Author: Kenny Chao, MD
Editor: Nicole Anthony, MD
Ring ring. Notification: “Trach’d patient in respiratory distress.” Check your patient board: chief complaint of a small bleed from the tracheostomy tube that has since stopped.
Pre-COVID, roughly 110,000 tracheostomies were performed yearly in the United States. Of those, only half survive more than one year, and only 12% are at home and functionally independent at the one year mark. This year has likely seen a spike in mechanically ventilated patients and with that, we can expect a rise in performed tracheostomies and the number of tracheostomy-related complications presenting to our hospitals.[1]
Here’s a short guide to tracheostomy complications.
Components
Know your trach parts.
‣ Neck plate / palette. Piece that braces against the patient’s outer neck to hold the tube in place. It also includes important information regarding the tube’s attributes (e.g. size, fenestration, cuffed vs. uncuffed).
‣ Outer cannula. Rigid plastic tube that serves as the hull of the tracheostomy tube.
‣ Inner cannula. Removable tube that fits within and runs along the outer cannula lumen. Removal of it allows secretions to be cleared from the lumen more easily without removing the entire outer tube. Additionally (and arguably more importantly), the inner cannula can attach to a bag-valve-mask or ventilator. Therefore, the inner cannula must be inserted before ventilating. The inner cannula can be replaced as needed if dirty or damaged. Note, pediatric tubes do not have an inner cannula due to their already small lumen. In this case, the ventilator connectors attach directly to the outer cannula.
‣ Obturator. Used during insertion of tube to provide structure. It has a blunted tip to smooth out the abrasive distal end of the outer cannula to prevent trauma during insertion.
Figure 1. ‘Tracheostomy Components [2]
Know your variations.
Size. Measures the inner diameter. Typical sizes: Adult 5-10 mm; Pediatrics 2.5-6.5 mm.
Lengths. Trachs can have extended lengths, located either:
‣ Proximal – before the curve and behind the neck plate [to accommodate thick necks]
‣ Distal – after the curve [to bypass tracheal stenosis or tracheomalacia
Cuff / uncuffed.
‣ Cuffed tubes are required for ventilating, otherwise air leak occurs with each breath delivered. If the patient has an uncuffed tracheostomy tube and requires emergent ventilation, you must switch to a cuffed tube. A balloon valve allows the cuff to be inflated.
‣ Uncuffed tubes are typically reserved for those who don’t require ventilation, i.e. they are awake and alert, and likely further along in recovery. Uncuffed tubes tend to have less incidence of mucosal and tissue injury and are easier to place. Additionally, if the trach lumen is obstructed, the patient can still breathe around the tube.
Fenestrated. The fenestration is an opening along the dorsal surface of the outer cannula that allows for air passage to vocal cords and consequently, speech during exhalation. In order for this to work, both the inner and outer cannulas must be fenestrated.
Valves. One-valves can be placed overlying the outer tip of the inner cannula. They allow for inward air movement, but not outward, allowing exhalations to be redirected physiologically across the vocal cords and out the mouth/nose facilitating speech.
Complications
A whole slew of complications can arise from having a tracheostomy. What’s the worst that can happen, you ask? Well, you’re dealing with the patient’s airway, AKA the first part of your ABCs. So yeah, it can evoke some sphincter tightening.
Timing after placement can help you anticipate which type of difficulty to expect. Below is a fairly extensive list of complications respective to timing after tracheostomy placement. Some folks suggest early complications occur within a week after trach placement, but there’s no hard-fast cutoff timeline.
Figure 2. Tracheostomy Complications [3]
We’ll cover 3 basic complications: obstruction, dislodgment, bleeding.
Obstruction
This is a common issue amongst tracheostomy patients. The obstruction may be at the level of the tube itself, or even further down in the patient’s endogenous airway, especially given that the patient has a decreased ability to clear their airway. Oftentimes, the culprit is a mucus plug, which acts as a ball-valve allowing air to enter the lungs but restricts exhalation. Another consideration is granulation tissue crusting over fenestrations, or over the distal tracheostomy opening.
