Airway and respiratory

Tracheostomy Emergency Algorithm

Blocked or displaced tube, and the laryngectomy stoma (NTSP)

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

Each step lists what to do, then the choices that lead on. In the app the algorithm is tapped through one decision at a time.

1 Call for help and check the bedhead sign

Call the rapid response team with an airway expert (anesthesia), ENT or the surgical team and respiratory therapy; bring the trach kit
Bedhead sign: tracheostomy (mouth and nose still connect to the lungs) or laryngectomy (neck breather: they do not)
Look, listen and feel at the mouth and the stoma; put waveform capnography on the tube
High-flow oxygen to the face and the stoma (stoma only after laryngectomy)
Not breathing: call a code; no pulse: start CPR while the airway steps continue

Tracheostomy, or not sure → step 2 Laryngectomy (neck breather) → step 3

2 Clear the tube, then pass a suction catheter

Remove a speaking valve, cap or HME
Remove the inner cannula (some tubes need a clean inner cannula to connect a bag)
Pass a suction catheter down the tube

Catheter passes easily → step 4 Catheter will not pass → step 5

3 Laryngectomy: the neck is the only airway

Oxygen and capnography on the stoma only: the mouth and nose do not connect to the lungs
Remove the stoma cover or HME and any inner cannula; leave a voice prosthesis in place
Pass a suction catheter; if it will not pass, remove the laryngectomy tube or button and reassess the stoma
No pulse: CPR, ventilating through the stoma

Breathing and improving → step 6 Not breathing or not improving → step 7

4 Tube patent: suction and reassess

Suction; a partial block or a partly displaced tube is still possible
Not breathing: bag through the tube with 100% O₂ and watch the capnography trace
Continue the ABCDE assessment

Improving, CO₂ trace present → step 6 Not improving or no CO₂ trace → step 5

5 Deflate the cuff

Deflate the cuff fully with a syringe on the pilot balloon
Look, listen and feel at the mouth and the stoma; watch the capnography
Air can now pass around a blocked or misplaced tube to the upper airway

Stable or improving → step 6 Not improving → step 8

6 Improving: keep it safe

Stay with the patient; keep oxygen and capnography on
A tube that only works with the cuff down may be partly out: the airway team checks it with a scope
Find the cause: secretions, poor humidification, a speaking valve with the cuff up, a moved tube
Restock the bedside kit: obturator, spare tubes (same size and one smaller), syringe, suction

End of this path.

7 Ventilate through the stoma

Small (pediatric) face mask or an SGA over the stoma, bag with 100% O₂
Watch chest rise and the CO₂ trace; suction again for crusts or plugs

Breathing on their own again → step 6 Still needs ventilation or cannot oxygenate → step 9

8 Remove the tracheostomy tube

Cut the ties and take the tube out
Oxygen again to the face and the stoma
Look, listen and feel at the mouth and the stoma; capnography
No pulse: CPR

Breathing and improving → step 6 Not breathing or still failing → step 10

9 Intubate the stoma (expert)

Small tracheostomy tube or 6.0 cuffed endotracheal tube into the stoma
Guide it with a fiberoptic scope, bougie or airway exchange catheter
Advance only until the cuff is inside: a deep tube enters a main bronchus
Confirm with waveform capnography before ventilating

Next: airway secured → step 11

10 Oxygenate from above or through the stoma

From above: bag-mask over the mouth and nose with the stoma covered (gauze or a gloved hand); oral or nasal airway; SGA if needed
Through the stoma: a small (pediatric) face mask or an SGA held over the stoma; close the mouth and nose if gas leaks out above
Use whichever route gives chest rise and a CO₂ trace; two people, 100% O₂

Next: secure the airway (expert) → step 12

11 Airway secured

Confirm with capnography, chest rise and SpO₂; scope or chest x-ray for position
Cuff 20–30 cm H₂O; secure the tube; record its size, route and depth
ENT or the surgical team plans the formal tube change or revision
Debrief; restock the emergency kit; update the bedhead sign

End of this path.

12 Secure the airway: which route?

The airway expert decides; set up both: spare tubes, a 6.0 cuffed ETT, bougie, fiberoptic scope, video laryngoscope
NTSP lists oral intubation first; a mature stoma often takes a new tube easily
A stoma under about 7 days old has no formed tract: a blind tube can enter the neck tissues (false passage)

From above: fresh stoma, or the stoma attempt failed → step 13 Through the stoma: mature stoma, or a difficult upper airway → step 14

13 Oral intubation by the airway expert

Plan for a difficult airway: video laryngoscope, bougie and an SGA ready
Use an uncut tube and advance it past the stoma so the cuff sits below it
Cover the stoma; confirm with waveform capnography

Tube in, CO₂ trace present → step 11 Fails: keep oxygenating, try the stoma → step 10

14 Re-insert a tube through the stoma

Mature stoma: a new tracheostomy tube, same size or one smaller, with its obturator; then remove the obturator and insert the inner cannula
Or a 6.0 cuffed endotracheal tube, advanced only until the cuff is just inside the trachea
Guide it over a bougie or airway exchange catheter, or with a fiberoptic scope (a fresh stoma: expert with a scope only)
Inflate the cuff and confirm with waveform capnography before ventilating

CO₂ trace and chest rise → step 11 Will not pass or no CO₂ trace → step 13

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