Case 1: “Patient was admitted to intensive care after laparotomy for small bowel obstruction and ischemia.
Tracheostomy done to help with weaning and was on trachy mask 28% oxygen. Attempted above cuff vocalisation...Sudden development of surgical emphysema and cardiac arrest. Died despite CPR attempts.”

Case 2: “The patient had a surgical tracheostomy inserted... It leaked air past the cuff into the patient's mouth and required high cuff pressures. [Two weeks later] the patient was taken to theatre for a change of tracheostomy and was found to have a large tracheo-oesophageal fistula.”

Cuff pressures on tracheal or tracheostomy tubes should be checked regularly and kept as low as possible. For patients receiving invasive ventilation, the cuff pressure needs to be at or above the inspiratory pressure to maintain a seal. Pressures above 30 cm H2O can affect tracheal mucosal blood flow, which can lead to pressure necrosis and fistulae.

If a patient develops a ‘cuff leak’ then this might imply that the tracheostomy tube is malpositioned within the trachea. An endoscopic evaluation of the tube is recommended. This might result in a tube change, usually for a larger or longer tube. Changing a relatively new tracheostomy tube can be difficult and a thorough assessment of the tube position after initial insertion is recommended. Leaving the (partially withdrawn) tracheal tube in place after the tracheostomy has been performed allows an easy route to assess tube position from above. The position of the tube can change between the hyperextended insertion position and the 30-degree sat up nursing position that an ICU patient will spend most of their time in. Re-positioning the
patient after insertion before checking endoscopically adds some time to the insertion procedure but will allow any problems with the tube position to be identified when all of the people required to change the tube are available.

The take home messages from this report are to consider cuff leaks in the context of the ventilator pressures, to check the position of the tracheostomy tube meticulously at the time of insertion and if a cuff leak is identified, and to act promptly when a cuff leak is identified. Simply hyperinflating the cuff might make the problem appear to go away, but this is likely going to cause new problems related to mucosal ischaemia.

McGrath and colleagues have written a useful open access guide to ways of assessing tracheostomy position.[1]

1. McGrath, BA; Lynch, K; et.al. Assessment of Scoring Systems to Describe The Position Of Tracheostomy Tubes Within The Airway – The Lunar Study. BJA, 2017. 118(1): 132-138