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Acute airway obstruction in a patient with a total laryngectomy — MRCEM SBA MCQ

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HardRespiratory emergenciesAcute airway obstruction in a patient with a total laryngectomyMRCEM SBA

A 67-year-old man attends the emergency department with rapidly worsening breathlessness. He underwent a total laryngectomy eight months ago and has a laryngectomy tube and a tracheoesophageal voice prosthesis. He is conscious and breathing spontaneously, but his SpO₂ is 82% despite high-flow oxygen applied to the stoma. The resuscitation and airway teams have been called. After removal of the stoma cover and inner cannula, an appropriately sized suction catheter cannot be advanced through the outer tube. His breathing and oxygen saturation continue to deteriorate. What is the most appropriate immediate next action?

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

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Correct answer: B — Remove the laryngectomy tube and deliver oxygen directly to the stoma.

The failed attempt to pass an appropriately sized suction catheter after removal of the cover and inner cannula indicates that the remaining laryngectomy tube may be obstructed or displaced. As the patient is deteriorating, the emergency laryngectomy algorithm directs removal of that tube, followed by reassessment and reapplication of oxygen to the stoma. Total laryngectomy creates an end stoma: the mouth and nose do not provide a route to the lungs. Airway expertise and resuscitation support are already being summoned. ([royalwolverhampton.nhs.uk](https://www.royalwolverhampton.nhs.uk/wp-content/uploads/2025/06/CP_01_PUBLIC_Policy_Printable_Version.pdf?utm_source=openai)) A is attractive because a mucus plug may respond to suction, but repeated attempts through a tube that will not admit the catheter delay removal; suction is appropriate when the catheter passes. C confuses the voice prosthesis with an obstructed airway tube: the prosthesis should remain in place. D would be relevant to a patient with a patent upper airway, such as someone with a tracheostomy rather than a total laryngectomy. E may become necessary if breathing fails after tube removal and oxygenation or ventilation via the open stoma is inadequate. It does not precede removal and reassessment of the potentially obstructed tube in this spontaneously breathing patient. ([royalwolverhampton.nhs.uk](https://www.royalwolverhampton.nhs.uk/wp-content/uploads/2025/06/CP_01_PUBLIC_Policy_Printable_Version.pdf?utm_source=openai))

Reference: CP01, Appendix 4: Emergency Algorithm for Laryngectomy Patients (Approved June 2025) — https://www.royalwolverhampton.nhs.uk/wp-content/uploads/2025/06/CP_01_PUBLIC_Policy_Printable_Version.pdf