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A Case Report of an Inadvertent Placement of Tracheostomy Tube Into the Pharynx After Emergency Tracheostomy: Management of a Failed Surgical Airway

Awad, Motaz MD; Yaghoubian, Saman DO

doi: 10.1213/XAA.0000000000000930
Case Reports

Inadvertent placement of a tracheostomy tube through the stoma with the distal tip cephalad in the pharynx is an unusual but potentially devastating complication. Previously reported only once in the literature, its occurrence is not well known. There are several causes of ineffective ventilation after an emergency surgical airway, and an incorrectly placed tracheostomy tube is a differential diagnosis to consider. Prompt identification of this rare complication is essential because the consequences can be fatal. We present a case describing the inadvertent insertion of a tracheostomy tube into the pharynx during emergency tracheostomy and its subsequent management.

From the Department of Anesthesiology, New York Medical College, Westchester Medical Center, Valhalla, New York.

Accepted for publication October 11, 2018.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Motaz Awad, MD, Department of Anesthesiology, Westchester Medical Center, 100 Woods Rd, Macy Pavilion, Room 2391, Valhalla, NY 10595. Address e-mail to

The American Society of Anesthesiology (ASA) difficult airway algorithm establishes that invasive airway access is the final step in a patient who will die without life-saving surgery and in whom neither intubation nor ventilation is possible.1 We present a case in which a tracheostomy tube was inadvertently advanced superiorly past the vocal cords with the distal tip in the pharynx. Without prompt identification of this problem, this complication could lead to hypoxia and possibly even death. This complication has been documented only once in the literature.2 It is vital that anesthesiologists be aware of this potential problem and become familiar with its management. We obtained informed written consent from the patient to publish the case report.

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A previously healthy 33-year-old man was brought in by ambulance to the emergency department after a motor vehicle collision. He was hypotensive, and free fluid was identified on a focused abdominal ultrasound. The patient was subsequently transferred to the operating room for an emergency exploratory laparotomy. His airway was unremarkable.

He was preoxygenated for 3 minutes with 100% oxygen. While maintaining cricoid pressure, rapid sequence induction with 4 mg midazolam and 200 mg succinylcholine was performed. During fasciculations, the patient regurgitated abundant thick gastric contents. Visualization on direct laryngoscopy was significantly limited due to the secretions, and oropharyngeal suctioning was ineffective. Mask ventilation was also attempted, but it was not adequate. With the pulse oxygen saturation decreasing to 87%, the attending trauma surgeon performed an emergency tracheostomy, inserting a 6.0 mm internal diameter Shiley tracheostomy tube (Medtronic, Minneapolis, MN). After placement, end-tidal carbon dioxide could not be detected. The Shiley tracheostomy tube was therefore exchanged for a 6.0 mm internal diameter endotracheal tube (ETT). Despite this, no end-tidal carbon dioxide was detected. Oxygen saturation further decreased to 30%. The trauma surgeon requested a fiberoptic bronchoscope to evaluate the surgical airway, but one was not immediately available.

Meanwhile, the anesthesia team attempted to establish an alternative secure airway. The oropharynx was suctioned again, which was effective in clearing the regurgitated matter and improving mask ventilation. Oxygen saturation improved to 80%. Oral intubation was attempted with a video laryngoscope, and it revealed that the tip of the ETT inserted into the tracheal stoma ended superiorly, past the vocal cords and into the pharynx (Figure 1).3 With adequate visualization of the laryngeal aperture, the ETT in the tracheal stoma was removed, and oral endotracheal intubation was performed. The ETT was suctioned yielding thin clear secretions. Waveform capnography and adequate ventilation confirmed correct placement of the ETT. Oxygen saturation quickly increased to 99%.

Figure 1.

Figure 1.

After securing the airway, the trauma surgeon started the surgical procedure. The patient underwent an exploratory laparotomy with a left nephrectomy and splenectomy for traumatic solid organ injury. He was transferred to the intensive care unit and was neurologically intact on examination. The tracheostomy site was closed at the skin with sutures and allowed to heal. The patient was successfully weaned from mechanical ventilation and was extubated without issue. He made a full recovery from his intraoperative hypoxic event and his traumatic injuries.

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In adherence to the ASA difficult airway algorithm, when neither mask ventilation nor oral intubation is possible, and death without surgery is likely, invasive airway access is pursued.1 An invasive airway may include a surgical or percutaneous airway, jet ventilation, and retrograde intubation over a wire. In our case, invasive airway access failed. This case indicates the need to include additional steps in the ASA algorithm to guide management if an invasive airway is unsuccessful. It would caution practitioners of this possibility and serve as a practical advisory directed at determining the cause of failure of an invasive airway. Recognizing a failed surgical airway should involve examining the patient, assessing chest excursion with ventilation, auscultation of breath sounds, and analyzing capnography. Once identified, supplemental oxygen by facemask should be delivered to provide apneic oxygenation, assuming facemask ventilation is inadequate. The next step is to determine the actual placement of the surgical airway.

A fiberoptic bronchoscope inserted through an invasive airway would provide valuable information on its precise location and patency, and adjusting the invasive airway under fiberoptic guidance may help correct its position. In our case, the incorrectly placed tube was discovered through video laryngoscopy as a fiberoptic bronchoscope was not immediately available. Using a fiberoptic bronchoscope may have easily corrected the failed surgical airway, and this may have reduced or possibly prevented the severe hypoxic event our patient suffered. Traditionally, using a fiberoptic bronchoscope in the difficult airway algorithm is one of the airway techniques suggested for awake intubation and in the nonemergency pathway.1 We believe that using a fiberoptic bronchoscope should also be considered in the emergency pathway of the algorithm particularly when contemplating emergency invasive airway access. We have added additional steps in the ASA difficult airway algorithm to provide recommendations on clinical management in the event of a failed surgical airway (Figure 2).1

Figure 2.

