This chapter addresses the scenario where a recent receptient of a tracheostomy suddenly suffers a respiratory deterioration. Such a scenario has come up in Question 11 from the second paper of 2016. The patient in that scenario also desaturated and developed subcutaneous emphysema. In brief, the approach consists of rapidly excluding dislodgement of the tracheostomy by an attempt at manual bag ventilation and suctioning. If manual ventilation is met with solid resistance and the catheter does not pass easily, one must assume that the tracheostomy has become dislodged. Other causes of subcutaneous emphysema and respiratory failure need to be discussed (i.e. tension pneumothorax, and accidental perforation of god only knows what hollow structures in the neck) but these are probably not as rapidly fatal as the loss of the airway.
This scenario is not something that is usually handled very well, and a 2007 interview study found "significant gaps in knowledge among healthcare professionals regarding the management of specific tracheostomy-related emergencies.". For something as important and ICU-ish as this topic, there is surprisingly little literature. A Google Scholar search reveals case reports (eg. Hutchison et al, 1991) and simulation scenarios (eg. Eisenhauer, 1996). A good article about reinserting a more mature tracheostomy can also be found in the (Pattanong, 2012). At the bottom of this chapter, the suggested techniques are from this article.
The following (non-canonical) approach is suggested, and is used as the answer to Question 11 from the second paper of 2016.
If the bag ventilation is easy and the patient improves with it:
If the bag ventilation is difficult and the patient is still unwell:
If the tracheostomy being dislodged is a real possibility:
Options for reinserting an "older" tracheostomy
HUTCHINSON, ROBERT CHARLES, and RODNEY DICKSON MITCHELL. "Life-threatening complications from percutaneous dilational tracheostomy." Critical care medicine 19.1 (1991): 118-119.
Eisenhauer, Brenda. "DISLODGED TRACHEOSTOMY TUBE." Nursing2015 26.6 (1996): 25.
Seay, Shirley Jordan, Sonja L. Gay, and Melvin Strauss. "Tracheostomy Emergencies: Correcting accidental decannulation or displaced tracheostomy tube." AJN The American Journal of Nursing 102.3 (2002): 59-63.
Pattanong, Paradorn. "Dislodged tracheostomy." The Journal of Prapokklao Hospital Clinical Medical Education Center-วารสาร ศูนย์ การ ศึกษา แพทยศาสตร์ คลินิก รพ. พระ ปก เกล้าฯ 24.4 (2012): 304-308.
Chew, John Y., and Robert W. Cantrell. "Tracheostomy: complications and their management." Archives of Otolaryngology 96.6 (1972): 538-545.
Casserly, P., et al. "Assessment of healthcare professionals' knowledge of managing emergency complications in patients with a tracheostomy." British journal of anaesthesia 99.3 (2007): 380-383.