Anesthesia Patient Safety Podcast

#275 Tracheostomy and Laryngectomy Patient Safety: Bedside Signs, Algorithms, and the Discipline that Prevents Catastrophe

• Anesthesia Patient Safety Foundation • Episode 275

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A patient rolls into the OR with a tracheostomy—do you maintain the current tube, intubate orally, or go through the stoma? We break down the decision tree that keeps patients safe, from assessing tract maturity and surgical needs to choosing cuffed vs uncuffed strategies and planning for positive pressure ventilation. Then we shift to a critical safety pivot: total laryngectomy. When the trachea is sutured to the skin, the mouth and nose no longer connect to the lungs, and attempts at oral intubation can be deadly. We explain how to recognize the anatomy fast, oxygenate at the neck, and advance through a stepwise algorithm that reduces risk in time‑sensitive emergencies.

Drawing on practical pearls and human‑factors design, we highlight why bedside signs and EMR alerts matter, how standardized language improves handoffs, and where airway exchange catheters, bougies, and wire‑reinforced tubes fit into safe practice. You’ll hear clear guidance on cuff placement relative to the stoma, avoiding mainstem intubation, using waveform capnography for continuous confirmation, and preventing false passages in fresh tracheostomies. We also review eye‑opening data on attempted oral intubations after laryngectomy, underscoring the need for staff education, patient engagement, and systems that make the right move the easy one.

If you manage airways in perioperative or emergency settings, this conversation strengthens your mental models and your muscle memory. Tune in for concise, actionable steps, download the signage and algorithms from the show notes, and share the episode with your team. If this helped sharpen your airway plan, subscribe, leave a review, and tell us your go‑to approach for trach and laryngectomy cases.

For show notes & transcript, visit our episode page at apsf.org: https://www.apsf.org/podcast/275-tracheostomy-and-laryngectomy-patient-safety/

© 2025, The Anesthesia Patient Safety Foundation

SPEAKER_00:

You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.

SPEAKER_01:

