Nothing makes me more nervous than a phone call about a lost airway. If the airway is lost and the patient is unable to breath on his own, you have just a few minutes before the level of oxygen drops to a dangerous level. Once the level of oxygen is low, the patient goes into a cardiac arrest. Brain damage from inadequate oxygen supply is also possible. Depending on the patient’s preexisting condition and the severity of the situation, you might only have three to tens minutes to reestablish the airway and provide oxygen delivery to the vital organs. When I get one of those calls, I do not walk, I run.

There are two types of airways being used in the ICU - the endotracheal tube and the tracheostomy tube. The endotracheal tube is a temporary option. The flexible plastic tube is inserted through the patient’s oropharynx into the trachea. The presence of the plastic tube in the throat usually makes patients very uncomfortable. The tube might get dislodged with moving. It is also not unusual for the tube to be pulled by inadequately sedated or restrained patient. Once the tube gets dislodged, in most cases, it needs to be replaced. Replacing the endotracheal tube, usually, is not a big concern as long as the patient is not unstable or has a difficult airway.

The tracheostomy tube (trach) is surgically inserted directly into the trachea through an incision on the patient’s neck. This tube is considered a long term option. The trach rarely gets dislodged. Once it happens, though, it could be a really big problem. The first question to ask is how long the trach has been there. If the trach was inserted more than ten to fourteen days ago, the tract is usually mature and you can try to reinsert the trach through the same hole. You might also consider taking a smaller size trach to facilitate insertion.

If the trach is new (less than ten days), then you might have a problem. The tracheostomy tract is not mature at this point and you are at risk of inserting the tube into the subcutaneous tissue (tissue beneath the skin) instead of the airway. If you try to ventilate the patient with the trach in the subcutaneous tissue, the patient will develop subcutaneous (SQ) emphysema (air under the skin). The patient might look like a Michelin Man. SQ emphysema is not the biggest problem. Remember, the patient is still not getting oxygen and the clock is running fast.

An alternative option to reestablish the airway, if a fresh trach gets dislodged, is to intubate the patient from above using the endotracheal tube. This option is preferred if the trach is very fresh (one or two days). It usually works unless the patient has a difficult airway.

One thing to remember when dealing with a difficult airway: try to get as much help as early as possible. Calling anesthesia and surgery is always a good idea if things are not going well.

Time goes very, very fast if you have an airway problem. You have to think and move fast as well. Otherwise, it might cost the patient his or her life.