Figure 2.

In this case, the significant vomiting that occurred during induction made intubation impossible. Therefore, mask ventilation was attempted. Ideally, oropharyngeal contents should be evacuated before providing positive-pressure ventilation.4 Because ventilation was not possible, a surgical airway was pursued. The Shiley tracheostomy tube that was placed failed to provide adequate ventilation and a reassuring carbon dioxide waveform. The reason for this is unclear. It is unlikely that it was advanced superiorly into the pharynx due to its preformed curvature, which facilitates placement into the trachea. A fiberoptic bronchoscope through the Shiley tracheostomy tube could have been useful in determining the cause. An alternative to a fiberoptic bronchoscope is passing a suction catheter through the tube. Encountering resistance while inserting the suction catheter would suggest incorrect placement of the tracheostomy tube.

The Shiley tracheostomy tube was removed, and an ETT was placed through the tracheal stoma inadvertently into the pharynx. The direction in which the ETT was inserted might explain its misplacement. An insertion angled caudally toward the patient’s feet might help avoid advancement cephalad and guide the tube to the carina instead of directing it perpendicular or superior to the stoma site. Also, it has been recommended that the bevel of the tube should be facing cephalad so that the ETT will be directed caudally once its distal tip contacts the posterior tracheal wall.2 It is possible that the ETT, being longer than a Shiley tracheostomy tube, was advanced more than necessary causing it to pass the vocal cords. Therefore, it might be reasonable to withdraw the tube incrementally and determine whether ventilation is adequate after each adjustment. A fiberoptic bronchoscope would also be helpful in this situation by allowing visualization of the ETT after each incremental change.

With a failed surgical airway that cannot be corrected with fiberoptic guidance, a provider should consider alternative invasive airway techniques. Beyond this point, the difficult airway algorithm is exhausted. It could be argued that a physician should consider extracorporeal membrane oxygenation (ECMO). Using ECMO for emergency respiratory support has been used in the management of the patient with a difficult airway with examples in the literature including upper airway obstruction secondary to malignancy or tracheal stenosis.5 Mobilizing the necessary staff and equipment to perform ECMO cannulation takes a considerable time, which could prove fatal in a patient that cannot be ventilated. However, it has been well reported in emergency situations including out-of-hospital cardiac arrests with promising results.6 Therefore, it is prudent to consider calling for ECMO before exhausting all or even multiple measures in the airway algorithm. Our modified algorithm incorporates the consideration of ECMO in the emergency pathway when the surgical airway is unsuccessful (Figure 2).1 This rare complication has only been documented once in the literature. A case published by Slobodkin et al2 describes a patient’s desaturation after placing an ETT through an emergency cricothyrotomy. Direct laryngoscopy revealed that the tube had entered the pharynx through the glottis from the surgical airway site. After replacing the ETT correctly, the patient’s oxygen saturation improved.

Complications arising from emergency tracheostomy carry significant morbidity and mortality. Klemm et al conducted a systematic review of adult tracheostomy-related deaths, including open surgical tracheostomy, which was the surgical procedure performed in our case.7 A total of 109 publications with 7934 open surgical tracheostomies and 49 deaths were described, for a mortality rate of 0.62%. Fifteen of these deaths were intraoperative, translating to an intraoperative tracheostomy mortality rate of 0.19%. The mechanisms for these tracheostomy-related deaths included severe injury to the tracheal wall and tracheoesophageal fistula, loss of airway, pneumothorax, and hemorrhage. Reasons for such complications included incorrectly placed surgical incision, extreme neck swelling, obesity, and inadvertent cannula dislocation, but some publications did not describe the mechanism of the complication.

Halum et al8 conducted a multi-institutional analysis of tracheostomy complications, in which 1175 tracheostomy procedures were reviewed. The number of intraoperative complications was 17 or a 1.4% rate. They included severe or prolonged desaturation, death, cerebrovascular accident, pneumothorax, and severe blood loss. These complications are serious and certainly relevant to an anesthesiologist providing for such patients.

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This case describes a rare complication of surgical airway management that has been reported only once in the literature. The identification and management of a malpositioned tracheostomy tube after tracheostomy can prevent disastrous consequences, including hypoxia, cardiac arrest, stroke, and death. In this scenario, fiberoptic guidance may prove to be extremely helpful in the management of the difficult airway when surgical measures have failed. It is for this reason that we have suggested modifications to the difficult airway algorithm to address this situation.

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Name: Motaz Awad, MD.

Contribution: This author helped care for the patient and write the manuscript.

Name: Saman Yaghoubian, DO.

Contribution: This author helped care for the patient and write the manuscript.

This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.

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1. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for management of the difficult airway. Anesthesiology. 2013;118:251–270.
2. Slobodkin D, Topliff S, Raife JH. Retrograde intubation of the pharynx: an unusual complication of emergency cricothyrotomy. Ann Emerg Med. 1992;21:220–222.
3. Kuehn L; LibmanEducation. Coding endotracheal tube (ETT) insertion. Available at: Published July 9, 2015. Accessed January 20, 2018.
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7. Klemm E, Nowak AK. Tracheostomy-related deaths. Dtsch Arztebl Int. 2017;114:273–279.
8. Halum SL, Ting JY, Plowman EK, et al. A multi-institutional analysis of tracheostomy complications. Laryngoscope. 2012;122:38–45.
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