Figure 3. Obstructing mucus plug on the end of a removed tracheostomy tube [4]
Check out the “An Approach” section for an algorithmic way to troubleshoot a potential obstruction. In general, remove the inner cannula to look for obstruction. If present, clean it with tap water or just replace it. If there is no obvious obstruction in the inner cannula, consider a distal obstruction. Use a suction catheter and attempt to pass it through the tube while suctioning and looking for improvement in breathing. You can consider injecting some saline to help break up mucus plugs.
Keep your pulmonary specialists in mind to consider a bronchoalveolar lavage (BAL), emergent versus urgent based on symptom severity. Reach out if concerned for continued airway obstruction, especially with persistent abnormal respiratory exam findings (e.g. stridor, tachypnea, increased work of breathing) and abnormal radiographic findings (e.g. focal hyper-lucency on chest x-ray) suggestive of post-obstructive pneumonia.
Dislodgment
It happens. Especially in more mobile, awake, or agitated patients or during patient transport. Patients may still be oxygenating well despite a dislodged tube.
Be sure to inspect the tube well. Is the neck plate flush with the skin? Is the tube rotated? If you can see the cuff or the end of the distal tube, you’ve probably already concluded – it’s out. And despite what you see externally, the tube can still be dislodged. Go through your tracheostomy tube troubleshooting algorithm (again, another plug for the “An Approach” section below). In a stable patient where you can’t pass a suction catheter through the tube or you have a strong suspicion of dislodgment, consider x-rays – both PA and lateral. If you only get a PA view, it’ll stand for ‘poor assessment’ (or likely ‘assessment poor’). One-view can give you an appropriately-placed optical illusion of an anterior-posteriorly displaced tube.
Figure 4. Partially displaced and anteriorly displaced tube [5]
If dislodged but with a well visualized stoma and posterior tracheal wall, consider replacing the tube yourself. As a benchmark, mature stomas fully close generally a week after tube decannulation; however they can close as fast as 50% in the first 12 hours, and 90% in the first 24 hours. Immature stomas close faster.[6][7] DO NOT REPLACE THE TRACHEOSTOMY IF IT WAS PLACED LESS THAN 7 DAYS AGO. When attempting to cannulate immature stomas less than 7 days old, there is a high risk of creating a false lumen. Call a specialist in this case, but also for complicated cases (e.g. obese necks, neck masses, partially / fully-closed stomas).
General replacement steps:
‣ Prepare your materials ahead of time. Include suction, trach tube plus an additional smaller size, and adjunct airways.
‣ Visualize both the cutaneous and tracheal stoma. If the tracheal stoma is not visualized, palpate for it. You need to know if the openings are in the same plane or not; align the openings prior to tube insertion to decrease risk of creating a false lumen.
‣ Insert the tracheostomy tube (with the obturator in place). Do so with the distal end at 90 degrees and in-line with both the cutaneous and tracheal stoma. Once in the tracheal lumen, rotate it caudally to allow the distal end to follow the trachea downward.
‣ Remove the obturator, and inflate the cuff (if present).
‣ Confirm placement with end tidal CO2, colorimetry, passing a suction catheter through the tube, and/or chest x-rays (PA and lateral).
Figure 5. 90-degree initial approach, followed by caudal turn [7]
Placement should be relatively smooth. If not, you can consider trying again, this time with lubrication, or call your hospital specialists for back up (ENT, Critical Care). Consider additional tools to help guide placement, such as a bougie which, when placed directly into the trachea via the stoma, provides a track for the tube to slide over and into place. Another technique includes using a nasopharyngoscope or flexible bronchoscope to replace the tracheostomy under direct visualization.
