Surgical Critical Care: Tracheostomy – Complications

Bleeding

Early Minor Bleeding

  • Bleeding from Local Trauma to Superficial Veins
  • Occurs within First 48 Hours
  • Treatment:
    • Silver Nitrate
    • Packing Petroleum Gauze
    • Packing Surgicel Gauze
    • Injection of Lidocaine with Epinephrine

Tracheo-Innominate Fistula (TIF)

  • Fistula Between Innominate Artery & Trachea
  • Causes Rapid Exsanguination
  • Occurs After 48 Hours
  • 50% are Heralded by a Sentinel Bleed
  • Most Common Causes:
    • Prolonged Exposure to Overinflated Cuff Pressures
    • Abnormally Low Tracheostomy Placement
    • Repetitive Head Movements Causing Repeated Contact
  • Treatment:
    • Initial: Pressure
      • Overinflate Cuff – Pressure Against Sternum
      • Utley Maneuver – Finger Through Incision into Pretracheal Space to Apply Anterior Pressure Against Sternum (Not into the Trachea Itself)
    • Small Sentinel Bleed: Preform Bronchoscopy in OR to Examine
    • Definitive Treatment: Median Sternotomy & Innominate Artery Ligation
      • Primarily Repair Trachea and Buttress with Viable Tissue
      • Failure to Ligate Has High Risk for Re-Fistulation
      • Do Not Use Interposition Graft (Will Become Infected)
      • Some Have Suggested Use of Endovascular Stents if Prohibitively High Surgical Risk
      • 10% of Patients Experience a Neurologic Event After Ligation

Tracheoinominate Fistula on Angiogram 1

Utley Maneuver 2

Other Complications

Tracheoesophageal Fistula (TEF)

  • Risk Factors:
    • High Cuff Pressure (#1)
    • Concomitant Nasogastric Tube
    • Excessive Motion
  • Presentation:
    • Ono’s Sign – Uncontrolled Coughing After Swallowing
    • Respiratory Distress
    • Recurrent Pneumonia
  • Treatment:
    • Initial Management: Large Volume Cuff Endotracheal Tube Below the Fistula
      • Prevent Aspiration
    • Definitive Treatment: Surgical Repair (Primary Repair vs Resection)
    • If Not a Surgical Candidate: Combination Tracheal & Esophageal Stenting
      • Tracheal Stent Before Esophageal Stent – Esophageal Expansion May Compress Trachea

Tracheostomy Obstruction

  • Causes:
    • Mucous Plugging
    • Clotted Blood
    • Passage into A False Lumen (Paratracheal Soft Tissue)
    • Tube Angulation
  • Presentation: Acute Respiratory Deterioration
  • Treatment:
    • Initial Attempt: Suctioning of Tracheostomy Tube
    • If Fails: Exchange Inner Cannula

Dislodgement/Accidental Decannulation

  • Emergency if Occurs within First 7 Days
    • Without a Mature Tract Replacement Could Cause a False Tract
  • Presentation: Acute Respiratory Distress & Subcutaneous Emphysema
  • Treatment: Endotracheal Intubation
    • If Stable May Consider Bronchoscopic-Guided Replacement in Experienced Hands

Tracheal Stenosis

  • The Most Common Late Complication
    • Almost All Have Some Degree of Stenosis
    • Only 3-12% Have Clinically Significant Stenosis
  • Typically Seen at the Level of the Stoma
  • Often Asymptomatic Until Lumen Reduced to < 5 mm (25-50% of Original Diameter)
  • Presentation:
    • Elevated Peak Airway Pressures if Infra-Stomal Stenosis
    • Dyspnea, Stridor & Respiratory Failure After Decannulation
  • Grading:
    • Grade I: ≤ 50%
    • Grade II: 51-70%
    • Grade III: 71-99%
    • Grade IV: 100%
  • Complexity:
    • Simple: < 1 cm, Granulation Tissue, Web-Like Lesion, Concentric or No Involvement of Tracheal Wall
    • Complex: > 1 cm, Scarring or Presence of Tracheomalacia
  • Diagnosis: Bronchoscopy
  • Treatment:
    • Simple: Bronchoscopic Serial Dilation
      • Possibly Bronchoscopic Resection or Laser Ablation
    • Complex: Tracheal Resection (Up to 6 cm) & End-to-End Anastomosis

Tracheoesophageal Fistula 3

References

  1. Richter T, Gottschlich B, Sutarski S, Müller R, Ragaller M. Late life-threatening hemorrhage after percutaneous tracheostomy. Int J Otolaryngol. 2011;2011:890380. (License: CC BY-3.0)
  2. Kim JH, Lee JY, Cho HR, Lee JS, Ryu JM. A tracheoinominate artery fistula presenting with massive hemorrhage in a 13-year-old boy. Ped Emerg Med. 2015;2(2):89-92. (License: CC BY-NC-3.0)
  3. Paraschiv M. Tracheoesophageal fistula–a complication of prolonged tracheal intubation. J Med Life. 2014 Oct-Dec;7(4):516-21. (License: CC BY-2.0)