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A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care

Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.


Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.

Elizabeth Gould, NP-C, CORLN, Krystal Craddock, BSRC, RRT, RRT-ACCS, RRT-NPS, AE-C, CCM, Tyler Le Tellier, RRT, Brooks T Kuhn, MD, MAS | May 29, 2024
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Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), the University of California, Davis, Health must ensure balance, independence and objectivity in all its CME activities to promote improvements in health care and not proprietary interests of a commercial interest. Authors, reviewers and others in a position to control the content of this activity are required to disclose relevant financial relationships with ineligible companies related to the subject matter of this educational activity. The Accreditation Council for Continuing Medical Education (ACCME) defines an ineligible company as “as any entity whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients” and relevant financial relationships as “financial relationships in any amount occurring within the past 24 months that create a conflict of interest.

Krystal Craddock, MSc, RRT, FAARC disclosed a relevant financial disclosure with an ineligible company related to this CME activity which has been mitigated through UC Davis Health, Office of Continuing Medical Education procedures to meet ACCME standards.

Krystal Craddock, MSc, RRT, FAARCFisher & PaykelSpeaker

Debra Bakerjian, PhD, APRN, RN; Elizabeth Gould, NP-C, CORLN; Brooks T Kuhn, MD, MAS; Tyler LeTellier, RRT and Patrick Romano, MD, MPH and for this Spotlight Case and Commentary have disclosed no relevant financial relationships with ineligible companies related to this CME activity. 

Learning Objectives

  • Describe the risk factors of tracheostomy complications, especially in the days immediately after insertion.
  • Identify common pitfalls in the inter-facility transfer of patients with recent placement of tracheostomies.
  • Understand tracheostomy maintenance and complication-preventive interventions.

The Case

A 55-year-old man with a history of osteoarthritis and supraventricular tachycardia was admitted with a 3-day history of left-sided chest pain, cough, and shortness of breath. He was found to have severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). His respiratory failure worsened, and he was ultimately transferred to the intensive care unit (ICU) and underwent endotracheal intubation and invasive mechanical ventilation. After 12 days in the ICU, he could not be weaned from mechanical ventilation and underwent a tracheostomy. Two days later, he was transferred directly to a long-term care hospital (LTCH) for continued mechanical ventilation weaning. At transfer, the LTCH did not receive tracheostomy-specific instructions (i.e., when tracheostomy tube should be changed, how it should be managed, etc.). A physician and respiratory therapist performed intake assessments, but their documentation only addressed ventilator management, not tracheostomy management (e.g., protocols for tube change, suctioning, humidification, or monitoring for mucus plugs). Several days after transfer, the patient was found to be tachypneic with a respiratory rate of 29, complaining of difficulty breathing. Increased resistance was noted with suctioning. Later that day, the patient experienced a cardiac arrest, during which the resuscitative team was unable to ventilate the patient.

On post-mortem evaluation, the tracheostomy tube was found to be plugged with blood clots and thick mucus. Retained sutures were in place with no evidence the tracheostomy tube had ever been changed. A review of the physician, nursing, and respiratory therapy notes found no tracheostomy management plan.

The Commentary

By Elizabeth Gould, NP-C, CORLN, Krystal Craddock, BSRC, RRT, RRT-ACCS, RRT-NPS, AE-C, CCM, Tyler Le Tellier, RRT, Brooks T Kuhn, MD, MAS


This case highlights some of the issues that may arise when caring for patients with a tracheostomy: premature transfer to a lower level of care during a high-risk period after tracheostomy, lack of tracheostomy-related communication between facilities and clinicians, and the ill effects of tracheostomy occlusion. Any patient with a recently placed tracheostomy must be stable enough for transport and ongoing management before transfer to a post-acute care setting. Clinicians must understand how to maintain and manage tracheostomies, how to troubleshoot problems, and how to prevent and resolve emergency situations.

The patient in this case died after a series of events and decisions that culminated with cardiopulmonary arrest due to an occluded tracheostomy tube. Given the failure to wean from mechanical ventilation, the decision to place a tracheostomy tube was correct. Mechanical ventilation by tracheostomy has several advantages over ventilation through endotracheal tubes, including a more secure airway, allowing transfer to lower levels of care. However, many clinicians delay transfers out of the ICU, let alone to a LTCH, until after the tracheostomy site has matured and post-tracheostomy complications have been managed or avoided. During this patient’s transfer, no plan was conveyed for tracheostomy care, and standard maintenance was not performed to prevent airway occlusion at the LTCH. This commentary will discuss tracheostomy function, proper care, risks and complications, including how tracheostomy needs should be handled at care transitions.

