Stoma Care: Airway Management and Emergency Considerations

A stoma is a surgically created opening that provides direct access to the trachea through the neck. In respiratory care, stomas are most commonly associated with tracheostomy and laryngectomy patients. Although both involve an opening in the neck, their airway anatomy can be very different.

Proper management requires understanding whether the upper airway remains connected to the lungs, how the stoma should be cleaned and protected, how secretions should be managed, and how oxygenation and ventilation should be provided during routine care and emergencies.

What Is a Stoma?

A stoma is an opening created surgically to connect the trachea with the external surface of the neck. It may be temporary or permanent depending on the underlying procedure and clinical condition.

In patients with a tracheostomy, the stoma is created so that a tracheostomy tube can provide direct access to the airway. This may be necessary because of upper airway obstruction, prolonged mechanical ventilation, impaired airway protection, trauma, or another condition affecting normal breathing.

In patients who have undergone a total laryngectomy, the stoma becomes the permanent airway. The trachea is surgically redirected to the neck, and the patient no longer breathes through the mouth or nose.

This difference has major implications for respiratory therapy. A patient with a tracheostomy may still have a functional upper airway, whereas a patient with a total laryngectomy does not. Oxygen administration, suctioning, ventilation, airway replacement, and emergency resuscitation must therefore be adapted to the patient’s anatomy.

Tracheotomy and Formation of a Stoma

A tracheotomy is a procedure in which an opening is created in the trachea through the anterior neck. The resulting opening is commonly referred to as a tracheostomy.

A tracheotomy may be performed surgically or using a percutaneous dilation technique. In a traditional surgical procedure, an incision is made in the neck and the tissues are separated until the trachea is exposed. An opening is then created through or between the tracheal rings, usually in the region of the second or third tracheal ring.

A tracheostomy tube is inserted through the opening and advanced into the trachea.

During a percutaneous tracheotomy, a needle and sheath are introduced into the trachea. A guidewire is placed, and progressively larger dilators are used to enlarge the opening until a tracheostomy tube can be inserted. The resulting stoma provides direct access to the lower airway.

Reasons for Creating a Tracheostomy Stoma

A tracheostomy may be used for several clinical reasons, including:

• Bypassing an upper airway obstruction
• Managing severe facial or airway trauma
• Providing long-term airway access
• Supporting prolonged mechanical ventilation
• Improving secretion removal
• Assisting patients with impaired airway protection
• Reducing airway resistance compared with a long-term endotracheal tube

Note: The presence of a stoma changes normal airway physiology because inspired gas no longer passes entirely through the nose and upper airway.

Tracheostomy Stoma Maturation

The age of the stoma is an important consideration when managing a tracheostomy.

A newly created tracheostomy does not immediately form a mature tract between the skin and trachea. During the first several days, the opening may begin to close if the tube is removed. Reinsertion can also be difficult because the tube may enter soft tissue rather than the trachea. For this reason, early tracheostomy tube changes require caution.

The first routine tube change is often delayed until the stoma has begun to heal, generally around 7 to 10 days or sometimes up to 14 days depending on the clinical situation and institutional protocol.

When a fresh tracheostomy tube must be changed, airway equipment should be immediately available. A physician or other clinician experienced in airway management may perform the procedure because accidental loss of the airway can become an emergency.

A mature stoma is generally more stable and easier to manage. Even then, a replacement tube of the same size and another tube one size smaller should be available during tube changes.

Tracheostomy Tube Placement Through the Stoma

A tracheostomy tube must be inserted correctly to avoid airway trauma, false passage, obstruction, or inadequate ventilation. During insertion, an obturator is placed inside the tracheostomy tube. The obturator provides a smooth, rounded tip that helps guide the tube through the stoma and into the trachea.

Once the tube is positioned, the obturator must be removed immediately so that airflow can occur through the tube.

The tracheostomy tube should follow the natural curvature of the airway. Force should not be necessary. Resistance may indicate improper alignment, an inappropriate tube size, or entry into surrounding soft tissue. The flange of the tube should rest against the neck without excessive pressure.

Correct placement can be assessed by confirming:

• Bilateral breath sounds
• Appropriate chest movement
• Exhaled carbon dioxide
• Adequate oxygenation
• Absence of gastric breath sounds
• Proper positioning of the tube and flange

Note: A chest or airway radiograph may be used when additional confirmation is necessary.

