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Displaced Tracheostomy — FRCA Final MCQ

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HardAirway ManagementDisplaced TracheostomyFRCA Final

A 66-year-old man has a surgical tracheostomy performed on day 10 of an ICU admission solely to facilitate prolonged ventilation. Two days later, the tracheostomy tube is coughed completely out. The upper airway was straightforward before tracheostomy and there is no upper-airway obstruction. After calling for expert help and applying high-flow oxygen to both the face and stoma, he becomes apnoeic and his oxygen saturation falls. The tracheostomy tract is immature. What is the most appropriate immediate manoeuvre to provide positive-pressure oxygenation?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: A — Occlude the stoma and provide bag-mask ventilation through the mouth and nose

Explanation lettering: B = shown as A · A = shown as B · D = shown as C · C = shown as D

B is correct. This is complete decannulation from a two-day-old, immature tract in a patient with a known patent upper airway. The immediate priority is oxygenation: occluding the stoma prevents a major leak and permits bag-mask ventilation from above. Blind reinsertion through an immature tract risks pretracheal placement, surgical emphysema and loss of time. Bronchoscopy may facilitate a subsequent visually guided stoma approach but is not the first oxygenation manoeuvre. Waiting for surgical replacement is unsafe during desaturation. Oral tracheal intubation is an appropriate secondary airway strategy if facemask or supraglottic-airway ventilation is inadequate, but immediate oxygenation should be attempted first. This sequence assumes that help has already been summoned and oxygen applied to both potential airways.

Reference: Royal College of Anaesthetists. Guide to the FRCA Examination, SOE 1: Tracheostomies and their complications, 2020. https://www.rcoa.ac.uk/media/49226