Tracheostomy Management 

Adult tracheostomy tubes usually include inner and outer cannulas. The outer cannula maintains the patency of the stoma, and the inner cannula is more frequently changed to avoid infection and occlusion.1 The inner cannula should be changed or cleaned regularly depending on manufacturer instructions for use, commonly multiple times per day or week, to ensure secretions do not accumulate inside the cannula.1 If, at any time, a patient experiences dyspnea or shows signs of obstruction, the inner cannula should be changed as a first-line intervention.1 Single cannula tubes are sometimes used for patients with specific anatomical challenges, but they require cannula change every one to two weeks,1 and some subacute care facilities do not accept patients with these tracheostomy tubes due to concern for obstruction.1 Even small changes in luminal size can significantly reduce flow and ventilation through a tracheostomy tube. Regardless of the type of tracheostomy tube, patients require regular assessment and monitoring to ensure airway patency and function, to prevent mucus plugging, and to intervene quickly if needed to restore effective ventilation.

Artificial airways such as tracheostomies bypass the mucosa in the upper airway, which is responsible for heating and humidifying inhaled air.2 As a result, adequate humidification must be provided by other means, especially when high gas flows are delivered via mechanical ventilation. Typically, in long-term care facilities, heat moisture exchangers (HME) or heated humidifiers (HH) are used. HMEs are condensers of disposable foam, synthetic fiber, or paper, with a surface area that retains heat and moisture from each exhaled breath and returns it to the patient on each inspiration.2 HHs allow air to pass over a heated water surface, providing circulating gas with heat and humidity.2 Although a Cochrane review demonstrated no difference between HME and HH regarding airway blockages, with overall low quality of evidence, patients must meet several parameters to use an HME effectively, including adequate body temperature and minute ventilation.3 HMEs have additional limitations, including added dead space and resistance.2 Clinicians must be cognizant of these limitations, recognize when the HME is impeding ventilation, and have alternative options available. Regardless of the device, humidified air is necessary to prevent inspissated mucous, which can lead to airway occlusion, as in this case.

Complications of tracheostomy can occur days, months, or even years after placement. In the short term, emergent complications include tube decannulation, tube obstruction, and hemorrhage.4 To prevent dislodgement and undesired movement, many proceduralists place sutures at the flange of the tracheostomy tube, but consensus on the effectiveness of this approach is lacking.1,5,6 Sutures can cause skin breakdown and require a plan for removal.5,7 Obstruction of the tracheostomy tube can occur due to mucous plugging, clotted blood, and tube displacement.4 Persistent bleeding from venous sources injured during the tracheostomy procedure usually presents within the first 48 hours.4 Monitoring for these complications in the early postoperative period, while providing adequate tracheostomy care, helps to minimize tracheostomy-associated morbidity and mortality.

Management of the first tracheostomy tube change is often based on the judgment of the physician who performed the procedure and patient-specific considerations, as there is limited evidence guiding best practice.8 The first tracheostomy tube change is performed to confirm that the tract is healed and to adjust the tube sizing for function and comfort.9 The timing of change is based on the placement approach (percutaneous or surgical), the patient's ability to heal and form a tract, the presence of complications, and hemodynamic and respiratory stability.6,10 A new tracheotomy tract is more prone to a false passage occurring during the first tube change, resulting in loss of the airway.11 Therefore, the first tracheostomy change is typically performed by a physician with the ability to manage complications and place an alternative artificial airway if needed. After the tract is considered established, future tube changes can be performed by non-physician clinicians or other caregivers who have been trained to perform tracheostomy tube changes.1,6,9,10,12

Expert recommendations vary about who should be involved in which tracheostomy tube changes, with some authors suggesting physician presence for the first tracheostomy tube change.6,10,12 Other recommendations include physician presence during accidental decannulations prior to the first tracheostomy tube change, and that a physician should be present whenever complications are anticipated.11,13 A clinician who may be involved in changing a tracheostomy tube should have a sufficient understanding of the patient's tracheostomy to determine whether they can perform the change.8,12,14

Timing recommendations for first tracheostomy tube changes range from 7-14 days for percutaneously placed and 3-7 days for surgically placed tubes, due to healing times.1,15 If the type of placement is unknown, no change should occur within the first five to seven days of the procedure.11,12 Long-term care hospitals should be cautious in accepting patients in the first few days following tracheostomy placement and should have staff on-site trained in managing complex airways.9 When considering transfer to a lower level of care, acute care hospitals must assess the ability of the accepting facility and the patient-specific risk of complications during the first tracheostomy change. In this case, the patient was transferred within two days of tracheostomy placement with no communicated plan regarding tracheostomy change or monitoring for complications.