Choosing an Appropriate Tracheostomy Tube

Tube size affects airflow, airway resistance, secretion removal, patient comfort, and cuff function. The internal diameter determines resistance to airflow through the tube, while the outer diameter determines how much space the tube occupies inside the trachea.

A tube that is too large may place excessive pressure on the tracheal wall and may prevent adequate airflow around the tube when the cuff is deflated. A tube that is too small may increase airway resistance or require excessive cuff inflation to create an appropriate seal.

The outer diameter should generally remain sufficiently smaller than the patient’s tracheal diameter so that surrounding tissues are not compressed. Tube selection should also account for patient anatomy, ventilation requirements, secretion burden, and whether speech or upper airway breathing is expected.

Stoma Assessment

Routine inspection of the stoma is an essential part of tracheostomy care. The surrounding tissues should be assessed for signs of irritation, infection, trauma, drainage, or pressure injury.

Important findings include:

• Redness
• Swelling
• Pus
• Foul-smelling drainage
• Bleeding
• Excessive moisture
• Skin breakdown
• Granulation tissue
• Pressure injury
• Abnormal narrowing

Note: A small amount of drainage may occur during healing, but persistent or purulent drainage can indicate infection. Stomal infection is important because inflammation and tissue injury may contribute to later complications such as tracheal stenosis.

Stoma Cleaning and Infection Prevention

Routine cleaning helps prevent accumulation of secretions and reduces skin irritation. Sterile or aseptic technique should be used according to institutional protocol. The site may be cleaned with sterile saline or another approved cleaning solution.

Some care protocols use diluted hydrogen peroxide to loosen dried secretions and crusted mucus. However, hydrogen peroxide can irritate tissue, so sterile saline may be preferable when irritation occurs.

The skin should be cleaned gently, and dried secretions should be removed without causing tissue trauma. Soiled dressings should be replaced promptly. Routine gauze should not be cut manually around the tube because loose fibers may enter the airway. Precut tracheostomy dressings are generally preferred.

Dressing Selection

The appropriate dressing depends on the amount of drainage and the condition of the surrounding skin. A standard sterile tracheostomy dressing may be appropriate when drainage is minimal.

When heavier drainage is present, a foam dressing may be useful because it can draw moisture away from the skin. Wet dressings should not remain against the stoma because prolonged moisture exposure can contribute to skin breakdown.

Pressure from the tracheostomy flange should also be evaluated. If pressure injury develops, a hydrocolloid or another protective dressing may be placed beneath the flange when appropriate.

In some cases, persistent tissue damage may indicate that the tube design, length, angle, or flange configuration is not suitable for the patient’s anatomy.

Tracheostomy Ties and Tube Security

The tracheostomy tube must be secured to prevent accidental displacement. Ties or hook-and-loop holders are attached to the flange and placed around the patient’s neck. The ties should be secure enough to prevent movement while avoiding excessive pressure on the skin.

When ties are changed, the tube should be stabilized to prevent accidental decannulation. A second clinician may hold the tube in position while the ties are replaced. Patients who are able to participate safely may sometimes help stabilize their tube.

Excessive traction should be avoided. Pulling on attached tubing or respiratory equipment can cause discomfort, airway trauma, disconnection, or accidental tube removal.

Inner Cannula Care

Many tracheostomy tubes contain an inner cannula. The inner cannula can accumulate mucus, blood, and dried secretions. If it becomes obstructed, airflow through the tube can be significantly reduced.

A removable inner cannula allows the airway to be rapidly cleared without replacing the entire tracheostomy tube. During routine care, the inner cannula can be removed, inspected, cleaned, and replaced. Disposable inner cannulas are discarded and replaced with clean units according to manufacturer recommendations.

Reusable cannulas may be cleaned with approved solutions and a tracheostomy brush, rinsed thoroughly, dried, and replaced. A spare inner cannula should be available at the bedside when appropriate.

Suctioning Through the Stoma

Patients with artificial airways may have difficulty clearing secretions because the normal upper airway is bypassed. Suctioning is performed when clinical findings suggest retained secretions.

Possible indications include:

• Visible secretions
• Coarse breath sounds
• Increased airway pressure
• Decreased oxygen saturation
• Difficulty ventilating
• Increased respiratory effort
• Weak cough
• Audible mucus

Note: A suction catheter is passed through the tracheostomy tube or directly through the stoma when appropriate. If the catheter cannot pass through the tube, obstruction should be suspected.

