General Considerations

• Emergency if Occurs within First 7 Days
  • Without a Mature Tract Replacement Could Cause a False Tract
• Up to 15% of Tracheostomies are Accidentally Decannulated
• Mortality: 1-3%
• 50% of Airway-Related Deaths are Associated with Accidental Decannulation

Risk Factors

• Loose Strap
• Neck Edema or Swelling
• Morbid Obesity
• Agitation or Under-Sedation
• Excessive Coughing
• Too Short/Small Tracheostomy Tube
• Low Supervision of Staff or High Nurse-to-Patient Ratios

Presentation

• Hypoxia and Acute Respiratory Distress
• Subcutaneous Emphysema
• Absent Breath Sounds
• Unable to Pass Suction Catheter
• Loss of End-Tidal CO2
• May Be Dislodged Out of the Trachea and into the Subcutaneous Tissues Even if Still Going into the Stoma Opening at the Skin

Management

• Do Not Hesitate to Secure the Airway by Endotracheal Intubation if Concerned for Respiratory Distress
• Occurs After ≥ 7 Days: Stoma Tract is Generally Mature
  • Can Replace with an Obturator Right Through the Stoma
• Occurs Before < 7 Days: Stoma Tract is Generally Immature
  • Low Threshold to Secure the Airway by Endotracheal Intubation
  • May Consider Attempts at Tracheostomy Replacement if Stable (Only in Experienced Hands)
  • Options to Replace:
    • Replacement Over an Obturator
    • Stay/Traction Sutures Can Be Pulled to Bring the Trachea Forward and Assist in Replacement if Present from an Open Tracheostomy
    • Bronchoscope-Guided Replacement Through the Tracheostomy Tube