Tracheostomy emergencies: blocked or displaced tube

What it is

Patients with a tracheostomy breathe through a tube in the front of the trachea. The commonest life-threatening problems are tube blockage by secretions or blood clots and tube displacement, especially in the first days before the tract has formed. A key question is whether the upper airway is still connected: after a laryngectomy the patient breathes only through the neck stoma and cannot be oxygenated or intubated through the mouth. Emergency algorithms used by ENT, anaesthesia and critical care teams follow the same logic: oxygenate, test the tube, and remove it if it is blocked or misplaced.

How to recognise it

• Respiratory distress, noisy breathing, falling saturation, agitation.
• Loss of the capnography trace or inability to pass a suction catheter.
• Subcutaneous emphysema or a tube that looks longer or moves (displacement or false passage).
• Bedside equipment: spare tubes of the same and a smaller size, obturator, suction, and a sign stating whether the upper airway is patent.

Step-by-step management

1. Call for help from an airway expert; give high-flow oxygen to the face and the stoma, and attach capnography.
2. Remove any speaking valve or cap and the inner cannula; clean or replace the inner cannula.
3. Try to pass a suction catheter: if it passes, suction and assess; the tube is probably patent.
4. If it does not pass, deflate the cuff and reassess breathing.
5. If there is no improvement, remove the tracheostomy tube.
6. Then oxygenate via the face (bag-mask, covering the stoma) or via the stoma (small mask or supraglottic device over it).
7. Secondary airway by an expert: oral intubation past the stoma, or a smaller tube through the stoma, ideally with a fibrescope.

Red flags

• Desaturation, cyanosis or respiratory arrest.
• No air movement through the tube, no capnography trace.
• Bleeding from the stoma or tube, especially a small sentinel bleed.
• Subcutaneous emphysema in the neck or chest.
• Displacement in the first days after the tracheostomy, before the tract has formed.

Next step / Initial management

• After stabilisation: chest X-ray for tube position, pneumothorax and emphysema; blood gas; endoscopy through the tube if needed.
• Prevention is first-line: humidification, regular suction and inner cannula care, secure ties, and bedside emergency equipment.
• Refer as an emergency, the same moment, to ENT and anaesthesia any blocked or displaced tube, especially within the first days after surgery.
• Refer as an emergency to ENT any bleeding from the tracheostomy, including a small sentinel bleed.

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Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.

Sources: Tracheostomy (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2026); Tracheostomy Tube Change (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2026); Pediatric Tracheostomy (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2026).

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