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The patient with a tracheotomy presents a special circumstance when experiencing respiratory distress. An initial consideration is whether the distress is directly related to the tracheotomy itself. If not, then assessment and treatment should proceed as it would otherwise, with the added benefit of an effectively secured airway already in place.

Respiratory distress related to tracheotomies generally relates to complications that manifest as airway obstructions. Commonly, secretions are the culprit, causing mucus plugging or drying inside the cannula and resulting in various degrees of obstruction. Initially, EMS clinicians should attempt to suction the airway through the inner cannula of the tracheotomy tube. Except in children, whose tracheotomy tubes have no inner cannula, the clinician can remove it if suctioning is inadequate. If there is no relief, the clinician should suction through the tracheotomy tube. Small aliquots of saline instilled into the tube may help loosen secretions to improve suctioning results. In the event that an appropriately sized suction catheter cannot be passed into a tracheotomy tube, it may also be removed with important considerations.

The longer the tracheotomy has been in place, the more mature and stable the tract is. While the inner cannula can be safely removed, the tracheotomy tube should generally not be removed if the surgery to place it was recent, especially within 7 days. Risks include airway collapse and the potential to create a false passage during attempts to reintubate the stoma. In any case, the EMS clinician must be prepared for a difficult airway situation (see Chapter 3). Unless the tracheotomy was concomitant with laryngectomy, the patient may be intubated orally. He or she can also be reintubated through the existing stoma, using an appropriately sized endotracheal tube. A gum elastic bougie can be used to facilitate such a tube change.

Bleeding from a tracheotomy can occur early or later after its placement. Bleeding at the site, until definitive hemostasis can be accomplished, may be controlled with application of hemostatic dressings. Bleeding within the airway, causing respiratory distress, may be cleared with suctioning through the tracheotomy inner cannula or tube. In critical circumstances, the tracheotomy tube may be removed so that the stoma can be reintubated with an endotracheal tube that is advanced distal to the site of bleeding to secure the airway. In some cases, the endotracheal tube cuff may also tamponade the bleeding source, and overinflation of the tracheotomy cuff or the endotracheal tube cuff may be considered.

While tracheotomies provide a potential source of respiratory distress, it is important that their presence does not result in overlooking other causes, as discussed. If supplemental oxygen is necessary, humidification is appropriate to prevent drying of secretions.