Bleeding
Bleeding in tracheostomies is common and often benign. Frequent causes include minor suction trauma or tube manipulation causing trauma to small blood vessels. Consider applying pressure with saline-soaked gauze if the bleeding is visualized near or around the stoma. If bleeding continues, further investigate by removing the tube (with ENT or critical care consult present, if stoma is immature) and examining the stoma and surrounding area (including the tracheal wall). Application of silver nitrate or even strip gauze like Surgicell may help stop the bleeding. Consult ENT or surgery if electrocautery is needed.
Other more serious causes of bleeding tend to occur later after placement. These include:
‣ Tracheoinnominate fistula (TIF). Occurring usually within 6 weeks of placement (peak 7-14 days), this rare (incidence < 1%) but often fatal complication occurs when a fistula develops, leading to communication between the trachea and the innominate artery lumen.[8] The illustration below shows a few pathways that lead to a fistula, including cuff necrosis and erosion from the tube itself. Another name for the innominate artery? Brachiocephalic artery, the first major branch coming off the aortic arch. So yeah, it’ll bleed big. About 50% of TIFs present with a sentinel, or herald bleed, so don’t discount every ‘small’ tracheostomy bleed you encounter.[9]
Further investigation is needed for bleeds with no inciting event or obvious cause. Dr Kenji Inaba, trauma surgeon at LAC + USC Medical Center, suggests starting with an external exam and bronchoscopy to rule-out bleeding etiology from skin down to the lung. If both are negative or bronchoscopy is unavailable, he suggests performing a CTA of the chest. It rarely will reveal active bleeding nor a complete fistula but would suggest clues to a developing fistula – including close apposition of the tracheal wall to the innominate artery, compression of the artery, and signs of tissue inflammation in the region.[10]
‣ Granulation tissue growth. Irritation from the foreign tracheostomy tube promotes growth of vascularized granulation tissue. Manipulation of the tissue can cause bleeding. This makes it even more difficult to remove the tube if required. Consider backup (e.g. airway cart, specialists).
Figure 6. Tracheoinnominate fistula, common etiologies [11]
How to approach a serious bleed? In the ED, your goals are to 1) temporize the bleed, and 2) secure the airway. Given the speed of exsanguination, cardiovascular collapse and cardiac arrest are imminent necessitating re-prioritization of thel ABC approach.
1. First step, hyper-inflate the cuff to 50 cc. The balloon can take that amount. You’re trying to tamponade the bleed while preventing the bypass of blood into the lower airway. Be aware, your hyper-inflated balloon may obscure visualizing continued distal bleeding, so continue monitoring your patient and their vital signs.
2. If there’s continued bleeding, apply direct digital pressure against the bleed. Place a finger downward through the stoma and apply pressure towards you (against the anterior tracheal wall) to tamponade the bleed. Note, if you own that tamponading finger, you’re keeping it there and riding to the OR with the patient. There are case reports of a foley catheter balloon being used to tamponade bleeds, freeing up a staff member.[12,13]
3. Secure the airway. If the tracheostomy tube is patent and in the correct place, you can leave it there. Otherwise, replace the tracheostomy tube with a cuffed endotracheal tube. You can place it orally OR through the stoma. The cuff should be inflated below the site of bleed to help prevent aspiration. Accomplish this through direct visualization via nasopharyngoscope or bronchoscope, if possible.
4. Go to the OR. Call your surgeon (ENT, vascular, trauma, etc).
An Approach
That’s great that you now know what sort of complications to expect. But how do you troubleshoot up to this point? If someone’s in the midst of respiratory distress, where do you start? Luckily, someone’s thought about this before you and brainstormed an algorithm with which to approach tracheostomy complications.
A paper by McGrath, Bates, Atkinson, and Moore from the UK’s NHS presents two general approach algorithms meant for first responders. They consist of the “green” algorithm for patients with a patent upper airway, and a “red” algorithm for those with a laryngectomy. The latter cannot be intubated nor oxygenated via the mouth. The authors started the National Tracheostomy Safety Project in the UK to improve safety and quality of care to tracheostomy patients. They developed and recommend the use of colored reference cards with the algorithms to be posted above patient beds, as a quick resource to troubleshoot complications.[14]
Figure 7. Emergency Tracheostomy Management Flowchart [14]
Here are a few key points:
‣ Get history. Specifically, what is the reason the patient has a tracheostomy? Do they have a laryngectomy, a tumor impinging on the airway, or perhaps pharyngeal / laryngeal sclerosis? This information will help you anticipate a difficult intubation and may lead you to intubate the stoma instead. In the case of a laryngectomy, however, the tracheostomy stoma is their ONLY path to ventilation.
