AHRQ WebM&M: Morbidity and Mortality Rounds on the Web ► Breathe Easy: Safe Tracheostomy Management Commentary by Matthew S. Russell, MD, and Marika D. Russell, MD

AHRQ WebM&M: Morbidity and Mortality Rounds on the Web

Breathe Easy: Safe Tracheostomy Management

Commentary by Matthew S. Russell, MD, and Marika D. Russell, MD

A 75-year-old man was admitted to the hospital with sepsis due to multilobar pneumonia. He rapidly developed acute respiratory failure with evidence of acute respiratory distress syndrome that required mechanical ventilation. The patient improved with initial treatments but on hospital day 12, a decision was made to place a tracheostomy given the anticipated need for a prolonged respiratory recovery period. The patient reported feeling more comfortable after the tracheostomy than he felt with the endotracheal tube.

A few days later, the patient became increasingly agitated due to delirium. He developed acute hypoxia and respiratory distress when it was noted that his tracheostomy was dislodged. The critical care physician on call was notified and he tried to reinsert the tracheostomy tube. Multiple unsuccessful attempts were made and the patient ultimately went into cardiac arrest. The code team arrived and placed an endotracheal tube to secure the airway, which allowed successful resuscitation of the patient. The patient improved once again, had his tracheostomy replaced, and was eventually discharged to an acute rehabilitation facility for continued recovery.

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