Practical Guide to Tracheostomy and Laryngectomy

Figure: Visualization of a tracheostomy and laryngectomy. This image is credited EMRAP and published with their permission. Illustrated by David Mason. Courtesy of CorePendium and EM:RAP.org.The EMS crew wheels in a hypoxic, middle aged man. Dispatch had reported a patient with oxygen saturations in the 70s and plans to intubate. On arrival to the emergency department (ED), he's clutching his neck and gasping for air, visibly distressed. Despite being placed on a nonrebreather, his saturation hasn't improved. As you move closer, you notice a neck stoma. But you're not yet sure if it's a tracheostomy or a laryngectomy. Why Distinction Matters The airways in tracheostomy and laryngectomy patients are fundamentally different. A tracheostomy patient has a communicating upper and lower airway—they can be ventilated through the mouth, nose, or trach. If the trach becomes obstructed, oxygenation is still possible with bagvalvemask (BVM) ventilation or intubation via the upper airway. In contrast, a laryngectomy patient has no connection between the upper and lower airways.1 After a total laryngectomy, the upper airway is completely separated from the trachea, meaning oxygenation and ventilation can occur only through the stoma.2 Recognizing this distinction quickly can be the difference between saving a life and a devastating outcome. Key Anatomical Differences A tracheostomy is a surgically created airway in the trachea below the vocal cords. The stoma and tube direct airflow into the lower airway, while the upper airway remains connected. Ventilation can be performed through the stoma or through the face.1 Tracheostomies are typically performed for prolonged intubation, upper airway obstruction, or neurological impairment. In contrast, a total laryngectomy removes the larynx and permanently separates the airway from the mouth and nose.2 In these patients, the stoma is the only route for oxygenation and ventilation.3 How to Quickly Tell the Difference When you must quickly decide whether this patient has a trach or a laryngectomy you can: Look for alert tags/documentation. Many laryngectomy patients have neck breather ID bracelets, wallet cards, or other forms of documentation.4 Examine the stoma site. A larger, stable-appearing stoma without trach tubing suggests laryngectomy.3 A heat-moisture exchanger (HME) or a voice prosthesis suggests a laryngectomy.3 Tracheostomies often have a tube with a flange.1 Ask anyone who might know EMS, family, caregivers. Functional bedside test. Place a BVM over face and squeeze i. If chest rise is present → likely tracheostomy1 ii. No chest rise → likely laryngectomy or stenotic trach; switch fully to the stoma to ventilate.4 If you are uncertain, treat the stoma as the primary airway until proven otherwise. Resuscitating a Patient with a Tracheostomy The first step in resuscitating a patient with a tracheostomy is to assess whether the patient is breathing. If they are, apply highflow oxygen to both the face and the tracheostomy. If they are not breathing and there is no pulse or signs of life, begin CPR immediately. Next, evaluate airway patency. Remove the inner cannula, as this is the most common site of obstruction, and perform deep suctioning to clear any mucus plugs.1 A BVM can be used to ventilate through the trach, checking for adequate chest rise. If the trach is obstructed or ventilation is ineffective, replacing the tube with one of the same size or slightly smaller is reasonable. If replacement fails, oral intubation can be attempted. In extremis, or if there is severe upper airway stenosis, intubation through the stoma with a 6.0 endotracheal tube may be necessary.5 Special caution is required with fresh tracheostomies (