Also, know what type of tracheostomy tube your patient has. If ventilation is required, an uncuffed tube will need to be switched for a cuffed tube. Know and grab the right tube size plus one size smaller, in the event that you need to attempt tube replacement.
‣ Onion approach. The algorithm employs a stepwise approach to assess tracheostomy patency, methodically peeling away at the layers of the tracheostomy tube to troubleshoot. First, preoxygenate the patient. Then, start with taking off the valve cap, followed by removing and assessing the inner cannula / lumen, deflating the cuff, and eventually removing the entire outer cannula.
‣ Two airways. Barring the patient having a laryngectomy, you have TWO airways to work with – the oropharynx and the tracheostomy stoma (or 2.5 airways if you want to count the nasal route). This has several implications:
Pre-oxygenation. Prior to investigation, manipulation, suctioning, or tube removal, preoxygenate the patient. Cover the naso-oral airway with a face mask and trach stoma with a tracheostomy mask and oxygenate. See video.[15]
‣ Bagging. If respiratory distress continues despite investigation and removal of tube, you’re on a path of providing rescue breaths and potentially intubating – both of which can be provided naso-orally or via the tracheostomy stoma. When bagging via one route, cover the other to create a seal and prevent air leakage.
You can apply your standard bag-valve-mask (BVM) over the naso-oral airway. Consider your adjuncts (e.g. oropharyngeal airway, nasal trumpet, laryngeal mask airway [LMA]) if needed. Place a hand or occlusive dressing if available over the stoma to prevent air leakage. If bagging through the tracheostomy stoma, use a pediatric BVM mask, adult BVM mask turned 90 degrees, or LMA to create the seal over the stoma and provide breaths. An additional set of hands would need to close the mouth and nose to prevent air leakage until clinical improvement or intubation. The following videos demonstrate ventilation through both airways (naso-oral, stoma).[16][17]
‣ Intubation. Endotracheal tubes can be inserted nasally, orally, or through the stoma. Likewise, adjunct devices used for standard endotracheal intubations can also be used through the stoma, including bougies and direct visualization tools. If intubating through the stoma, keep in mind the carina is only 4 to 6 cm distal, so you don’t need to advance the tube very far.
Take-Home Points
“At a cardiac arrest, the first procedure is to take your own pulse.” Wise words from Samuel Shem’s ‘Laws of the House of God.’. Modify this, & you get, “At a respiratory arrest, the first procedure is to take a breath.” Basically, “check yourself before you wreck yourself.”
When troubleshooting a tracheostomy issue, take a breath. Use the time to go over what you know and who you need to call for help. Determine what tube type the patient has (cuffed vs. uncuffed, fenestrated vs. non-fenestrated) and whether the patient can be naso-orally intubated and ventilated.
Remember your troubleshooting algorithms such as the “Green” algorithm which encourages working your way from the outer to inner components of the tracheostomy tube. If the patient needs to be ventilated via their tracheostomy tube, the patient needs a cuffed, non-fenestrated tube. And finally, have all your adjuncts and tools available nearby (suction, additional tracheostomy tubes, airway cart, direct visualization modalities, surgical consults).
