February 27, 2021

Troubleshooting Tracheostomies

By ejschwartz

Dr. Haefke is a PGY 2 in Emergency Medicine at the Mayo Clinic.

Intro Case: It is 3:00 AM. You are working in a community hospital with no surgical backup. A patient presents with a chief complaint of “Tracheostomy Problem”.

You enter the room and see an older gentleman with a tracheostomy in obvious respiratory distress. A quick listen to his lungs demonstrates that he is not moving air at all. You look around for a Respiratory Therapist to help, but your nurse tells you they are caring for a patient in the ICU and won’t be at the bedside for at least 10 minutes.

Do you know what to do?

Learning Objectives:

This blog post will serve as a primer for understanding the basic parts of tracheostomy tubes and caring for them in the Emergency Department.

Indications & Human Anatomy

Indications for Tracheostomy Placement

There are several reasons why a patient may require a tracheostomy to be placed as part of their medical care. By far, the most common is prolonged ventilation in an ICU setting, in which case an orotracheal tube is exchanged for a tracheostomy tube to allow the patient to be awake, communicate with loved ones, and even participate with rehab therapy while still receiving mechanical ventilation. This scenario alone accounts for two-thirds of all indications for tracheostomy1. Some less common reasons would include a patients undergoing a surgical laryngectomy (usually due to malignancy), patients with severe upper airway obstruction (e.g. severe OSA), and rarely for an elective surgery for which orotracheal intubation is desired but technically impossible.

Human Anatomy

It is important to delineate a tracheostomy from a cricothyroidotomy, a procedure already familiar to emergency physicians. A cricothyrotomy is an incision through the cricothyroid membrane. In contrast, a tracheostomy is traditionally performed between the cricoid and 1st tracheal ring, or between the 1st, 2nd, or 3rd tracheal rings.

A second important distinction is that a cricothyrotomy (“otomy” = incision) is intended to provide emergency oxygenation for a short period of time, while a tracheostomy (stoma = mouth) intend to form a permanent or semi-permanent opening or “stoma” between the trachea and the body’s exterior. Finally, the location of a tracheostomy may vary in location based on approach. A percutaneous tracheostomy is typically above or below the 1st tracheal ring, while a traditional surgical tracheostomy may be placed substantially lower. In reality, either a percutaneous or surgical tracheostomy can be done at any tracheal ring level.

Tracheostomy Anatomy

In its most basic form, a tracheostomy tube is a catheter communicating between the trachea and the outside world. However, not all tracheostomy tubes are alike, and understanding the features present on your patient’s device is a critical part of providing good care.

Inner Cannula & Obturator

Many tracheostomy devices are not simply one tube, but have an inner cannula that can be removed and exchanged. In addition, tracheostomy tubes are placed and exchanged with an obturator in place, which occludes the lumen of the tube and gives it a rounded edge. If you pull a new tracheostomy tube out of a package, it will probably have both of these inserted.

•Patients will often remove or replace the inner cannula at home to clear it of mucus and debris that accumulates.

•The size of the inner cannula is designed to interface with the standard 15 mm connector on BVMs and ventilator tubing. If the inner cannula is removed, the patient will still be able to move air spontaneously but you will not be able to provide external ventilation.


Some tracheostomy tubes have an inflatable cuff, materially identical to the one on the end of an endotracheal tube. Tubes with a cuff should have an apparent cuff port with a pilot balloon on their exterior. When the cuff is inflated, all air will be delivered to the distal airway, with no passage to the proximal trachea or upper airway.

•An inflated cuff is necessary for providing any sort of positive pressure ventilation

•A cuff can also be useful in protecting the patient’s lungs from unmanaged secretions.

•An inflated cuff also prevents a patient from phonating, as they cannot direct air towards their proximal trachea & vocal cords.


A fenestrated tracheostomy tube is the antithesis of a cuffed tube. It allows free air exchange between the upper and lower airways. It is typically placed as part of the process of weaning a tracheostomy and assessing if the patient is a candidate for decannulation3.

•A fenestrated tube cannot be effectively used for ANY form of positive pressure ventilation, and if the patient requires this the tube must be exchanged.

Speaking Valve

A speaking valve is essentially a one-way valve placed on the opening of the tracheostomy tube. When this is in place, a patient may draw air inward through the tube, but on exhalation all air will be forced upward to the proximal trachea and through the vocal cords. This is placed on patients to allow them to phonate more easily while they have a tracheostomy in place.

•One prominent manufacturer of speaking valves is the company Passy-Muir. Due to this, you may hear them referred to at “Passy-Muir valves” or “PMVs.”

•For any patient in extremis, this should be immediately removed to take it out of the equation.

Important pearl: If a patient has an inflated cuff AND a speaking valve applied at the same time, they have no channel for exhalation and essentially cannot breathe. Patients discharged with a cuffed tracheostomy tube should have received extensive education to prevent this...but mistakes happen!

The Flange Tells All

How can you ever keep all of these features straight? Fortunately, the flange (neck plate) of each tracheostomy tube clearly shows its features.

•“Size” is a measure of the inner diameter of the tube. Larger sizes also increase in length. You can think of these values a being analogous to endotracheal tube sizing.

•“ID” (inner diameter) is the size of the channel ventilation can occur through.

•“OD” (inner diameter) is the maximum circumference of the tube, and is the determiner of whether the tube will physically fit in the patient’s airway.

•If a flange shows “FS” “CFS” or “FEN”, these are codes indicating a fenestrated tube.


It is easy for us to feel intimidated when we see a patient with a tracheostomy, especially if their presenting complaint has to do with the tracheostomy itself. However, in reality these devices are not complicated. Being able to identify the size and features of a tracheostomy tube will enable emergency physicians to quickly troubleshoot

Case Resolution: You rapidly assess the older gentleman, and find that he has a 6.0 cuffed tracheostomy tube, with the pilot balloon currently inflated. You also note that he has a speaking valve connected. You quickly remove the speaking valve, which provides the patient with instant relief of his dyspnea. Through further discussion with the patient and his wife, you learn that he recently had a laryngectomy and is adjusting to caring for his tracheostomy at home. You provide him and his wife education regarding the safe use of speaking valves, and how his cuff should always be deflated when the speaking valve is in place. He is very appreciative, and you discharge him home in excellent condition.


1.Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes Nora H Cheung and Lena M Napolitano Respiratory Care June 2014, 59 (6) 895-919; DOI: https://doi.org/10.4187/respcare.02971

2.Epstein SK. Anatomy and physiology of tracheostomy. Respir Care. 2005 Apr;50(4):476-82. PMID: 15807905.

3. Dean Hess. Tracheostomy Tubes. Respiratory Care, April 2005. http://rc.rcjournal.com/content/respcare/59/6/956.full.pdf

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