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel, and I'm your host. Thank you for joining us for another show. We hope you tuned in last week for the first part of our two-part series on keeping patients safe during emergency tracheostomy management. Last week, we talked about an emergency algorithm for a malfunctioning tracheostomy and the importance of bedside signs for patients with tracheostomies. This week, we are covering what to do when a patient presents to the operating room with a tracheostomy in place for a different surgical procedure and special considerations for patients with laringectomies. Before we dive further into the episode today, we'd like to recognize Solventum, a major corporate supporter of APSF. Soul Ventum has generously provided unrestricted support to further our vision that no one shall be harmed by anesthesia care. Thank you, Soul Ventum. We wouldn't be able to do all that we do without you. Our featured article again today is Keeping Patients Safe During Emergency Tracheostomy Management by Jack Buckley. To follow along with us, head over to apsf.org and click on the newsletter heading. First one down is the current issue, and then scroll down until you get to our featured article today. You can also find the June 2025 APSF newsletter in the newsletter archives. And don't worry, I will include a link in the show notes as well. Have you provided anesthesia care for a patient undergoing a tracheostomy? Have you had to troubleshoot a malfunctioning tracheostomy before? Does your hospital use bedside signs for all patients with tracheostomies in place? There are so many great resources available in this article to help keep your patient safe. Let's do a quick review of the tracheostomy bedside sign. This is figure four in the article. The bedside sign should accompany patients with tracheostomies throughout their hospital stay. The sign says that, quote, this patient has a tracheostomy. There is a potentially patent upper airway, intubation may be difficult. Then you can circle surgical or percutaneous for the type of tracheostomy with the following information performed on and the date, the tracheostomy tube size if present, and the hospital number. There is a picture of the different types of tracheostomies, including percutaneous, bioric flap, and slit type. There are additional notes on the card to help fill it out. You can indicate the tracheostomy type by circling the relevant figure. Indicate the location and function of any sutures, laryngoscopy grade, and notes on upper airway management, any problems with this tracheostomy. Then in case of emergency, call anesthesia, ICU, ENT, MaxFax, and the emergency team. For more information about this bedside sign, you can head over to tracheostomy.org.uk and check out the show notes for more details. Now it's time to get back into the article right where we left off. When was the last time you provided anesthesia care for a patient presenting to the operating room with a tracheostomy in place? What was your plan for airway management? There are several considerations. First, we need to obtain a tracheostomy history. Does the patient have a patent upper airway? When was the tracheostomy tube placed? And more. Next, we need to know what the ventilation needs are for the procedure. The simplest option is to use a cuffed tracheostomy that will not be in the surgical field. You can use this without needing to make any changes. If there is an uncuffed tracheostomy, this may be used if positive pressure ventilation is not indicated and the procedure can be completed with spontaneous ventilation. This is a decision point. Is positive pressure ventilation going to be required during the procedure? It is also important to determine if the tracheostomy tube will be in the surgical field. Then you may need to replace the tracheostomy tube with an endotracheal tube that is placed either through the mouth or the tracheostomy stoma. Here is another decision point. Do you need to replace the tracheostomy tube with an endotracheal tube? And how will you accomplish this? Important considerations for attempting oral intubation include inexperience with replacing tracheostomies, history of easy intubation, no oral pharyngeal pathology present, and a new tracheostomy. Remember, a new surgical tracheostomy is less than four days old and less than seven to ten days old for a percutaneous tracheostomy. Factors in support of intubating through the tracheostomy stoma include the following comfort with replacing a tracheostomy, history of difficult intubation, known oral pharyngeal pathology that will make oral intubation difficult, and a mature tracheostomy with a well-healed stoma. Following oral intubation, the cuff of the endotracheal tube should be placed just beyond the stomacy to create a seal with the trachea. A wire-reinforced endotracheal tube may be needed for intubation through the stomacy to decrease the risk for kinking. The tracheal stoma is usually positioned between the second to fourth tracheal ring, and the distance from the stoma to the carina is about 6.5 centimeters. So you need to be careful to avoid placing the endotracheal tube in the main stem bronchus. It is important to listen for bilateral breath sounds after endotracheal tube placement to ensure proper position and make any changes if needed before the procedure starts. Remember, if there are any concerns for difficult placement of the endotracheal tube through the stoma, then you may want to use an airway exchange catheter to facilitate the exchange of the tracheostomy tube. This is a good option for patients with a fresh tracheostomy. Using the exchange catheter helps to minimize the risk of creating a false passage in the subcutaneous tissue with the endotracheal tube. Some exchange catheters also have an open channel to allow for insuflation of oxygen during the exchange to help decrease the risk for desaturation. Now we have a laryngectomy patient presenting to the operating room. There are special considerations for providing safe anesthesia care for these patients who have had their larynx surgically removed and their trachea sutured to the skin of their anterior neck. As a result, the trachea does not communicate with the oropharynx, which means that patients cannot be orally intubated or mask ventilated through the oral pharynx. Anesthesia professionals need to remain vigilant, especially in the setting of respiratory distress. Let's look at the literature on this. There's a 2021 article by Brenner