Tracheostomy Emergency

A patent upper airway is what separates this from a laryngectomy — a tracheostomy patient can usually still be oxygenated through the mouth and nose. So you give oxygen to BOTH the face and the stoma until you know which is working. Waveform…

NTSP Green Algorithm

The pathway

1 · Call for help — say the words

Put out an emergency call and say "tracheostomy emergency"
Ask explicitly for the airway trolley, suction and waveform capnography
If you are not airway-trained, this is your most important action. Everything below buys time until they arrive.

2 · Oxygen to BOTH face and stoma

15L via non-rebreathe to the face AND paediatric mask or catheter mount to the tracheostomy
Costs nothing, and you do not yet know which route works
Do not assume the upper airway is blocked

3 · Look, listen, feel — at mouth AND tracheostomy

Chest movement, breath sounds, misting
Waveform capnography: a trace means the tube is in the airway
No trace does not always mean displaced — check for low cardiac output

4 · Remove anything attached to the tube

Speaking valve or cap MUST come off — a valve left in place causes complete obstruction on expiration
This alone resolves a proportion of these calls

5 · Remove the inner tube

The commonest reversible cause. Secretions dry and occlude it
Some inner tubes must be replaced to connect a bag — know your tube type
Reassess breathing immediately after

6 · Pass a suction catheter

Passes freely → the tube is patent. Suction and reassess
Will not pass → the tube is blocked or displaced

7 · Deflate the cuff

Only if the catheter will not pass
Deflating may allow the patient to breathe around the tube via their own upper airway
Reassess: any improvement means the upper airway is working

8 · Remove the tracheostomy tube

If still no breathing after cuff deflation
A blocked tube in the airway is worse than no tube — the upper airway is patent in a tracheostomy patient
Cover the stoma and oxygenate via the face, or oxygenate via the stoma
Do not attempt to reinsert it unless you have been trained. A false passage is fatal

9 · Continue standard resuscitation

If no breathing and no pulse: ALS
Airway management continues by face and stoma
Anaesthetic and ENT teams take over the definitive airway

Drugs

Drug	Dose	Route	Notes
Oxygen	15L	NRB to face AND stoma	Both routes until you know which is working. This is the whole point of the green algorithm.
Sodium chloride 0.9%	2–5ml	Via tracheostomy	Saline nebs or instillation to loosen thick secretions — only if the tube is patent and help is en route.

When to escalate

Any tracheostomy patient in respiratory distress — call early, do not wait,Suction catheter will not pass,No capnography trace,Tube removed and patient still not oxygenating,Bleeding from the stoma — consider tracheo-innominate fistula, this is a surgical emergency

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

This page is the reference half

The app adds what a web page cannot: a VINDICATE differential builder, worked on-call scenarios with full A–E findings, recall practice, and all of it offline.