Emergency Department Management of Surgical Airway Complications
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Emergency Department Management of Surgical Airway Complications

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Table of Contents

About This Issue

Tracheostomies can allow patients who require ongoing ventilatory support significant improvement in their quality of life; however, the devices and their placement may be prone to complications, such as dislodgment and obstruction, infection, and bleeding, leading to potentially life-threatening complications. In this issue, you will learn:

Tracheostomy tube types and the tube parts that may become dislodged or obstructed.

The uses and management of cuffed, uncuffed, and fenestrated tubes.

When the tracheostomy can be managed in the ED and when urgent surgical intervention is needed.

The critical post surgical time frames when you should and should not attempt re-insertion of a dislodged tube.

How small sentinel bleeds can point to the presence of life-threatening fistulas and how to control bleeding until surgery can be arranged.

What the limitations of x-ray and ultrasound are in the diagnosis of fistulas, and when bronchoscopy or CT angiograms will be necessary.

Strategies for clearing an obstructed tube, replacing a dislodged tube, and managing suspected infection.

Table of Contents
  1. About This Issue
  2. Abstract
  3. Case Presentations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Etiology and Pathophysiology
    1. Tracheostomy
    2. Cricothyrotomy
  7. Differential Diagnosis
    1. Tracheostomy Tube Obstruction
    2. Tracheostomy Tube Dislodgment
    3. Other Causes of Respiratory Distress
    4. Erosions and Bleeding
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. History
    2. Physical Examination
  10. Diagnostic Studies
    1. Laboratory Testing
    2. Chest X-Ray
    3. Ultrasound
    4. Advanced Imaging
  11. Treatment
    1. Tracheostomy Emergencies
      1. Managing an Obstructed Tracheostomy Tube
      2. Managing a Dislodged Tube
      3. Managing Bleeding at the Tracheostomy Site
      4. Replacing a Tracheostomy Tube
      5. Managing Suspected Infection at the Airway Site
      6. Placing a Definitive Airway
    2. Acute Surgical Airway: Cricothyrotomy
  12. Special Populations
    1. Patients With Laryngectomy
  13. Controversies
  14. Disposition
  15. Summary
  16. Risk Management Pitfalls in Managing Surgical Airways in the Emergency Department
  17. 5 Things That Will Change Your Practice
  18. Time- and Cost-Effective Strategies
  19. Case Conclusions
  20. Clinical Pathways
    1. National Tracheostomy Safety Project (United Kingdom): Emergency Tracheostomy Management Algorithm
    2. National Tracheostomy Safety Project (United Kingdom): Emergency Laryngectomy Management Algorithm
  21. Tables and Figures
  22. References


Emergency clinicians are often responsible for the acute management of complications pertaining to both the acute difficult airway and the chronic surgical airway; however, clinical knowledge and/or experience may be lacking. This review provides an overview of surgical airway complications, which can be a result of mechanical, infectious, or hematologic causes, and provides best-practice recommendations. Current consensus guidelines for the management of the difficult airway and indications for a surgical airway are discussed.