Tracheostomy Tube Obstruction

Acute obstruction of a tracheostomy tube can rapidly cause respiratory distress.

The obstruction may result from:

• Thick mucus
• Dried secretions
• Blood
• Inner cannula blockage
• Tube displacement
• Cuff herniation
• Tube kinking
• Malposition

Initial assessment should focus on determining whether air can move through the tube. If a removable inner cannula is present, it should be removed and inspected. A mucus plug may be located inside the cannula.

A suction catheter should then be passed through the tracheostomy tube if possible. If the catheter passes, suctioning may remove the obstruction. If the catheter cannot pass, the tube itself may be blocked or displaced.

Cuff Management

Cuffed tracheostomy tubes are commonly used in patients who require positive-pressure ventilation or increased protection from aspiration. Cuff pressure should be high enough to create an appropriate seal while avoiding excessive pressure against the tracheal wall.

In adults, cuff pressure is commonly maintained between 20 and 30 cm H₂O. Excessive cuff pressure can reduce blood flow to tracheal mucosa and contribute to tissue injury, ulceration, stenosis, or other complications.

Insufficient cuff pressure may allow air leakage during ventilation and may increase aspiration risk. Cuff pressure should therefore be measured rather than estimated by touch alone.

Changing a Tracheostomy Tube

A tracheostomy tube may need to be changed because of obstruction, equipment failure, cuff damage, infection concerns, tube sizing needs, or routine long-term care. Before beginning, appropriate equipment should be assembled.

Typical supplies include:

• Replacement tube of the same size
• Replacement tube one size smaller
• Obturator
• Spare inner cannula
• Suction equipment
• Oxygen
• Manual resuscitation bag
• Tracheostomy ties or holder
• Sterile dressing
• Lubricant
• Syringe for cuff inflation
• Appropriate personal protective equipment

The patient’s airway is usually suctioned before removing the old tube. The cuff is deflated, the old tube is removed, and the stoma is inspected. The replacement tube is lubricated when appropriate and inserted through the stoma using the obturator.

Once the tube is in place, the obturator is removed immediately. The inner cannula is inserted, the cuff is inflated when indicated, and oxygen or ventilation is resumed. Tube position is confirmed before the device is secured.

Accidental Decannulation

Accidental decannulation occurs when the tracheostomy tube becomes partially or completely displaced from the stoma. Management depends heavily on the age of the stoma.

A mature stoma may allow relatively straightforward reinsertion. A fresh stoma presents greater risk because the tract may not be fully formed. Blind reinsertion can create a false passage in the soft tissues and make ventilation impossible.

If a fresh tracheostomy tube becomes displaced, immediate airway support is required while experienced airway personnel are called. Depending on the patient’s anatomy and reason for the tracheostomy, oxygenation or ventilation may temporarily be provided through the upper airway while the stoma is covered.

Humidification Through a Stoma

The nose normally warms, filters, and humidifies inspired gas. When air enters directly through a stoma, these functions are reduced or bypassed. Dry gas can cause secretions to become thick and difficult to clear. This can increase the risk of mucus plugging and airway obstruction.

Humidification may be provided using:

• Heated humidification
• Aerosol systems
• Tracheostomy masks
• Heat-moisture exchangers
• Specialized stoma covers

Note: A heat-moisture exchanger captures heat and moisture from exhaled gas and returns part of it during the next inspiration. These devices are especially useful in stable patients but require adequate airflow.

HME Obstruction

A heat-moisture exchanger can itself become obstructed by mucus, secretions, or blood. An obstructed HME can dramatically increase resistance and may prevent adequate ventilation.

If a patient using an HME suddenly develops difficulty breathing, the device should be removed immediately and assessed.

An HME contaminated with secretions or blood should generally be discarded and replaced rather than cleaned and reused unless specifically designed for reuse. Patients with large amounts of thick secretions or active airway bleeding may not be appropriate candidates for certain HMEs.

Tracheostomy Buttons

A tracheostomy button may be used after a tracheostomy tube is removed when continued access to the stoma is desired. The device helps keep the stoma open while allowing the patient to breathe through the upper airway when appropriate.

A closure plug may be used to seal the button so that air passes through the nose and mouth. A hollow inner cannula may also be inserted so that respiratory equipment can be connected or suctioning can be performed.

A standard 15-mm connection may allow attachment to certain respiratory devices. Tracheostomy buttons can be useful during the process of weaning from a long-term tracheostomy.

