3.4 Tracheostomy Emergencies, Speaking & Decannulation

3.4 Tracheostomy Emergencies, Speaking & Decannulation

Emergency Management of Accidental Decannulation

Accidental decannulation is a life-threatening pediatric emergency. The clinical management algorithm depends entirely upon one critical factor: the age and maturity of the stoma tract.

1. Fresh Stoma (<7 Days Post-Operative)

In the first week following surgical tracheostomy, the stoma tract between the skin and the anterior tracheal wall is completely unepithelialized. The surrounding tissue planes (skin, subcutaneous fat, strap muscles, pretracheal fascia) are held together only by tension sutures.

• Why the fresh tract is dangerous: Soft tissue can shift after decannulation, and forceful blind insertion can create a false passage. Call the specialist airway team, oxygenate the face and stoma, and follow the bedside plan. Trained personnel may use stay sutures or direct visualization when the surgical plan permits; stop if resistance or subcutaneous inflation suggests a false route.
• Immediate actions:
  1. Call the airway, ENT, and surgical team; provide high-concentration oxygen to both the face and the stoma while assessing breathing and airway patency.
  2. Avoid blind forceful recannulation. Use the fresh-tracheostomy emergency plan, stay sutures, and direct visualization only by trained personnel.
  3. If the upper airway is patent and the child is not ventilating, use bag-mask ventilation from above; gentle stoma occlusion may improve the seal. If the upper airway is not patent, prioritize oxygenation/ventilation through the stoma with expert airway support.
  4. Confirm any restored airway with exhaled CO2, chest movement, and clinical response.

2. Mature Stoma (>7 to 14 Days Post-Operative)

After 7 to 14 days, the surgical tract has fully epithelialized, forming a stable, well-defined fibrous tunnel between the cervical skin and the tracheal lumen.

• Immediate Step-by-Step Action:
  1. Lubricate the spare, same-size tracheostomy tube with water-soluble jelly with the obturator locked in place.
  2. Position the patient's neck in slight extension (using a shoulder roll) to expose the stoma.
  3. Gently insert the tube following the downward and backward anatomical curvature of the stoma tract.
  4. Immediately withdraw the obturator once the tube enters the trachea to restore airway patency.
  5. Confirm proper intratracheal placement: observe bilateral chest rise, auscultate bilateral air entry, confirm condensation within the tube, and connect colorimetric capnography (EtCO2 detection).
  6. If resistance is encountered: Do NOT force the tube. Immediately set aside the same-size tube and attempt gentle insertion of the half-size smaller spare tube (0.5 mm ID smaller) with its obturator.
  7. If the downsized tube also cannot be passed: Immediately occlude the stoma and deliver bag-mask ventilation from above with 100% O2 while mobilizing the emergency airway team for endotracheal intubation from above.

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Speaking Valves & Decannulation Protocols

Restoring verbal communication, swallowing function, and eventual decannulation are primary rehabilitative goals in pediatric tracheostomy management.

The Passy-Muir Speaking Valve (PMV)

The Passy-Muir valve is a biased-closed, one-way valve attached to the standard 15-mm tracheostomy hub. During inspiration, the silicone diaphragm opens, permitting ambient air or blended ventilator gas to enter the tracheostomy tube. Upon expiration, the valve closes tightly. Exhaled air cannot escape through the tube; instead, it is diverted upward around the outer diameter of the cannula, through the subglottic space and vocal cords, and exits through the nose and mouth.

• Safety requirement: Fully deflate the cuff before a one-way speaking valve is applied, and verify a patent upper-airway exhalation route with appropriate clinical assessment.
• If exhalation is blocked: Pressure, distress, air trapping, and barotrauma can develop rapidly. Remove the valve immediately, restore the prior airway configuration, and reassess tube position, cuff, secretions, upper-airway anatomy, and readiness.

Decannulation Protocol & Readiness Criteria

Decannulation is the planned permanent removal of the tracheostomy tube.

1. Readiness Prerequisites:
   • The primary underlying disease process (stenosis, respiratory failure, neurological injury) has resolved or improved significantly.
   • The patient is entirely free from mechanical ventilatory support for at least several weeks.
   • The patient exhibits strong, unassisted airway clearance, effective cough, intact protective gag reflex, and absence of aspiration during swallowing.
2. Stepwise Decannulation Process:
   • Step 1: Downsizing: The current tracheostomy tube is downsized to a smaller cannula (e.g., down to a Size 3.0 or 3.5 mm uncuffed tube) to maximize airflow through the natural upper airway around the tube.
   • Step 2: Protocol-directed capping or occlusion assessment: When the child and tube type are suitable, supervised daytime and sleep observation can test breathing through the upper airway. Duration, location, monitoring, and whether full capping is used vary by age, diagnosis, sleep risk, and decannulation pathway; do not impose an uninterrupted universal 24- to 48-hour rule.
   • Monitoring During Capping: The patient is continuously monitored for stridor, tachypnea, intercostal retractions, diaphoresis, desaturations, or transcutaneous CO2 elevation.
   • Step 3: Decannulation and Stoma Dressing: If the 48-hour capping trial is passed without signs of respiratory distress, the tube is removed. The stoma edges are cleaned and approximated, covered with a sterile occlusive dressing, and the child is observed in the hospital for 24 to 48 hours.

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NPS Exam Traps Callout Box: Tracheostomy Management

[!WARNING] NPS Exam Trap 1: The Fresh Stoma False Tract In a fresh surgical tract, do not force a tube blindly because a false passage can be fatal. Call the specialist airway team, oxygenate the face and stoma, and choose face-mask or stoma ventilation based on upper-airway patency and the patient-specific emergency plan.

NPS Exam Trap 2: Air in a Bivona Silicone Cuff If a case vignette describes a home-ventilated child with a Bivona TTS tube who begins alarming low-exhaled-volume and low-pressure, and the chart indicates the cuff was filled with 2 mL of air, the problem is air diffusion across the silicone membrane. The correct intervention is to evacuate all air and inflate the cuff with sterile water.

NPS Exam Trap 3: Passy-Muir Valve Placement The very first step before attaching a speaking valve is ALWAYS deflating the cuff. If the question asks, "What must the respiratory therapist verify before applying a speaking valve?", look for "Complete deflation of the cuff and presence of trans-laryngeal air leak."