Case Presentations

EMS brings in a 54-year-old man who has a swollen tongue and is in obvious respiratory distress…
  • He is tripoding with accessory muscle use, demonstrates conversational dyspnea, and is drooling. His vital signs are significant for hypoxemia that corrects with a nonrebreather mask, tachycardia, and hypertension.
  • You see on his medication list that he takes lisinopril, and you are concerned he has progressing angioedema, so you decide to intubate.
  • Using an awake, flexible video laryngoscopic approach, you visualize swelling extending beyond the base of his tongue, and you are unable to pass the endotracheal tube.
  • The patient’s swelling is getting worse, and he is now becoming hypoxic.
  • How will you secure a definitive airway on this patient?
A 48-year-old man with a history of prolonged ICU stay for pneumonia who is status post tracheostomy presents to the ED after his tracheostomy tube fell out at home…
  • He is in no respiratory distress upon presentation, and he is not ventilator-dependent.
  • The patient’s family did not bring the tube that fell out, and they are unable to recall the size of his tracheostomy tube. They inform you that his surgery was approximately 6 months ago.
  • Upon your inspection, the skin surrounding the tracheostomy site appears well-healed, without evidence of bleeding or soft-tissue infection.
  • The patient’s surgery was not performed at your hospital, and you are unable to access outside records.
  • What is the best course of action to manage this patient’s dislodged tracheostomy tube?
A 41-year-old woman with a history of cerebral palsy presents to the ED from her long-term care facility for hypoxemia, with pulse oximetry measured at 84%…
  • She is status post tracheostomy, with a percutaneous endoscopic gastrostomy (PEG).
  • The patient is ventilator-dependent, and when the respiratory therapist takes her off the travel ventilator and attaches her to your ventilator, the ventilator alarm sounds for increased pressures.
  • The patient’s nurse reports increased secretions from the tube, requiring frequent suctioning. Your examination shows crusted mucus inside the inner cannula, with clear secretions.
  • What is the best way to clear obstructive secretions from the tracheostomy tube?
A 26-year-old woman presents from her brain injury rehabilitation facility for bleeding from her tracheostomy site…
  • The patient has a history of prolonged surgical ICU stay after multiple gunshot wounds. She is status post tracheostomy, with a PEG. Her tracheostomy was placed approximately 1 month ago, and blood appears to be oozing from the site.
  • The patient’s vital signs are within normal limits, and she appears well, apart from the bleed.
  • Are there red flags in this patient’s presentation?

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Clinical Pathways

National Tracheostomy Safety Project (United Kingdom): Emergency Tracheostomy Management Algorithm

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Tables and Figures

Table 1. Differential Diagnosis of Respiratory Distress and Airway Bleeding in a Patient with a Tracheostomy
Figure 1. Diagram of Structures of the Larynx
Figure 2. Tracheostomy Tube Parts
Figure 3. Tracheostomy Tube Types
Figure 4. Angiography Image of Tracheo-innominate Fistula

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. Hyzy RC. Complications of the endotracheal tube following initial placement: prevention and management in adult intensive care unit patients - UpToDate. 2021. Accessed October 10, 2022. (Review)

3. * Whitcroft KL, Moss B, McRae A. ENT and airways in the emergency department: national survey of junior doctors’ knowledge and skills. J Laryngol Otol. 2016;130(2):183-189. (Survey; 104 clinicians) DOI: 10.1017/S0022215115003102

7. * Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827-848. (Guideline recommendations) DOI: 10.1093/bja/aev371

9. * Long B, Koyfman A. Resuscitating the tracheostomy patient in the ED. Am J Emerg Med. 2016;34(6):1148-1155. (Review) DOI: 10.1016/j.ajem.2016.03.049

14. * Machado L, Mansilha A. Tracheo-innominate artery fistula. Eur J Vasc Endovasc Surg. 2016;52(6):822. (Case report) DOI: 10.1016/j.ejvs.2016.10.005

Subscribe to get the full list of 17 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: airway, tracheostomy, laryngectomy, cricothyrotomy, cannula, tube, obstruction, dislodgment, bleeding, fistula, bronchoscopy, endotracheal

Publication Information

John Dubensky, DO; Chelsea Schmidt, DO; Scott Goldstein, DO, FACEP, FAEMS, EMT-PHP

Peer Reviewed By

Calvin A. Brown, III, MD; Michael Self, MD

Publication Date

November 1, 2022

CME Expiration Date

November 1, 2025    CME Information

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.

Pub Med ID: 36279379

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Publication Information

John Dubensky, DO; Chelsea Schmidt, DO; Scott Goldstein, DO, FACEP, FAEMS, EMT-PHP

Peer Reviewed By

Calvin A. Brown, III, MD; Michael Self, MD

Publication Date

November 1, 2022

CME Expiration Date

November 1, 2025

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.

Pub Med ID: 36279379

Get Permission

CME Information

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