Tracheostomy Malpositioning: Managing Tracheostomy Displacement Events

Tracheostomy Malpositioning

Christofer D. BarthApril 21, 2015

Tracheostomy Malposition: #1

• Patient in CVICU• 79 yo female with NSTEMI and Ascending Aortic Aneurysm:

Ascending Aortic Aneurysm/CABG• Perioperative Neurologic Deficit: cerebral infarct with aphasia• Reintubated ~ 5 times• Underwent Otolaryngologist placed 8.0 Shiley Tracheostomy

tube.• Distal 8.0 XLT tube malpositioned and aborted

intraoperatively.

Tracheostomy Malpositioning: #1

• Tracheostomy Malposition event• Respiratory Therapy difficult ventilation with high peak

airway pressures– No imminent desaturation– Bag Tracheostomy Ventilation difficult.– Tracheostomy removed and bag masked ventilation from above.– Tracheostomy replaced, under direct visualization, and appeared

okay.– Later high peak airway pressures.




• Intubated bronchoscopically with standard 7.0 ET tube.• Chest Tube placed on L thorax.• 2nd Chest Tube placed on R thorax.• ENT scoped and confirmed perimembraneous tracheal

mucosal laceration.• Tracheostomy wound with significant breakdown, elected to

leave standard ET in stoma, sutured in place to allow stoma and trachea to heal.

• Discharged to LTAC with standard 6.0 cuffed Shiley.

Tracheostomy Malpositioning

• High tracheostomy peak airway pressures: what should not be done?– Suction Tracheostomy Tube.– Bag-Trach ventilate patient, standard bag mask okay.– Change to Pressure Control Ventilation– If you Bag-Mask ventilate patient, occlude tracheal stoma.– Insure availability of equipment for endotracheal intubation.– Acquire Bronchoscope as soon as possible, so that is simple

manuevers fail, bronchoscopy can procede.

Tracheostomy Malposition: #2• Awake Tracheostomy, POD 3

• Placed for oropharyngeal tumor/impending laryngeal airway compromise.

• CODE 4, hypoxemia• On arrival PEA and Respiratory Therapy

bag –trach ventilation with extreme difficulty.

Tracheostomy Malposition: #2• Diffuse Subcutaneous Emphysema and inability to ventilate via

tracheostomy; patient PEA.• Remove Tracheostomy and attempt intubation from above: grade

4 videolaryngoscopy, tube placed, unclear if ventilation, no available ETCO2 detector.

• Leave endotracheal tube in situ; bronchoscope arrives and intubated stoma with bronchoscope and ET tube.

• Identified carina, RUL bronchus.• Needle Thoracostomy.• No return of pulse, code called.

Tracheostomy Malpositioning: Suggested Algorithm for Concern

• Avoid excessive pressure ventilation: classic barotrauma.• Consider 100% O2 and pressure control/support ventilation.• Suction/lavage tracheostomy and evaluate for mucus plugging.• IF unable to pass catheter, consider replacing internal canula

and/or reintubation.– If ‘fresh’ tracheostomy, consider intubation from above as a

first option. Always intubate from above if percutaneous trach less than 1 week old.

– OR consider re-intubation with bronchoscope availability: from either above or below.

Tracheostomy Malpositioning: Suggested Algorithm

• Check list– Maintain ICU monitoring– Have equipment available for intubation from above and below

and a bronchoscope– Always have suction– Plan for assisted ventilation: ambu bag +/- vent.– Consider favoring airway topicalization over sedation.– If able, avoid paralytic.– If time, consult ENT and review OR record.


• For replacing trach through older stoma– Remove old tracheostomy– Insert new trach/obturator through stoma

• Check for ventilation• ETCO2• Breath sounds bilateral

– If unable, then load trach on bronchoscope and with bronchoscope enter tracheostomy stoma and identify carina and RUL.

– Place Tracheostomy tube over bronchoscope into the airway.


• If unable to do this, call ENT STAT.• If urgent, consider intubation from above.– Consider fiberoptic intubation from above– Consider permitting spontaneous ventilation to

permit the safety of patients patent conduit.

• If bag mask ventilation from above, occlude tracheostomy stoma, deep at tracheal wall.


• If high airway pressures (>40cmH2O PIP), consider need for chest tubes, obtain chest x-ray ASAP.

• If high airway pressures and airway complications encountered, consult with ENT ASAP and optimize equipment availability for consultants.

Health & Medicine

Tracheostomy Malpositioning: Managing Tracheostomy Displacement Events