Tracheostomy displacement in ICU — FFICM MCQ

Correct answer: A — Remove the tracheostomy tube and oxygenate from above

The correct answer is A, remove the tracheostomy tube and oxygenate from above. At 48 hours the tract is immature and unreliable, so a sudden desaturation with poor air entry, lost capnography trace and difficult bagging through the tube indicates probable tube displacement or complete obstruction (clot, mucus plug) rather than a ventilator or pressure problem. The National Tracheostomy Safety Project patent upper airway algorithm mandates removing a non-functioning tube and reverting to oronasal oxygenation or bag-mask ventilation while covering the stoma, since a tracheostomy in situ that cannot ventilate is worse than no tube at all. This patient still has a patent upper airway (surgical tracheostomy, no laryngectomy), so oxygenating from above is both safe and immediately life-saving while help and equipment for a formal airway exchange are gathered. Why the other options are wrong: C. Advance the tracheostomy tube with an introducer: blind advancement through an immature 48 hour old tract risks creating or extending a false passage in the pretracheal tissues, worsening obstruction and causing surgical emphysema or mediastinal compromise. E. Wait for an urgent chest radiograph: this delays definitive action in a desaturating, cyanosed patient; imaging has no role until the airway and oxygenation are secured. B. Insert a smaller tracheostomy tube blindly: same false passage risk as option C, and doing this blindly without confirming tract position is dangerous in an early, unestablished stoma. D. Increase ventilator pressure support: this assumes a ventilator or compliance problem, but the lost capnography trace and difficult bagging point to tube obstruction or malposition, which higher pressures will not overcome and may cause barotrauma. Key point: In an unestablished (less than 7 day) tracheostomy that fails to ventilate with a patent upper airway, remove the tube immediately and oxygenate from above rather than attempting blind reinsertion or exchange.

Reference: National Tracheostomy Safety Project, Emergency Tracheostomy Management: Patent Upper Airway algorithm, tracheostomy.org.uk (reviewed 2016, endorsed by FICM/ICS)