Tracheostomy care and the dislodged tube

A tracheostomy is the patient's airway, so the nurse keeps what is needed to restore it at the bedside at all times — the obturator, a spare tube of the same size and one a size smaller, suction and oxygen — and protects it through every part of routine care: the tube is held secure by ties that admit one finger and are never removed until new ones are in place or a second person is holding the tube; the stoma is cleaned and dressed with a manufactured split dressing, never gauze cut to fit, whose loose fibres can be inhaled; the inner cannula is cleaned or replaced so that secretions cannot narrow the lumen; the inspired air is humidified because the nose that once warmed and moistened it has been bypassed; the cuff is kept at the pressure that seals the airway, checked with a manometer rather than judged by feel, because a cuff overfilled for a better seal starves the tracheal wall of blood and leads to necrosis, stenosis or a fistula into the oesophagus; a one-way speaking valve is placed only after the cuff has been fully deflated, because over an inflated cuff the patient can breathe in but cannot breathe out; and the patient who cannot speak is given a way to call and communicate — while the nurse recognises the tube that has come out or slipped out of the trachea, which declares itself as sudden distress, air or voice escaping around the tube, a suction catheter that will not pass, or swelling and crackling of the skin of the neck, as an airway emergency answered at once by calling for help and oxygenating the patient, replacing the tube through an established tract using the obturator, but not forcing a tube blindly into a fresh tract that has not yet formed and can close or be driven into a false passage, where the stoma is held open and the patient oxygenated until someone skilled in airway management arrives.