Dislodged Tracheotomy Causes Respiratory Failure

This case takes place in Pennsylvania and involves a middle aged male patient who was receiving care after he was released from the ICU after suffering serious injuries in a motor vehicle accident. As a requirement of his recovery, he had a tracheotomy placed to assist in breathing. He was left unattended for a period of several hours, during which time his tracheotomy became displaced. His nurse and a member of the respiratory care team discovered the patient unconscious after an unknown period of time had elapsed, and they were unable to assist the patient. The tube was pushed back in through the patient’s throat, causing subcutaneous emphysema as a result of the trauma. He died that day. The death certificate lists immediate cause of death as respiratory failure due to traumatic self-extubation. It is alleged that the patient should not have remained unsupervised for such an extended period of time.

Question(s) For Expert Witness

1. Do you treat patients with the type of condition in this case?

2. What is your experience of self-extubation of a tracheotomy?

3. What measures can be taken to prevent extubation and how is it managed if it does occur?

Expert Witness Response E-007831

I have been called to care for patients with this condition. It is a relatively common condition with chronic, established tracheostomies, but in these cases it typically occurs without harm. With fresh tracheostomies, this is an emergency, though luckily it is rare. I routinely change chronic established tracheostomies in the office with minimal precautions because it is safe. With fresh tracheostomies, defined as less than 7-10 days old, where there is no established tracheostomy tract, these are considered a medical emergency. I have both successfully changed these tracheostomy tubes with either an adjunct device, or evaluated the stoma with a bronchoscope, and then made the decision to replace over the bronchoscope, or else to reintubate. Loss of a fresh tracheostomy easily becomes a catastrophic event. I consider this one of the major under appreciated medical emergencies. With fresh tracheostomies, my personal and the institutional practice is to leave retention sutures in place for the first 7 days, as well as a velcro tracheostomy tie tensioned to 2 fingers tight. If a removal occurs in the first 7 days, our practice is to reintubate the patient orally to stablize. If the patient is in an ICU, with appropriate staffing, for a partial extubation, I would check patency into the airway, potentially insert a guide, then reinsert the tracheostomy over the guide. If a bronchoscope is present, then stomal patency can be checked visually by bronchoscopy, with the tracheostomy being inserted over the bronchoscope, using the bronchoscope as a guide. For fresh tracheostomies, blind reinsertion often leads to extra-tracheal placement, subcutaneous emphysema, loss of airway, and death.