Tracheostomy Emergencies: Decannulation and Obstruction

A tracheostomy creates an artificial airway through an incision in the anterior tracheal wall between the 2nd and 4th tracheal cartilage rings, bypassing the upper airway. The tracheostomy tube sits within the tracheal lumen, secured by a flange and ties or a commercial holder. Fresh tracheostomy tracts (less than 7-10 days) are not yet epithelialized, meaning the tract can close rapidly if the tube is accidentally dislodged (accidental decannulation), making reinsertion extremely difficult and potentially creating a false passage into the pretracheal tissues. Mature tracts (established after 7-14 days) have an epithelialized stoma that maintains patency longer. Tube obstruction occurs when thick mucus, blood clots, or granulation tissue occludes the tube lumen or inner cannula. Tracheal granulation tissue forms as a foreign body response to tube contact with the mucosa, causing chronic inflammation and fibroblast proliferation. The bypass of the upper airway eliminates normal humidification, filtration, and warming functions of the nose and oropharynx, making the lower airway vulnerable to thick secretions and infection.