Speaking With a Tracheostomy

A tracheostomy can interfere with normal speech because exhaled gas may exit through the tracheostomy rather than passing through the vocal cords. Speech may be possible when enough airflow is redirected through the larynx.

Strategies may include:

• Cuff deflation
• Fenestrated tubes
• Speaking valves
• Tracheostomy buttons
• Digital occlusion when appropriate

A one-way speaking valve typically allows inspiration through the tracheostomy but closes during exhalation, redirecting gas through the upper airway and vocal cords. The upper airway must be patent before a speaking valve is used.

A cuff must generally be completely deflated before speaking valve use because an inflated cuff may prevent exhalation and create a dangerous obstruction.

Total Laryngectomy and the Permanent Stoma

A total laryngectomy involves complete removal of the larynx. The trachea is surgically separated from the upper airway and attached permanently to an opening in the neck. This creates a permanent laryngectomy stoma.

After total laryngectomy, there is no connection between the mouth and nose and the lungs. The patient breathes entirely through the stoma. This distinction is critical during respiratory emergencies.

Providing bag-mask ventilation over the patient’s mouth and nose will not ventilate the lungs after a total laryngectomy. Oxygen, suctioning, aerosol therapy, and ventilation must be delivered through the stoma.

Partial Laryngectomy

A partial laryngectomy differs from a total laryngectomy. Only part of the larynx is removed, and communication between the upper and lower airway may remain intact. A temporary tracheostomy may be present during healing.

Some patients eventually return to breathing through the upper airway after the tracheostomy tube is removed. Because the anatomy varies, clinicians should determine whether the patient has undergone a total or partial laryngectomy before providing emergency airway care.

Laryngectomy Tubes and Buttons

Some laryngectomy patients breathe directly through an open stoma, while others use a laryngectomy tube or button. These devices help maintain the size and shape of the stoma.

Laryngectomy tubes are usually short and uncuffed. Designs may include single cannulas, double cannulas, or fenestrations. Some patients develop stomal stenosis, in which the opening gradually narrows.

Laryngectomy tubes or progressively larger devices may be used to maintain or enlarge the stoma when clinically appropriate. Routine cleaning remains important because mucus can accumulate and reduce airflow.

Emergency Ventilation Through a Laryngectomy Stoma

When a patient with a total laryngectomy requires ventilation, breaths must be delivered through the stoma. A pediatric face mask can be placed over the stoma to create a seal for bag-mask ventilation.

The stoma should first be inspected for visible mucus, crusting, or foreign material. Any HME, filter, speaking valve, or removable cannula should be removed if obstruction is suspected. A suction catheter can then be passed through the airway.

If the catheter passes, suctioning may restore airway patency. If spontaneous breathing does not return, positive-pressure ventilation can be provided through the laryngectomy tube or directly over the stoma.

When a Suction Catheter Cannot Pass

Failure to pass a suction catheter may indicate severe obstruction or tube malposition. If a laryngectomy tube is present and the catheter cannot pass, the tube may need to be removed. Ventilation can then be attempted directly over the open stoma with a pediatric mask.

If airway access is still inadequate, the stoma may be intubated with an appropriately sized endotracheal tube. When longer-term mechanical ventilation is required, a cuffed tracheostomy tube may be placed through the stoma.

The key principle is that all airway interventions in a total laryngectomy patient must be directed through the neck opening.

Mouth-to-Stoma Ventilation

Mouth-to-stoma ventilation may be used when other equipment is unavailable. The patient is positioned supine with the airway aligned. The stoma is inspected and cleared of visible obstruction. Rescue breaths are then delivered directly into the stoma or existing airway tube.

If an uncuffed tracheostomy tube is present in a patient whose upper airway remains connected, air may leak from the nose and mouth. Sealing the mouth and nose may help direct ventilation into the lungs.

In a total laryngectomy patient, upper airway leakage is not expected because the upper airway is surgically separated from the lungs.

Communication After Laryngectomy

Removal of the larynx eliminates normal voice production, but several communication methods are available.

Patients may use:

• Writing
• Electronic communication devices
• An electrolarynx
• Esophageal speech
• Tracheoesophageal speech

A tracheoesophageal puncture creates a small passage between the trachea and esophagus. A one-way voice prosthesis is inserted into the passage.

During exhalation, the patient directs air through the prosthesis, allowing tissue within the upper digestive tract to vibrate and produce sound. The stoma may be manually occluded or covered with a specialized speaking valve.

