First, Don’t Panic…

You walk into the room and someone shouts, “The trach came out!”
Your heart jumps. The patient is gasping. Oxygen sats are falling.
This is a high-stakes moment — and the clock is ticking.

The Core Essentials

What You Need To Know:

Accidental tracheostomy decannulation can turn catastrophic quickly, especially in a newly placed tracheostomy. However, with a straightforward and practiced approach, you can turn chaos into control. When you’re done with this learning space, you should be able to:

• Prioritize Oxygenation and assess breathing. Some patients maintain airflow via a stoma or upper airway.
• Know why it’s essential to check whether the trach is mature (>7 days). Reinsertion may be safe, but only by experienced hands.
• Be prepared to shift focus to the upper airway — mask ventilation, LMA, intubation.
• Be able to replace a trach tube — one at the neck, one at the face.

“The most common, and most commonly lethal, problem was displacement of the tracheostomy, especially on movement or in the obese patient, or both.” – NAP4 Study.

Accidental Decannulation: What to Do When the Tube Pops Out

👉 Click Here for Detailed Steps for Managing Decannulation

Start Here

Stop when the patient is stable.

1. Assess Breathing

• The patient may be breathing adequately via:
  • The tracheostomy stoma, or
  • The upper airway
• If so, no immediate action may be required

2. Consider Replacing Tracheostomy Tube

• If >7 days post initial insertion:
  • Experienced staff can attempt to reinsert the tracheostomy tube

3. Upper Airway

• Manage the upper airway:
  • Mask ventilate
  • Laryngeal Mask Airway (LMA)
  • Intubate

4. Upper Airway and Tracheostomy at the Same Time

• Airway team: manage the upper airway
• Neck team: manage access via tracheostomy stoma
  Primary measures:
  • LMA or pediatric mask over the stoma
  Secondary measures:
  • Endotracheal or tracheostomy tube in the stoma
  • Consider using::
    • Traction on stay sutures
    • Tracheal dilators
    • Endotracheal tube on bronchoscope
    • Bougie or exchange catheter
    • Guidewire and Melker kit

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5. New Surgical Airway

• Prepare for surgical airway if unable to re-establish airway via existing routes

How to Replace that Tube

You’ve determined you can and should replace that trach tube. You need to know how to do it. Here are a few key pointers and a rapid review video. For a more detailed review, head to our Deep Cuts section. Here are a few things to remember:

🎧 Deep Cuts

You’ve got the basics down—great work! To keep learning, head to the next poster. Want to go deeper? Click Continue the Journey for extra clinical pearls, evidence reviews, and curated links to expand your learning network—or bookmark it and return anytime.

Click Here for Deeper Cuts

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A fantastic 👉 blog post.  from the Northwestern University Emergency Medicine department on accidental decannulation. It’s definitely worth exploring, and then adding them to your learning network.

And it comes with this great infographic!

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CLEAN TECHNIQUE: TRACHEOSTOMY TUBE CHANGE QUICK CARD

WHEN TO USE:

• Mature tracheostomy tract (>7 days)
• Routine inpatient or home care tube changes
• Low-risk patients

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PRE-PROCEDURE PREPARATION:

• Perform hand hygiene (alcohol-based hand rub or soap & water)
• Gather supplies:
  • Clean tracheostomy tube (same size + one size smaller)
  • Water-soluble lubricant
  • Clean gloves (non-sterile)
  • Clean trach ties or holder
  • Suction equipment
  • Bag-valve-mask (BVM)
  • Oxygen source
  • Backup airway equipment
• Clean work surface (wipe bedside table or tray)

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PATIENT PREPARATION:

• Explain procedure (if patient awake)
• Position patient supine with neck slightly extended
• Apply oxygen and pulse oximetry
• Suction stoma and trach tube prior to removal

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PROCEDURE STEPS:

1. Apply clean gloves
2. Loosen or remove old ties
3. Deflate cuff completely (if applicable)
4. Gently remove old tube along natural tract angle
5. Insert lubricated new tube into existing tract
6. Confirm placement:
   • Chest rise
   • Breath sounds
   • Oximetry
   • End-tidal CO2 (if available)
7. Secure with new trach ties or holder

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POST-PROCEDURE MONITORING:

• Observe for respiratory distress, bleeding, subcutaneous emphysema
• Verify ongoing oxygenation
• Document tube type, size, depth, and patient tolerance

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SAFETY NOTES:

• If any resistance is felt during insertion: STOP, reassess
• Have full airway rescue equipment immediately available

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Bottom Line

If the trach pops out, don’t panic — call for help, check the patient, and focus on oxygenation. That’s the mission. If the stoma is mature, you might reinsert it — but never force it. Think fast, act smart, and be ready to escalate. Oxygenation and airway always come first.

