What to do When a Fresh Trache Falls Out

From ClinicalBrainTraning.com, the blog of Dr Jeff Young

You have to remember, never try to replace a fresh tracheostomy in the ICU, ever.  I don’t care it there’s a suture hanging out and you can see the hole. If you’re in the E.D. and somebody comes in, they’re a chronic trach patient, that’s fine.  But in the unit, for somebody who’s on a ventilator, never, never try to replace a fallen out tracheostomy tube, just orally intubate them and put the trache back under controlled conditions (of course this does not apply if their pharynx and larynx were removed, you may have to try to get that one back in, but if it doesn’t go in easily, and if they’re breathing, put supplemental oxygen over the hole and call for ENT help).

Everybody thinks that when you put a trach in that’s the end of the airway, trachs are put in for convenience unless somebody gets a laryngectomy.  If the trach’s not working you pull it out and you put them back on the ventilator using an endotracheal tube.  Not remembering that has probably led to the demise to quite a few patients, because people just keep messing around with the trach and trying to suction through it and trying to repositioning it and trying to do this and trying to do that. Bottom line, if you don’t think the trache is in the right place, just pull it out, and just go ahead and endotracheally intubate them.  99% of the cases, the trach was not placed because there was a problem with the airway, the trach was placed because you were trying to get them off the vent.  Most important, you’re not going to have a lot of time think in those situations, a lot of times what you can do is just pull the trach out and bag.  Just put your finger over the hole and just bag them.  The other thing you can do in this situation is let the balloon down.  And then see if the patient can ventilate if you were too scared to pull the trach out.  You can let the balloon down and see if there was some problem with that.  A lot of times when that happens the trach is dislodged and is blocking the airway, so until you get the trach out, they’re not going to get any better.

OnSurg thanks Dr Young for permission to re-post his blog.

Featured image (CC): Navy Medicine 

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