›Assess for air movement, chest rise, and audible airflow at each site
›Step 4: assess tube patency with a suction catheter
›Pass a suction catheter down the tracheostomy tube
›Catheter passes easily and suctions freely: tube is patent, look for a cause outside the tube itself
›Catheter meets resistance or will not pass: assume tube obstruction and proceed immediately to step 5
›Step 5: remove the inner cannula
›A blocked inner cannula is the single most common and most easily reversible cause of tracheostomy tube emergencies
›Remove it as an early step, not a late one — do not wait until deterioration is severe before removing it
›Reassess air movement immediately after removal
›Step 6: deflate the cuff
›If still obstructed after inner cannula removal, deflate the cuff completely
›Deflation allows air entry around the tube and through the upper airway in a tracheostomy patient
›Reassess with suction catheter and look-listen-feel
›Step 7: reassess — if breathing improves, treat the underlying cause and stop escalation
›Step 8: decision point if still not ventilating after inner cannula removal and cuff deflation
›Remove the tracheostomy tube completely
›Reassess at the face: if the upper airway is patent, proceed to standard oral airway maneuvers, bag-mask ventilation at the face, and oral intubation with direct or video laryngoscopy
›Simultaneously prepare for stomal rescue: oxygenation or intubation directly through the stoma with a smaller endotracheal tube, especially if oral attempts fail or the obstruction is below the cords
›Cricothyrotomy or surgical airway if both routes fail and the patient remains unventilated
Laryngectomy emergency algorithm (no upper airway)
›Sequential emergency steps
›Step 1: call for help
›Emergency/resuscitation team, anesthesia or airway team, and ENT
›State clearly the patient has a laryngectomy — oral or nasal airway attempts are futile
›Step 2: high-flow oxygen to the stoma
›The stoma is the only route to the lungs — direct all primary oxygenation efforts there
›Do not spend time on facial oxygenation as a primary measure; the mouth and nose are a blind-ending pouch with no connection to the trachea
›Step 3: look, listen, and feel at the stoma only
›Step 4: assess tube patency with a suction catheter (if a tube or laryngectomy stoma button is in place)
›Catheter passes easily: tube patent, look for a cause outside the tube
›Catheter meets resistance: assume obstruction, proceed to step 5
›Step 5: remove the inner cannula (if present)
›Same rationale as tracheostomy — commonest reversible cause, remove early
›Step 6: deflate the cuff (if present) and reassess
›Step 7: decision point if still not ventilating
›Remove any tube or button present
›Attempt oxygenation and ventilation directly at the stoma: bag-mask ventilation with a pediatric or round mask sealed over the stoma, or a supraglottic-type device designed for stoma use
›Attempt intubation of the stoma directly with a small cuffed endotracheal tube (typically 6.0 mm internal diameter or smaller) under direct or fiberoptic vision
›Oral intubation, bag-mask ventilation at the face, and supraglottic airway placement at the mouth are ALL contraindicated and will not deliver any gas to the lungs — attempting them wastes the only time available for a viable rescue
›Step 8: emergent surgical airway at the stoma if the above fails
Tracheo-innominate artery fistula recognition and immediate action
›Recognition
›Any bleeding from or around a tracheostomy, however minor, in a patient more than 48 hours from tube placement is tracheo-innominate fistula until proven otherwise
›A herald bleed — a self-limited, moderate bleed from the stoma or in tube secretions — precedes the catastrophic hemorrhage in a majority of cases, occurring hours to weeks beforehand
›Failure to recognize a herald bleed as a warning sign is the single most preventable cause of a fatal outcome in this condition
›Pulsatile bleeding synchronous with the tube or visible tube pulsation in the suprasternal notch is a hard sign requiring the same emergent response as active massive bleeding
›Immediate temporising actions for massive bleeding
›Call for help: vascular surgery or cardiothoracic surgery emergently, activate massive transfusion protocol
›Cuff hyperinflation
›Overinflate the tracheostomy tube cuff (or an orally placed endotracheal tube cuff advanced past the fistula) well beyond the normal 20 to 30 cmH2O range to tamponade the bleeding vessel against the sternum
›Often attempted first because it is the fastest maneuver available at the bedside
›Digital compression (Utley maneuver)
›Insert a finger into the stoma and compress the innominate artery anteriorly against the posterior surface of the manubrium/sternum
›Maintain compression continuously until definitive surgical control in the operating room
›Both maneuvers are temporising only — definitive control requires emergent sternotomy with ligation, resection, or reconstruction of the innominate artery
›Secure the airway distal to or through the bleeding site (oral intubation with the cuff passed beyond the fistula, or the existing tracheostomy tube) before transport to the operating room
Iatrogenic harms from routine ED interventions in this population
›Intubation
›Oral intubation is contraindicated in laryngectomy — it delivers no gas to the lungs and delays the only viable rescue
›In tracheo-innominate fistula, advancing an endotracheal tube cuff past the fistula site is a therapeutic maneuver, not merely airway management
›Sedation
›Sedating a patient with marginal or partial tube obstruction before the airway route is secured can convert partial obstruction to complete obstruction by removing respiratory drive and airway-protective reflexes
›Reserve sedation for after a definitive airway plan (oral, stomal, or surgical) is confirmed achievable
›Fluid loading
›In tracheo-innominate fistula hemorrhage, prioritize blood products over large-volume crystalloid — excess crystalloid worsens dilutional coagulopathy without addressing the anatomic bleeding source
›Oxygen
›Apply to both face and stoma when airway type is uncertain; apply to the stoma only as the primary route once laryngectomy is confirmed
›Vasopressors
›Not first-line for tracheo-innominate fistula shock — the pathology is a mechanical arterial bleed, not vasodilatory shock; vasopressors do not achieve source control and can mask ongoing blood loss by transiently supporting blood pressure
›Mechanical circulatory support, including intra-aortic balloon pump
›Not indicated for this pathology; if a patient with a tracheostomy independently requires mechanical circulatory support, the anticoagulation it typically requires is contraindicated in the presence of active or recent tracheostomy-related bleeding
›Anticoagulation
›Contraindicated in active tracheo-innominate fistula bleeding or significant tracheal hemorrhage — hold and reverse any existing anticoagulation emergently
›Fibrinolysis
›Recent tracheostomy placement and any tracheo-innominate fistula bleeding are contraindications to systemic thrombolytic therapy if later needed for another indication such as stroke or pulmonary embolism
›Analgesia
›Opioids suppress cough and respiratory drive, impairing secretion clearance and potentially masking early airway compromise
›Provide adequate analgesia for stomal pain or procedures while monitoring respiratory status closely
Team activation and monitoring bundle
›Monitoring
›Continuous pulse oximetry
›SpO2 target 94 to 98%
›Exceptions: cyanotic congenital heart disease, chronic lung disease, and pulmonary hypertension may have a lower baseline and tolerated target — use the patient's documented baseline when known
›Continuous cardiac monitoring
›Hypoxia-related bradyarrhythmia as a pre-arrest sign
›End-tidal CO2 if intubated or ventilated
›Consultation triggers
›ENT or the surgical service who placed the tube for any tube-related emergency
›Vascular or cardiothoracic surgery for any suspected tracheo-innominate fistula
›Anesthesia or airway team for any failed or anticipated difficult tube exchange