Core Essentials

What You Need to Know

Let’s cut through the noise. These are the essentials. Want to go deeper? Scroll down to the Deep Cuts section. If you’re in one of our immersive pop-up spaces, hit the linked station for hands-on practice and next-level skills training.

🚨 Tracheostomy Emergency? Don’t Panic—Go Stepwise.

When a patient with a tracheostomy suddenly develops respiratory distress, the stakes are high and time is short. Follow this structured, high-yield approach to troubleshoot and resolve airway compromise via a tracheostomy tube. Your goal is to restore effective oxygenation and ventilation without delay.

🔑 Go step by step. Stop when the patient stabilizes. Think: Clear the tube, check patency, assess upper airway, consider systemic causes, and escalate as needed.

🧩 Stepwise Algorithm: Difficulty Breathing or Ventilating via Tracheostomy Tube

Stop when the patient is stable:

1. Remove attachments and inner cannula

• Remove/disconnect:
  • Ventilation circuit and filter
  • Speaking valve or HME (heat moisture exchanger)
  • Inner cannula (if present)

2. Suction

• Pass the suction catheter through the entire length of the trach tube
  • If the catheter does not pass:
    🚫 Do NOT ventilate via tracheostomy tube → go to Step 3
  • If the catheter passes easily:
    • If breathing: Apply O₂ via trach, consider partial obstruction
    • If not breathing: Ventilate via trach with Ambu bag
      ⚠️ Stop if high resistance

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3. Deflate the tracheostomy tube cuff

• Look, listen, and feel at the mouth
  • If breathing via the upper airway, Apply O₂ to the face
  • If not breathing: Manage upper airway → mask ventilate / LMA / intubate
    🔍 Consider partial obstruction regardless of breathing status

4. Patient causes

• Rapidly evaluate non-tube causes of respiratory distress:
  • Large pneumothorax
  • Anaphylaxis
  • Mucus plugging
  • Other systemic issues

5. Consider immediate bronchoscopy

• If a scope is available and:
  • Trach is new (<10 days)
  • The upper airway is obstructed

6. Remove the tube

• Remove the tracheostomy tube
• Plan for intubation from above

The Bottom Line

In tracheostomy-related respiratory distress, your priority is to restore oxygenation while quickly determining if the tube is the problem or just in the way. Remove attachments, check for patency, and deflate the cuff to assess upper airway function. If the tube can’t be used, shift to managing the airway from above or below. At the same time, don’t overlook systemic causes, such as pneumothorax, anaphylaxis, or mucus plugging. This stepwise approach helps you act fast, stay focused, and stabilize the patient without getting stuck on the tube.

What You Need to Know

Most bleeding in or around tracheostomies are minor. The tracheoinnominate fistula is the bleeding complication you hope you never see — but must be ready for. Rare, devastating, and unforgiving, a TIF can turn a stable tracheostomy patient into an airway and hemorrhage emergency in seconds. Early recognition, rapid action, and decisive airway and bleeding control are your only chance to save a life. In this session, we’ll arm you with the knowledge and skills to recognize the warning signs, understand the underlying anatomy, and manage this airway catastrophe when seconds count.

• Understand the Pathophysiology
• Recognize Timing and Risk Factors
• Identify Sentinel Bleeding
• Master Initial Emergency Management
• Know the Definitive Management Pathways

Causes of Tracheostomy Bleeding

Bleeding from a tracheostomy can occur at any stage, but the likely cause depends heavily on the age of the tracheostomy. In the first few days after placement, bleeding is usually from surgical trauma, vessel injury, or coagulopathy. Stoma site oozing is common early on but often self-limited. As the tract matures (days to weeks), granulation tissue, infection, or irritation from the tube or suctioning become more likely culprits. However, the most severe bleeding typically occurs later, between 3 and 14 days, when pressure necrosis can erode into major vessels, such as the innominate artery, resulting in a tracheoinnominate fistula (TIF). A slight bleed during this window is a red flag — it may be your only warning before a catastrophic hemorrhage.

The Tracheo-Innominate Artery Fistula (TIF)

Tracheo-innominate artery fistula (TIF) is a rare but life-threatening complication (0.1-1%) following tracheostomy, often caused by prolonged pressure from a tracheostomy tube or its cuff, leading to erosion of the trachea and innominate artery. While modern tracheostomy tube designs have reduced the incidence, TIF remains a significant emergency due to its high mortality rate. The condition most commonly presents within the first three weeks after tracheostomy, often with a herald bleed before catastrophic hemorrhage.