Voice Prosthesis Complications

Voice prostheses require routine maintenance. Food particles, mucus, or other material may obstruct the device. A malfunctioning valve can allow fluid from the esophagus to leak into the airway. Patients should be taught how to clean the prosthesis and recognize signs of malfunction.

Possible problems include:

• Leakage through the prosthesis
• Leakage around the prosthesis
• Difficulty speaking
• Obstruction
• Aspiration
• Tissue irritation
• Prosthesis displacement

Note: Speech-language pathologists often assist with prosthesis selection, training, and troubleshooting.

Stoma Protection From Water and Debris

A neck stoma provides a direct pathway to the trachea, so protection from water is important. Water entering a laryngectomy stoma can pass directly into the lower airway. Patients may use specialized shower guards or downward-facing protective devices while bathing.

Stoma covers and filters can also help reduce the entry of dust, debris, and airborne particles.

Patients should understand that activities involving water exposure require particular caution because normal protection from the nose, mouth, epiglottis, and larynx is no longer available after total laryngectomy.

Decannulation

Decannulation is removal of a temporary tracheostomy tube after the original need for the airway has resolved. Before decannulation, the patient should demonstrate adequate respiratory and airway function.

Important considerations include:

• Effective cough
• Manageable secretions
• Patent upper airway
• Adequate respiratory muscle strength
• Acceptable gas exchange
• Sufficient swallowing function
• Low aspiration risk
• Clinical stability

Note: Some patients undergo gradual weaning before complete removal. This may involve smaller tracheostomy tubes, cuff deflation, speaking valves, fenestrated tubes, capping trials, or tracheostomy buttons.

Stoma Closure After Decannulation

After a temporary tracheostomy tube is removed, the stoma generally begins closing spontaneously. The site is cleaned and covered with a sterile occlusive dressing.

The patient may be instructed to apply gentle pressure over the dressing when speaking or coughing to reduce air leakage through the opening. The stoma usually narrows over several days, although complete closure may take longer.

Persistent openings may occasionally require medical or surgical evaluation. The patient should be monitored for respiratory distress during the transition back to upper airway breathing.

Complications of Stoma Management

Several complications can affect patients with tracheostomy or laryngectomy stomas.

These include:

• Infection
• Bleeding
• Mucus plugging
• Tube obstruction
• Accidental decannulation
• False passage
• Granulation tissue
• Skin breakdown
• Tracheal stenosis
• Stomal stenosis
• Aspiration
• Hypoxemia
• Hypercapnia
• Airway trauma

Note: Early recognition of changes in respiratory status is essential. Sudden respiratory distress in a patient with a neck stoma should always prompt immediate assessment of airway patency and device position.

Emergency Equipment at the Bedside

Patients with tracheostomies should have appropriate emergency equipment readily available.

This commonly includes:

• Suction equipment
• Oxygen source
• Manual resuscitation bag
• Replacement tracheostomy tube of the same size
• Replacement tube one size smaller
• Obturator
• Spare inner cannula
• Suction catheters
• Airway equipment
• Appropriate masks for stoma ventilation

Note: For laryngectomy patients, clear identification of the patient’s airway anatomy is particularly important. Bedside signage may indicate that the patient is a neck breather and that ventilation must be delivered through the stoma.

The Most Important Airway Distinction

The most important consideration in stoma management is determining whether the upper airway remains connected to the lungs. A patient with a standard tracheostomy usually retains an anatomical connection between the mouth, nose, and trachea.

A patient with a total laryngectomy does not. This distinction determines how oxygen, ventilation, suctioning, and emergency airway support should be delivered.

When the anatomy is uncertain, clinicians should inspect the stoma, review the patient’s surgical history when available, assess airflow, and obtain assistance while maintaining oxygenation.

Stoma Practice Questions

1. What is a stoma in respiratory care?
A surgically created opening that provides direct access between the trachea and the outside of the neck.

2. Which two procedures are most commonly associated with a neck stoma?
Tracheostomy and laryngectomy.

3. Why is it important to determine whether a patient has a tracheostomy or a total laryngectomy?
Because it determines whether the upper airway remains connected to the lungs and affects oxygenation, ventilation, suctioning, and emergency airway management.

4. What is a tracheotomy?
A procedure that creates an opening through the neck into the trachea to establish direct airway access.

5. At approximately which tracheal rings is a traditional surgical tracheotomy commonly performed?
The second or third tracheal ring.

