Question about trach tube dislodgement/emergency

[Jedi of Zen]

According to my textbook, "if decannulation occurs after 72 hours, extend the client's neck and open the tissues of the stoma to secure the airway".

I assume that "extending the neck" means basically tilting the head back. This may sound like a stupid question, but should you have the patient lie flat in order to best facilitate that, or keep the patient upright so he/she can breathe easier?

I'm also wondering how extending the neck like that would help keep the stoma tissues open. I think it would be easier if the patient bends the neck (ie, with chin pointing down).

I would welcome any input on this. Thanks!

[NotReady4PrimeTime, RN]

A tracheostomy stoma is quite low on the neck, below the cricoid cartilage. Dropping the chin to the chest will make it difficult to see where the stoma is. And don't forget that this is where their airway has been diverted, for whatever reason... and this could include pharyngeal obstruction. You aren't going to be reducing their ability to breathe by extending their neck, because the entry point for air is now low on the neck. When you extend the neck you can open the stoma by putting a thumb on either side of the incision and retracting as widely as possible, thus re-establishing the airway. If you have a fresh trach tube, you can then insert it and secure it behind the neck with the included ties. This of course will take two people, one to hold the stoma open and one to insert and secure the trach tube. If there's just you, call for help first then intervene. Remember that a 72 hour old tracheostomy stoma isn't going to be healed and isn't going to hold itself open; this constitutes an emergency.

[Jedi of Zen]

A tracheostomy stoma is quite low on the neck, below the cricoid cartilage. Dropping the chin to the chest will make it difficult to see where the stoma is. And don't forget that this is where their airway has been diverted, for whatever reason... and this could include pharyngeal obstruction. You aren't going to be reducing their ability to breathe by extending their neck, because the entry point for air is now low on the neck. When you extend the neck you can open the stoma by putting a thumb on either side of the incision and retracting as widely as possible, thus re-establishing the airway. If you have a fresh trach tube, you can then insert it and secure it behind the neck with the included ties. This of course will take two people, one to hold the stoma open and one to insert and secure the trach tube. If there's just you, call for help first then intervene. Remember that a 72 hour old tracheostomy stoma isn't going to be healed and isn't going to hold itself open; this constitutes an emergency.

Thank you for your response!

What do you think about lying flat? Is that necessary or helpful to facilitate neck extension, or should the patient remain in Fowler's so that they can breathe easier by sitting more upright?

Thanks again!

[NotReady4PrimeTime, RN]

If they're conscious it really isn't an issue. If they're unconscious then they shouldn't be in high Fowler's for sure, because the head is really heavy! But whether they should be completely flat... that's probably not necessary.

[Shanny246]

Sitting the patient upright to breathe easier is for people who would breathe out of their mouths, as to prevent the tongue from falling back and constricting the airway. Keep in mind that a trach patient does not breathe through his/her mouth, so laying down flat with neck extended works well.