• Definition & Causes:
• TIF is a rare but serious complication of tracheostomy.
• This is caused by prolonged pressure from tracheostomy tubes, improper placement, excessive neck movement, prior radiation, steroids, and prolonged intubation.
• Incidence & Timing:
• Occurs in 0.1-1% of tracheostomy cases.
• It is most common in the first three weeks post-tracheostomy but can happen months later.
• Signs & Symptoms:
• Sentinel bleeding (minor bleeding before massive hemorrhage) occurs in about 50% of cases.
• Sudden, life-threatening hemorrhage from the tracheostomy site.
• Initial Emergency Management:
• Overinflation of the tracheal cuff to tamponade bleeding (successful in 85% of cases).
• Manual compression of the innominate artery against the sternum.
• Immediate preparation for surgical intervention.

Initial management focuses on securing the airway and controlling bleeding through tracheal cuff overinflation or manual innominate artery compression. In the operating room, bronchoscopy aids in diagnosis and airway stabilization, while surgical intervention via sternotomy is required for definitive treatment. The preferred approach involves ligation of the innominate artery rather than reconstruction, as the latter carries a high risk of recurrent bleeding. Emerging techniques, such as endovascular stent grafting, show promise in controlling acute hemorrhage but require further evaluation. Despite aggressive management, survival rates remain low, with long-term prognosis being poor due to the severity of the condition and associated comorbidities.

Tracheostomy Bleeding: Simplified Emergency Algorithm

You get called into the room. There’s bleeding from the trach. It seems minor, but you’re not so sure. This algorithm outlines a straightforward, stepwise approach to stabilize the patient, control bleeding, and escalate care as needed. Early recognition and decisive action are critical, especially when a high-risk complication, such as a tracheoinnominate fistula, could be lurking just beneath the surface.

1️⃣ Protect the Airway First

• Sit patient up.
• Hyperinflate the trach cuff to tamponade bleeding.
• If needed, apply finger pressure inside the stoma.
• Use large-bore suction to clear blood and visualize.

2️⃣ Support Oxygenation & Access

• Deliver oxygen via the trach.
• Get large-bore IV access for possible fluid and blood resuscitation.

3️⃣ Call for Immediate Help

• ENT or Thoracic Surgery.
• Anesthesia.
• OR and critical care team.

4️⃣ Prepare for Definitive Intervention

• Move urgently to OR or Interventional Radiology.
• Always take small bleeds seriously — they may signal an impending tracheo-innominate fistula (TIF).

🎧 Deep Cuts

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🎸 Great! Welcome to the Deeper Cuts for this Topic

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Curated MedEd

Here’s everything an emergency clinician needs to know to manage their patients with a TIF properly. First10EM is a free, open-access medical education (FOAMed) platform created and run by Dr. Justin Morgenstern, dedicated to high-quality education focused on resuscitation and evidence-based medicine. Watch this video, visit his site, and add it to your learning network.

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Surgical Management

• Bronchoscopy (flexible or rigid) for diagnosis and airway control.
• Surgical Approach: Sternotomy is preferred for optimal exposure.
• Definitive Treatment: Ligation of the innominate artery (preferred) vs. reconstruction (higher failure rates).
• Tracheal Repair: Debridement and suturing, reinforced with a muscle flap (sternocleidomastoid or strap muscles).
• Alternative & Emerging Treatments:
• Endovascular stent grafts for temporary hemorrhage control.
• Reconstruction with a vein graft if the patient has critical vascular anatomy (e.g., severe left carotid stenosis).
• Postoperative Considerations:
• Maintain airway with an 8-mm endotracheal tube below the repair site.
• Control blood pressure to prevent rebleeding.
• Leave the tracheostomy site open for dressing changes.
• Outcomes & Prognosis:
• Survival rates range from 25-50%.
• Long-term survival is poor (<25% at one year).
• High risk of infection and mediastinitis after sternotomy.

What to do for a Patient With A Bleeding Trach

Tracheostomy patients that are bleeding from their tracheostomy…Knowing what to do and how to manage this quickly and efficiently. Dr Kelly Cranes dives into this in more detail in the video below 👇

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The Bottom Line

Bleeding from a tracheostomy demands immediate attention, and the patient’s timeline matters. Early bleeding is usually related to procedural trauma or local irritation, while late bleeding raises the alarm for serious complications like tracheoinnominate fistula (TIF). TIF typically develops between days 3 and 14 as pressure from the tube or cuff erodes into the innominate artery, leading to a potentially fatal hemorrhage. A small, self-limited “sentinel bleed” may be the only early warning. Always stabilize the airway first, hyperinflate the cuff to tamponade bleeding, and call for surgical help early. When it comes to trach bleeds, think fast, act early, and respect even minor bleeding as a possible signal of disaster.

References:

Open Evidence