Tracheostomy-Specific Considerations in Respiratory Distress

While mechanical ventilation can be lifesaving, it carries the risk of significant harm,16 requiring careful patient monitoring. Continuous pulse oximetry is used in many facilities to alert providers of possible cardiopulmonary issues, especially in patients who may not be able to communicate effectively with the nursing staff due to cognitive impairment, decreased alertness, or medication effects. Although routine continuous monitoring of oxygen saturation has been shown to decrease rates of some pulmonary complications, it did not reduce ICU transfers or overall mortality in one systematic review of controlled trials in the perioperative setting.17 Capnography measures the partial pressure of expired carbon dioxide (PeCO2). Accurate measurements of PeCO2 are acceptable estimates of alveolar PCO2. However, the PeCO2 and arterial CO2 (PaCO2) in patients with pulmonary disease can be widely different.12 SpO2 and PeCO2 monitoring can provide visual and audible alarms, but these alarms must be set appropriately, and providers must be able to recognize causes and troubleshoot problems. Clinicians may need help determining how to set alarm delays, widen parameter settings, or turn off parameters, as there are few evidence-based best practices.18 Additionally, clinicians exposed to significant volume and frequency of alarms may experience desensitization, also known as alarm fatigue.19 Clinicians need to be familiar with what low versus high priority alarms sound like and what to do when these occur.18 When monitoring a mechanically ventilated patient, three questions should be considered: Why are we monitoring, how good are the monitoring tools, and does monitoring lead to a change in management improving outcomes?16 Finally, clinicians need to know when not to rely solely on alarm numbers and how to assess the patient’s clinical presentation.

Systems Change Needed

It is essential for clinicians to have suitable experience and training for specialty needs such as tracheostomy care. This case illustrates how, unfortunately, tracheostomy management is often overlooked, and such errors can lead to grave consequences. In addition, although we do not know the race or ethnicity of this patient, it has been found that patients of color have experienced higher mortality in relation to tracheostomies compared with white adults. Clinicians should also assess the patients with tracheostomies who may be at increased risk for greater morbidity and mortality, including patients of color.20

Post-tracheostomy care is not codified into universally accepted pathways; therefore, provider-specific approaches can lead to miscommunication during transitions of care between ICU and lower levels of care, and especially between institutions including transition to LTCH facilities. These transitions are not just between physical locations, but between providers with different procedural expertise. Institutions should implement clear and standardized communication of information to ensure optimal care is provided during and after transitions. These hand-offs should include a plan for the next tracheostomy change, an explanation of complications that have occurred or may occur, a strategy and devices for humidification and mucous clearance, and coordination with mechanical ventilation weaning. In addition, all staff who care for tracheostomies should be trained in the emergency management of patients with tracheostomies, including dislodged and occluded tubes.21 Clinicians should have an appropriately sized tracheostomy tube replacement, including an inner cannula and obturator, at the bedside of all patients.


This case highlights the need for appropriate tracheostomy maintenance, specialized training in emergency management of patients with tracheostomies, and tracheostomy-specific communication in care transitions. Many patients need tracheostomies to enable them to benefit from mechanical ventilation when recovering from severe respiratory, neuromuscular, or cardiac disease. In caring for these patients, the tracheostomy and accompanying tube cannot be ignored.

Take Home Points

  • Tracheostomies offer long-term airway management as a destination therapy or as a bridge to recovery.
  • Tracheostomy tubes require maintenance and monitoring by trained clinicians who can prevent, identify, and manage complications, ideally before they become severe.
  • Transitions of care—especially between facilities—require sharing a plan regarding tracheostomy tube care, maintenance, and any potential complications that may arise.