6. What device is used during tracheostomy tube insertion to provide a smooth, blunt tip?
An obturator.

7. What should be done with the obturator immediately after a tracheostomy tube is inserted?
It should be removed immediately so the patient can breathe through the tracheostomy tube.

8. Why is a newly created tracheostomy stoma more difficult to manage if the tube becomes displaced?
The tract may not be mature, so the stoma can begin to close and reinsertion may create a false passage.

9. When is the first routine tracheostomy tube change commonly performed?
Generally after about 7 to 10 days, although some protocols may wait up to 14 days.

10. What replacement tubes should be available when changing a mature tracheostomy tube?
A tube of the same size and another tube one size smaller.

11. What signs around a stoma may indicate infection?
Redness, swelling, pus, foul-smelling drainage, and tissue inflammation.

12. Why is preventing stoma infection important?
Because infection can damage surrounding tissues and may contribute to complications such as tracheal stenosis.

13. What type of dressing may be useful when substantial drainage is present around a stoma?
A foam dressing.

14. Why can wet gauze around a stoma be problematic?
It can trap moisture against the skin and contribute to irritation and skin breakdown.

15. What type of dressing may be used beneath a tracheostomy flange when pressure injury develops?
A hydrocolloid dressing.

16. What should be suspected if a suction catheter cannot pass through a tracheostomy tube?
Tube obstruction, malposition, or another mechanical problem.

17. What should be done first if a tracheostomy tube with a removable inner cannula appears obstructed?
Remove and inspect the inner cannula for mucus or other blockage.

18. What adult tracheostomy cuff pressure range is generally recommended?
20 to 30 cm H₂O.

19. Why should excessive tracheostomy cuff pressure be avoided?
It can impair blood flow to the tracheal mucosa and cause tissue injury, ulceration, or stenosis.

20. What is the most important airway difference after a total laryngectomy?
The upper airway is permanently separated from the trachea and lungs.

21. Where must oxygen and ventilation be delivered in a patient with a total laryngectomy?
Through the neck stoma.

22. Why is bag-mask ventilation over the mouth and nose ineffective after a total laryngectomy?
Because the mouth and nose no longer communicate with the lungs.

23. What type of mask can be used to provide bag-mask ventilation over a laryngectomy stoma?
A small pediatric face mask.

24. What should be removed if a laryngectomy patient develops sudden respiratory distress while using an HME or stoma filter?
The HME, filter, speaking valve, or other removable device that may be obstructing airflow.

25. What normally happens to a temporary tracheostomy stoma after decannulation?
It usually closes spontaneously over several days while being covered with a sterile occlusive dressing.

26. What is the purpose of a tracheostomy tube flange?
It rests against the neck and provides an attachment point for ties or a tube holder that secures the tube.

27. What may indicate that a tracheostomy tube has not been inserted far enough?
The cuff may be visible at the stoma, air may leak around the opening, or secretions may bubble from the stoma.

28. How can exhaled carbon dioxide monitoring help after tracheostomy tube placement?
It can help confirm that the tube is positioned within the airway.

29. Why should force not be used when inserting a tracheostomy tube?
Resistance may indicate improper direction, entry into soft tissue, or an inappropriate tube size.

30. Why is the outer diameter of a tracheostomy tube important?
It affects how much space the tube occupies in the trachea and how much airflow can pass around it when the cuff is deflated.

31. What problem can occur if a tracheostomy tube is too large?
It can place excessive pressure on the tracheal wall and restrict airflow around the tube.

32. What problem can occur if a tracheostomy tube is too small?
It may increase airway resistance or require excessive cuff pressure to create an adequate seal.

33. Why should the tracheostomy tube be stabilized when ties are changed?
To reduce the risk of accidental decannulation.

34. Why should pulling or rocking the tracheostomy tube connector be avoided?
It can cause disconnection, airway trauma, or accidental decannulation.

35. Why must an inner cannula be cleaned or replaced regularly?
Secretions can accumulate inside it and obstruct airflow.

36. What can happen if thick secretions are not adequately humidified?
They can become more difficult to clear and increase the risk of mucus plugging.

37. What is the purpose of a heat-moisture exchanger used with a stoma?
It captures heat and moisture from exhaled gas and returns some of it during the next inspiration.

38. What should be done with an HME that becomes obstructed by blood or secretions?
It should be removed and replaced with a clean device.

39. Why may an HME be inappropriate for a patient producing large amounts of secretions?
Secretions can block the device and increase resistance to airflow.

