Dislodged Tracheotomy Causes Respiratory Failure

I have been called to care for patients with this condition. It is a relatively common condition with chronic, established tracheostomies, but in these cases it typically occurs without harm. With fresh tracheostomies, this is an emergency, though luckily it is rare. I routinely change chronic established tracheostomies in the office with minimal precautions because it is safe. With fresh tracheostomies, defined as less than 7-10 days old, where there is no established tracheostomy tract, these are considered a medical emergency. I have both successfully changed these tracheostomy tubes with either an adjunct device, or evaluated the stoma with a bronchoscope, and then made the decision to replace over the bronchoscope, or else to reintubate. Loss of a fresh tracheostomy easily becomes a catastrophic event. I consider this one of the major under appreciated medical emergencies. With fresh tracheostomies, my personal and the institutional practice is to leave retention sutures in place for the first 7 days, as well as a velcro tracheostomy tie tensioned to 2 fingers tight. If a removal occurs in the first 7 days, our practice is to reintubate the patient orally to stablize. If the patient is in an ICU, with appropriate staffing, for a partial extubation, I would check patency into the airway, potentially insert a guide, then reinsert the tracheostomy over the guide. If a bronchoscope is present, then stomal patency can be checked visually by bronchoscopy, with the tracheostomy being inserted over the bronchoscope, using the bronchoscope as a guide. For fresh tracheostomies, blind reinsertion often leads to extra-tracheal placement, subcutaneous emphysema, loss of airway, and death.