and colleagues, Oral Intubation Attempts in Patients with a laryngectomy, a significant safety threat. The results revealed that over half of the U.S. otolaryngologists who responded to this study reported cases of attempted oral intubations in patients with laryngectomy with a resultant mortality rate of 26%. Similar results were found in the UK as well, with failed resuscitation leading to increased morbidity and mortality. The authors of this study highlight the need for staff education, patient engagement, effective signage, systems-based practices, and necessary resources as critical steps for safe airway management for laryngectomy patients. The first step for improving patient safety is to highlight that laringectomy patients do not have a patent upper airway. This can be done with a bedside sign for all laryngectomy patients, as well as placing an alert in the electronic medical record. Let's check out figure five in the article for an example of this bedside sign. The sign states this patient has a laringectomy and cannot be intubated or oxygenated via the mouth. Below that it states, follow the laringectomy algorithm of breathing difficulties. Then you can put information about the date of the procedure, the tracheostomy tube size if present, and the patient's hospital number. There is also an anatomical picture which shows the disconnection and space for notes with two important points highlighted. There may not be a tube in the stoma, and the trachea or windpipe ends at the next stoma. At the bottom of the card is information about who to call for an emergency. For more information about this bedside card, head over to www.tracheostomy.org.uk and check out the show notes for more details. Now it's time to talk about management strategies for total laryngectomy patients who experience respiratory distress. The first step is to apply an oxygen mask over the stoma site. A pediatric mask may be placed over the stoma site to provide mask ventilation. Keep in mind that most patients with a total laryngectomy do not have a cuffed tracheostomy tube in place. A cuffed tracheostomy tube or appropriately sized endotracheal tube can be placed in the stoma in the neck to provide positive pressure ventilation if needed. The tube should advance easily into the trachea since most patients have a reasonably sized stoma. Since the trachea is sutured to the skin during the laringectomy, it is more difficult to advance the tube into a false passage even after the sutures have been removed. Once again, having an algorithm for the management of respiratory distress for laringectomy patients can be helpful to provide safe care, especially during a time-critical emergency event. Check out figure six in the article for an example. We are going to review it now. The first step is to call for airway expert help and then look, listen, and feel at the mouth and laringectomy stoma. Use waveform capnography whenever available, since exhaled carbon dioxide indicates a patent or partially patent airway. The first question is: is the patient breathing? If yes, then apply high flow oxygen to the laringectomy stoma. And if there's any doubt about whether the patient has a laryngectomy, also apply oxygen to the face. If no, call the resuscitation team and begin CPR if needed. The next step is to assess the laringectomy stoma for patency. Not all laringectomy stomas will have a tube present. First, remove the humidification cover or button if present and remove the inner liner if present. Some inner liners will need to be reinserted to connect with the breathing circuit. Do not remove the tracheoesophageal puncture prosthesis if present. Now, can you pass a suction catheter? If yes, then the laringectomy stoma is patent. Perform suction, consider partial obstruction, ventilate via the stoma if not breathing, and continue to assess the patient. If no, deflate the cuff if present and look, listen and feel at the stoma. Is the patient stable or improving? If yes, continue your assessment. If no, remove the tube from the laryngectomy stoma if present and look, listen, feel at the stoma site while using waveform capnography if available. Is the patient breathing now? If yes, continue your assessment. If no, call the resuscitation team and begin CPR if needed. The steps for primary emergency oxygenation include ventilation with the pediatric face mask or LMA applied to the stoma. Secondary emergency oxygenation involves attempted intubation through the laryngectomy stoma with a 6-0 cuffed endotracheal tube or a small tracheostomy tube. Consider using the ANTRE catheter, bougie, or fiber optic scope if needed. At the bottom of the resuscitation algorithm is the statement laringectomy patients have an end stoma and cannot be oxygenated via the mouth and nose. Applying oxygen to the face and stoma is the default emergency action for all patients with a tracheostomy. You can check out this algorithm in the article and in the show notes for more details. This is an excellent resource to have available anytime you are providing care for a patient with a total laringectomy. We made it to the end of the article. Buckley reminds us that patients with tracheostomies are commonly seen in clinical practice, and we need to be prepared since complications may occur. By understanding the management steps that we talked about over the past two shows, anesthesia professionals can help to keep patients safe from harm related to their artificial airway. Bedside signs and emergency management algorithms are excellent tools to provide the necessary information for safe care in the setting of respiratory distress and a malfunctioning surgical airway. If you have any questions or comments from today's show, please email us at podcast atapsf.org. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit apSF.org for detailed information and check out the show notes for links to all the topics we discussed today. Our podcast series on the 2025 APSF Stolting Conference is coming up. If you just can't wait to learn more about transforming maternal care, we hope that you will check out the recordings from the conference, which are up now. Head over to APSF.org and click on the conferences and events heading. Then select APSF Stolting Conference 2025, where you will see the recordings. You can also check out the recordings on the APSF YouTube channel. There is so much to learn about improving maternal patient safety, and we hope that you will check it out. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.