oral intubation: there is nothing to intubate into

9 · Definitive airway is via the stoma

A small cuffed tracheal tube passed into the stoma by the airway team
Your job is oxygenation at the stoma until they arrive

Drugs

Drug	Dose	Route	Notes
Oxygen	15L	Paediatric mask to STOMA	Add a face mask too if the anatomy is not confirmed. Face alone is never sufficient in a true laryngectomy.
Sodium chloride 0.9%	2–5ml	Into the stoma	For crusting and thick secretions, then suction. Laryngectomy stomas crust readily as the air is not humidified by the nose.

When to escalate

Any laryngectomy patient in respiratory distress,Uncertainty about whether this is a laryngectomy or a tracheostomy — escalate AND treat as laryngectomy,Suction catheter will not pass into the stoma,Bleeding from the stoma,Team attempting to bag-mask or orally intubate — say out loud that there is no upper airway

Reference: National Tracheostomy Safety Project (NTSP) — Emergency Laryngectomy Management

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