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Blocked tracheostomy

Up Blocked tracheostomy Ciaglia technique Tracheostomy tubes

Charles Gomersall, Thomas Li, Gordon Choi, Gavin Joynt

This is a potentially life threatening emergency, particularly if the tracheostomy was inserted for upper airway obstruction, a cuffed tracheostomy tube is being used or if the situation is not managed appropriately and rapidly.

An algorithm for initial management of possible tracheostomy tube blockage is given below.


  • administer 100% oxygen until the patient's condition has improved and is stable
    • use self-inflating resuscitator with reservoir bag via mask or tracheostomy as appropriate
  • a key step in management is to determine whether the patient's respiratory distress is due to obstruction of the tracheostomy tube or due to some other cause
  • if the patient has a double lumen tracheostomy tube (eg Shiley) remove the inner tube. This may, in itself, relieve the obstruction if the inner tube is blocked.

    If this does not result in a marked improvement in the patient's condition or the inner tube is required to provide assisted ventilation, replace the inner tube using a non-fenestrated tube (this is important for subsequent diagnostic and therapeutic steps)
  • passing a suction catheter down the tracheostomy tube has two purposes - diagnostic and therapeutic. As well as confirming an obstruction it may be possible to remove it by suction. Note that if the obstruction is due to blockage of the tracheostomy tube it should not be possible to advance the catheter by more than length of the tracheostomy tube (usually, but not invariably, <10 cm)
  • deflating the cuff of the tracheostomy may allow the patient to breath around the obstructed tracheostomy tube, unless the patient has total upper airway obstruction

  • if the patient is unable to breath or be bag-mask ventilated around the tube then the tracheostomy tube should be removed in most circumstances
    • if the tracheostomy was recently created (<7 days) because the patient had upper airway obstruction it may be advisable to attempt to unblock the tracheostomy using a bougie or similar instrument instead of removing the tracheostomy
    • cover the tracheostomy wound with a dressing so that gas passes down the trachea rather than through the wound when attempting bag-mask ventilation via mouth/nose
  • if it is necessary to re-insert an artificial airway the choices are to re-insert  tracheostomy tube, intubate (orotracheal) or provide alternative airway (eg laryngeal mask). Decision depends on:
    • anticipated difficulty of orotracheal intubation
    • whether tracheostomy track is well formed (usually takes 7-10 days)
      • unless orotracheal intubation is anticipated to be very difficult it is generally not advisable to attempt to replace the tracheostomy tube when the tracheostomy was formed <7 days earlier
    • individual doctor's skills
    • clinical urgency (in most circumstances, in skilled hands, it is more reliable to intubate the patient via the orotracheal route)

© Charles Gomersall, Thomas Li, Gordon Choi, Gavin Joynt June 2008

©Charles Gomersall, April, 2014 unless otherwise stated. The author, editor and The Chinese University of Hong Kong take no responsibility for any adverse event resulting from the use of this webpage.
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