40. What is a tracheostomy button used for?
It helps keep the stoma open after the tracheostomy tube has been removed while allowing upper-airway breathing when appropriate.

41. What is the purpose of a closure plug on a tracheostomy button?
It seals the opening so the patient breathes through the natural upper airway.

42. What feature of some tracheostomy buttons allows respiratory equipment to be attached?
A hollow inner cannula with a standard 15-mm connection.

43. What should be done if a tracheostomy button becomes obstructed and the patient has difficulty breathing?
Remove it and replace it with another button or an appropriate tracheostomy tube.

44. Why must the upper airway be patent before a speaking valve is used with a tracheostomy?
Exhaled gas must be able to pass around the tube and through the upper airway.

45. Why is a speaking valve unsafe if the tracheostomy cuff remains inflated?
The inflated cuff can block exhaled gas from escaping through the upper airway.

46. What is stomal stenosis?
Abnormal narrowing of the stoma.

47. Why may a laryngectomy tube or button be used after healing?
To help maintain the size and patency of the permanent stoma.

48. What is the purpose of a tracheoesophageal puncture after laryngectomy?
It creates a passage between the trachea and esophagus for placement of a voice prosthesis.

49. How does a tracheoesophageal voice prosthesis help produce speech?
Exhaled air is directed through the prosthesis to create vibration that can be shaped into speech.

50. Why should a laryngectomy stoma be protected during showering?
Water entering the stoma can pass directly into the lower airway.

51. Why is routine suctioning sometimes necessary in a patient with a tracheostomy?
Because the artificial airway can impair normal secretion clearance and allow mucus to accumulate.

52. What respiratory finding may suggest retained secretions in a tracheostomy tube?
Coarse breath sounds.

53. What change in ventilator mechanics may suggest a tracheostomy tube obstruction?
An increase in airway pressure.

54. What should be considered if a tracheostomy patient suddenly becomes difficult to ventilate?
Tube obstruction, displacement, mucus plugging, cuff problems, or malposition.

55. How can cuff deflation help when cuff herniation is suspected?
Deflating the cuff may relieve an obstruction caused by the cuff blocking the airway.

56. What should be done if a suction catheter passes through a tracheostomy tube and a mucus plug is suspected?
Suction the airway to remove the obstructing secretions.

57. What should be suspected if a tracheostomy tube tip enters the surrounding soft tissue instead of the trachea?
A false passage.

58. Why is a false passage dangerous?
Ventilation may be directed into soft tissue instead of the lungs, resulting in inadequate oxygenation and ventilation.

59. What should take priority after an obstructed artificial airway is removed?
Restoring adequate oxygenation and ventilation.

60. In a tracheostomy patient whose upper airway is still functional, how may ventilation be provided if the tracheostomy tube cannot be immediately replaced?
The stoma may be covered and manual ventilation provided through the mouth and nose.

61. What is accidental decannulation?
Unplanned partial or complete removal of a tracheostomy tube from the stoma.

62. Why is accidental decannulation especially dangerous in a fresh tracheostomy?
The stoma may quickly narrow or close, and reinsertion may be difficult.

63. What supplies should be checked before routine tracheostomy care begins?
Oxygen, suction equipment, and a manual resuscitation bag.

64. Why should a spare inner cannula be kept available when appropriate?
It allows rapid replacement if the existing inner cannula becomes obstructed or contaminated.

65. Why should ordinary cut gauze be avoided around a tracheostomy stoma?
Loose fibers can irritate the site and may be aspirated into the airway.

66. What can granulation tissue around a stoma cause?
Bleeding, irritation, narrowing, or difficulty with tube changes.

67. What is decannulation?
Removal of a tracheostomy tube after the patient no longer requires the artificial airway.

68. What cough characteristic should a patient demonstrate before decannulation?
An effective cough capable of clearing secretions.

69. Why is swallowing ability assessed before decannulation?
Poor swallowing can increase the risk of aspiration after the tube is removed.

70. Why is upper-airway patency important before decannulation?
The patient must be able to move air adequately through the natural airway after the tracheostomy tube is removed.

71. What respiratory muscle characteristic should be adequate before decannulation?
Sufficient respiratory muscle strength to maintain effective spontaneous ventilation.

72. What may be used to gradually transition some patients toward decannulation?
Smaller tracheostomy tubes, fenestrated tubes, capping, or tracheostomy buttons.