Elizabeth Gould, MSN, NP-C, CORLN
ENT and Tracheostomy Advance Practice Specialist Nurse
UC Davis Health

Krystal Craddock, MSc, RRT, FAARC
Reversible Obstructive Airway Disease (ROAD) Respiratory Therapist
Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine
UC Davis Health

Tyler LeTellier, RRT
Inpatient Tracheostomy Team – Respiratory Care
Department of Otolaryngology, Head and Neck Surgery 
UC Davis Health

Brooks T Kuhn, MD, MAS
Assistant Professor of Clinical Medicine
Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine
UC Davis Health


  1. Bodenham A, Bell D, Bonner S, et al. Standards for the care of adult patients with a temporary tracheostomy: standards and guidelines. Intensive Care Society Standards. 2014. [Available at]
  2. Plotnikow GA, Accoce M, Navarro E, et al. Humidification and heating of inhaled gas in patients with artificial airway. A narrative review. Rev Bras Ter Intensiva. 2018;30(1). [Free full text]
  3. Gillies D, Todd DA, Foster JP, et al. Heat and moisture exchangers versus heated humidifiers for mechanically ventilated adults and children. Cochrane Database Syst Rev. 2017;9(9):CD004711. [Free full text]
  4. Bontempo LJ, Manning SL. Tracheostomy emergencies. Emerg Med Clin N Am. 2019; 37(1):109-119. [Available at]
  5. Fine KE, Wi MS, Kovalev V, et al. Comparing the tracheostomy dislodgement and complication rate of non-sutured neck tie to skin sutured neck tie fixation. Am J Otolaryngol. 2021 Jan-Feb;42(1):102791. [Available at]
  6. Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Neck Surg. 2013;148(1):6-20. [Free full text]
  7. Mussa CC, Gomaa D, Rowley DD, et al. AARC Clinical Practice Guideline: management of adult patients with tracheostomy in the acute care setting. Respir Care. 2021;66(1):156-169. [Free full text]
  8. Tabaee A, Lando T, Rickert S, et al. Practice patterns, safety, and rationale for tracheostomy tube changes: a survey of otolaryngology training programs. Laryngoscope. 2007;117(4):573-576. [Available at]
  9. White AC, Kher S, O’Connor HH. When to change a tracheostomy tube. Respir Care. 2010;55(8):1069-1075. [Free full text]
  10. Ng J, Hamrang-Yousefi S, Agarwal A. Tracheostomy Tube Change. In: StatPearls. Treasure Island (FL): StatPearls Publishing, 2023. [Free full text]
  11. Raimonde AJ, Westhoven N, Winters R. Tracheostomy. In: StatPearls. Treasure Island (FL): StatPearls Publishing, 2023. [Free full text]
  12. Hess DR, Altobelli NP. Tracheostomy tubes. Respir Care. 2014;59(6):956-973. [Free full text]
  13. De Leyn P, Bedert L, Delcroix M, et al. Tracheotomy: clinical review and guidelines. Eur J Cardiothorac Surg. 2007;32(3):412-421. [Free full text]
  14. McGrath BA, Thomas AN. Patient safety incidents associated with tracheostomies occurring in hospital wards: a review of reports to the UK National Patient Safety Agency. Postgrad Med J. 2010;86(1019):522-525. [Available at]
  15. Hashimoto DA, Axtell AL, Auchincloss HG. Percutaneous tracheostomy. N Engl J Med. 2020;383(20):e112. [Free full text]
  16. Rackley CR. Monitoring during mechanical ventilation. Respir Care. 2020;65(6):832-846. [Free full text]
  17. Pedersen T, Nicholson A, Hovhannisyan K, et al. Pulse oximetry for perioperative monitoring. Cochrane Anaesthesia Group, ed. Cochrane Database Syst Rev. 2014;2014(3):CD002013. [Free full text]
  18. Scott JB, De Vaux L, Dills C, et al. Mechanical ventilation alarms and alarm fatigue. Respir Care. 2019;64(10):1308-1313. [Free full text]
  19. Bonafide CP, Lin R, Zander M, et al. Association between exposure to nonactionable physiologic monitor alarms and response time in a children’s hospital. J Hosp Med. 2015;10(6):345-351. [Free full text]
  20. Cramer JD, Graboyes EM, Brenner MJ. Mortality associated with tracheostomy complications in the United States: 2007–2016. Laryngoscope. 2019;129(3):619-626. [Available at]
  21. Budde AM, Kadar RB, Jabaley CS. Airway misadventures in adult critical care: a concise narrative review of managing lost or compromised artificial airways. Curr Opin Anaesthesiol. 2022;35(2):130-136. [Available at]
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This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers

Gould E, Craddock K, Le Tellier T, et al. A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2024.

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