Tracheostomy in the ED

September 11th, 2025

Tracheostomies are increasingly performed in intensive care unit settings for patients requiring prolonged mechanical ventilation, upper airway protection, or as an adjunct in head and neck surgeries. Although the procedure is generally safe, approximately 40% to 50% of patients will experience a complication — most minor, but up to 1% may be catastrophic, with high associated mortality.

A key distinction must be made between tracheostomy and total laryngectomy. In a tracheostomy, the upper airway remains intact, whereas in laryngectomy, the mouth and nose are completely disconnected from the lungs. This anatomical difference critically affects airway management during emergencies.

Tracheostomy tubes can be cuffed or uncuffed and typically include both inner and outer cannulas. The cuff prevents aspiration and enables mechanical ventilation but must be managed carefully to avoid tracheal injury. Overinflation of the cuff can cause ischemia and ulceration, while underinflation increases the risk of aspiration.

Emergent complications include accidental decannulation, obstruction, and hemorrhage. Accidental decannulation within seven days of tracheostomy is especially dangerous because of immature stoma formation. Reinsertion in these cases should only be attempted under endoscopic guidance to avoid creating a false passage. For mature stomas, cautious reinsertion can be attempted, but resistance may require use of a smaller tube or orotracheal intubation.

Obstruction, often caused by mucus plugs or clotted blood, typically is resolved by removing the inner cannula and attachments, followed by suction. Complete obstruction requires removal of the tracheostomy tube and initiation of bag-valve-mask (BVM) ventilation, with stoma occlusion as necessary.

Hemorrhage can range from minor oozing to life-threatening bleeding caused by a trachea-innominate artery fistula (TIF). Any bleeding within three weeks of placement should prompt urgent evaluation for TIF. Temporizing measures include hyperinflation of the cuff to stop the bleeding, external compression, and digital pressure via the Utley maneuver. Definitive treatment requires surgical or endovascular intervention.

Acute and subacute complications include pneumothorax, tracheal injuries, stoma or airway infections, and aspiration. Aspiration is common because of impaired swallowing, especially in patients with prolonged intubation or neurological deficits. Tracheoesophageal fistula, though rare, should be suspected in patients with ongoing aspiration or abdominal distension and is managed surgically.

Chronic complications include tracheal stenosis, tracheomalacia, tracheal granulomas, and tracheocutaneous fistulas. Many are related to prolonged cuff inflation or repeated tracheostomies and are often managed with bronchoscopic interventions.

Pediatric patients face unique risks because of their smaller anatomies and higher rates of obstruction and decannulation. Most tracheostomies in children are performed in those under 1 year of age. Red flag symptoms such as stridor, blood-stained secretions, or displaced tubes should prompt immediate intervention. Tracheostomy-associated respiratory infections are common and challenging to treat because of colonization with resistant organisms.

Airway management requires a stepwise approach: assess both airways, remove inner cannula and attachments, suction the tube, and, if obstruction persists, remove the tracheostomy tube. If necessary, ventilate via the upper airway with the stoma occluded or via the stoma with the mouth and nose closed. If all measures fail, intubation or cricothyroidotomy may be required.

Patients with T-tubes pose additional challenges due to their structure and should be managed cautiously, ideally with specialist support.

Conclusion

Tracheostomy complications range from minor to life-threatening. Emergency physicians must be able to distinguish tracheostomy from laryngectomy, recognize complications early, manage airways appropriately, and avoid dangerous interventions such as blind tube reinsertion. Structured airway assessment and a methodical approach are critical to ensuring patient safety and optimal outcomes.

For more information about performing tracheostomies and managing tracheostomy patients, click here.