73. Why should a patient be closely monitored after tracheostomy tube removal?
Respiratory distress, hypoxemia, hypercapnia, or difficulty breathing through the upper airway can occur.

74. What should be encouraged after a tracheostomy tube is removed?
Deep breathing and effective coughing.

75. What is the key difference between a temporary tracheostomy stoma and a total laryngectomy stoma?
A temporary tracheostomy stoma can close after decannulation, whereas a total laryngectomy stoma is a permanent breathing pathway.

76. Why does breathing through a stoma reduce normal airway humidification?
Because inspired gas bypasses the nose and upper airway, where warming and humidification normally occur.

77. What complication can occur if inspired gas through a stoma is inadequately humidified?
Secretions can become thick and difficult to clear.

78. What should be inspected before providing emergency ventilation through a stoma?
The stoma should be checked for mucus, blood, crusting, or other obstruction.

79. What is one advantage of using a pediatric mask over a stoma during ventilation?
Its smaller size can create a better seal around the neck opening.

80. When may mouth-to-stoma ventilation be necessary?
When a patient with a neck stoma is apneic and other ventilation equipment is not immediately available.

81. Why may the mouth and nose need to be sealed during ventilation through an uncuffed tracheostomy tube?
To reduce air leakage through the upper airway and direct more ventilation into the lungs.

82. Why is sealing the mouth and nose generally unnecessary during stoma ventilation after total laryngectomy?
Because the upper airway is permanently separated from the trachea.

83. What should be done if a suction catheter passes through a laryngectomy tube but spontaneous breathing does not return?
Provide oxygen and positive-pressure ventilation through the tube or stoma.

84. What should be done if a suction catheter cannot pass through an obstructed laryngectomy tube?
Remove the laryngectomy tube and ventilate directly through the stoma.

85. What type of artificial airway may be inserted through a laryngectomy stoma during a severe airway emergency?
An appropriately sized endotracheal tube.

86. What type of airway may be needed through a laryngectomy stoma when ongoing mechanical ventilation is required?
A cuffed tracheostomy tube.

87. Why are laryngectomy tubes typically uncuffed?
They are primarily used to maintain the permanent stoma rather than create a sealed airway for positive-pressure ventilation.

88. What is one purpose of a fenestrated laryngectomy tube?
It can permit exhaled airflow to reach a voice prosthesis and assist with phonation.

89. What communication device produces sound electronically for a patient without a functional larynx?
An electrolarynx.

90. What complication can occur if a tracheoesophageal voice prosthesis fails to seal properly?
Liquids may leak through the prosthesis and enter the airway.

91. Why should a voice prosthesis be cleaned regularly?
To reduce blockage from mucus or food particles and help maintain proper valve function.

92. What finding around a laryngectomy stoma should be reported as a possible sign of infection?
Pus or foul-smelling drainage.

93. Why should excessive head extension be avoided during insertion of some laryngectomy tubes?
It can alter or narrow the stoma and make insertion more difficult.

94. What type of lubricant is appropriate when inserting a laryngectomy tube?
A water-soluble lubricant.

95. Why should the distal end of a tracheostomy button be positioned carefully?
It must enter the trachea without causing airway obstruction or tissue injury.

96. What is the purpose of spacers used with some tracheostomy buttons?
They help achieve the appropriate insertion depth.

97. What should be assessed after a new tracheostomy tube is inserted?
Breath sounds, ventilation, oxygenation, tube position, and security.

98. Why is bilateral breath sound assessment important after tracheostomy tube placement?
It helps confirm that air is reaching both lungs and that the tube is appropriately positioned.

99. What is the primary goal of routine stoma and tracheostomy care?
To maintain a patent airway while preventing infection, tissue injury, secretion buildup, and device-related complications.

100. What anatomical question should be answered first when managing any patient with a neck stoma?
Whether the upper airway is still connected to the trachea and lungs.

Final Thoughts

A stoma can represent either temporary access to the trachea or a permanent breathing pathway, depending on the patient’s surgical anatomy. Effective care requires maintaining airway patency, removing secretions, protecting the surrounding skin, preventing infection, providing adequate humidification, and identifying tube obstruction or displacement quickly.

The distinction between a tracheostomy and a total laryngectomy is especially important because it determines whether ventilation through the mouth and nose can reach the lungs.

Respiratory therapists and other clinicians should always identify the type of stoma and underlying anatomy before performing routine or emergency airway interventions.