A Stable Airway? Fatal Airway Occlusion After Inadequate Post-Tracheostomy Care Elizabeth Gould, NP-C, CORLN, Krystal Craddock, BSRC, RRT, RRT-ACCS, RRT-NPS, AE-C, CCM, Tyler Le Tellier, RRT, Brooks T Kuhn, MD, MAS | May 29, 2024

https://psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care In this WebM&M Spotlight Case with CE/MOC, a 55-year-old man with a history of osteoarthritis and supraventricular tachycardia was admitted the hospital with severe COVID-19 and required endotracheal intubation and invasive mechanical ventilation. Following transfer to a long-term care hospital (LTCH) for continued weaning from mechanical ventilation, inadequate tracheostomy management protocols were evident, with no specific instructions provided. Subsequently, the patient experienced respiratory distress and cardiac arrest due to a blocked tracheostomy tube, highlighting critical deficiencies in care and communication. The commentary summarizes the risk factors for tracheostomy complications, the importance of tracheostomy tube maintenance and monitoring, and strategies to safeguard tracheostomy tube care during transitions of care. https://psnet.ahrq.gov/web-mm/stable-airway-fatal-airway-occlusion-after-inadequate-post-tracheostomy-care