The Intern At Work: Internal Medicine
Oct 11, 2026 · 17 min · 10 segments
Send us Fan Mail Written by: Dr. Tharaniya Vallipuram (Internal Medicine Resident) & Dr. Liang Chen (General Internal Medicine & ICU Fellow)…
After three and a half weeks in the ICU, she could not be extubated due to extensive secretions.
Therefore, tracheostomy was performed.
During her AM hygiene care, three days after the tracheostomy insertion, she was turned over to her side and cleaned.
However, upon returning her back supine, the tracheostomy tube fell out.
You were called urgently to the bedside.
Inadvertent tracheostomy tube decannulation can occur after placement.
However, decannulations within the first week of placement are most concerning, because the stoma has not had enough time to form and mature, and tracheocutaneous tract is narrower, which increases the risk of airway loss.
When decannulation occurs, there are important questions to consider.
1.
Is this a tracheostomy or laryngectomy? 2.
How long ago was the tracheostomy placed? 3.
How long before the presentation did the tracheostomy come out? And four, is the patient being ventilated? The priority in this case is to replace the tube without delay.
Even a mature stoma may significantly narrow over the course of hours, making delayed recannulation more challenging and necessitating a smaller tracheostomy tube for replacement.
Within the first week of placement, replacement should be done with direct visualization with fiber optic endoscopy to reduce the risk of creating false passage.
If not possible, then oral intubation may be needed to secure the airway.
If the tracheostomy is over 7 days old before the incidence of dislodgement, a new trach tube may be inserted through the stoma with placement confirmed by fiber optic visualization.
Regardless of stoma age, if resistance is met, recannulation should be paused, a smaller trach tube should be selected, and insertion reattempted.
After three and a half weeks in the ICU, she could not be extubated due to extensive secretions.
Therefore, tracheostomy was performed.
During her AM hygiene care, three days after the tracheostomy insertion, she was turned over to her side and cleaned.
However, upon returning her back supine, the tracheostomy tube fell out.
You were called urgently to the bedside.
Inadvertent tracheostomy tube decannulation can occur after placement.
However, decannulations within the first week of placement are most concerning, because the stoma has not had enough time to form and mature, and tracheocutaneous tract is narrower, which increases the risk of airway loss.
When decannulation occurs, there are important questions to consider.
1.
Is this a tracheostomy or laryngectomy? 2.
How long ago was the tracheostomy placed? 3.
How long before the presentation did the tracheostomy come out? And four, is the patient being ventilated? The priority in this case is to replace the tube without delay.
Even a mature stoma may significantly narrow over the course of hours, making delayed recannulation more challenging and necessitating a smaller tracheostomy tube for replacement.
Within the first week of placement, replacement should be done with direct visualization with fiber optic endoscopy to reduce the risk of creating false passage.
If not possible, then oral intubation may be needed to secure the airway.
If the tracheostomy is over 7 days old before the incidence of dislodgement, a new trach tube may be inserted through the stoma with placement confirmed by fiber optic visualization.
Regardless of stoma age, if resistance is met, recannulation should be paused, a smaller trach tube should be selected, and insertion reattempted.
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