Other resources:
– Clinical Monsters, ‘Trachs are a Pain’ Morning Report
– Basic Tracheostomy Education for Caregivers
– Essentials of Emergency Medicine – Bleeding Tracheostomy (Dr. Kenji Inaba, Keck School of Medicine USC
– National Tracheostomy Safety Project – Videos
References
1. McGrath BA, Brenner MJ, Warrillow SJ, et al. Tracheostomy in the COVID-19 era: global and multidisciplinary guidance. The Lancet Respiratory Medicine. 2020;8(7):717-725. doi:10.1016/S2213-2600(20)30230-7
2. Mount Sinai. 2021. ‘Tracheostomy Components’. Tracheostomy Education for Patients and Caregivers. [online] Available at: <https://www.mountsinai.org/files/MSHealth/Assets/HS/Care/ENT/General/TracheostomyEducationPatientsCaregivers2019.pdf> [Accessed 13 April 2021].
3. Jarosz K, Kubisa B, Andrzejewska A, Mrówczyńska K, Hamerlak Z, Bartkowska-Sniatkowska A. Adverse outcomes after percutaneous dilatational tracheostomy versus surgical tracheostomy in intensive care patients: case series and literature review. Ther Clin Risk Manag. 2017;Volume 13:975-981. doi:10.2147/tcrm.s135553
4. Law, J.A., Mariotti, C. & Mullen, T. Failure of both suction catheter passage and bronchoscopy to diagnose an obstructing tracheal mucus plug. Can J Anesth/J Can Anesth 59, 911–912 (2012). https://doi.org/10.1007/s12630-012-9738-0
5. McGrath B, Bates L, Atkinson D, Moore J. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012;67(9):1025-1041. doi:10.1111/j.1365-2044.2012.07217.x
6. Morris LL, Whitmer A, McIntosh E. Tracheostomy care and complications in the intensive care unit. Crit Care Nurse. 2013;33(5):18-30. doi:10.4037/ccn2013518
7. Morris LL, Afifi MS. Chapter 10: Complications and Emergency Procedures. In: Morris LL, Afifi MS. ed. Tracheostomies: The Complete Guide. Springer, 2010: 293. doi: 10.7748/en.19.2.9.s4
8. Fernandez-Bussy S, Mahajan B, Folch E, Caviedes I, Guerrero J, Majid A. Tracheostomy Tube Placement: Early and Late Complications. J Bronchology Interv Pulmonol. 2015;22(4):357-364. doi:10.1097/LBR.0000000000000177
9. Grant CA, Dempsey G, Harrison J, Jones T. Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical review. Br J Anaesth. 2006;96(1):127-131. doi:10.1093/bja/aei282
10. Inaba K. Bleeding Tracheostomy. Oral presentation at: Essentials of Emergency Medicine Live Presentation; September, 2016.
11. Dyer RK, Fisher SR. Tracheal-innominate and tracheal-esophageal fistula. In: Wolfe WG. Complications in Thoracic Surgery: Recognition and Management. St. Louis: Mosby Inc; 1992.
12. Lee SK, Son JH, Kim YS, Park JM, Kim DH. Tracheo-innominate artery fistula caused by isolated innominate artery pseudo-aneurysm rupture. J Thorac Dis. 2018;10(7):E577-E580. doi:10.21037/jtd.2018.06.137
13. Donaldson L, Raper R. Successful emergency management of a bleeding tracheoinnominate fistula. BMJ Case Rep. 2019;12(12):e232257. Published 2019 Dec 17. doi:10.1136/bcr-2019-232257
14. McGrath BA, Bates L, Atkinson D, Moore JA; National Tracheostomy Safety Project. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012;67(9):1025-1041. doi:10.1111/j.1365-2044.2012.07217.x
15. National Tracheostomy Safety Project. Ventilation via the face [Video]. YouTube. https://www.youtube.com/watch?v=vy2sUPXHoOk. Published December 7, 2011. Accessed April 16, 2021.
16. National Tracheostomy Safety Project. Ventilation via the face [Video]. YouTube. https://www.youtube.com/watch?v=e3l0ZX0VwXw. Published November 7, 2017. Accessed April 16, 2021.
17. National Tracheostomy Safety Project. Ventilation via the stoma [Video]. YouTube. https://www.youtube.com/watch?v=NCB3C0K3yoc. Published November 7, 2017. Accessed April 16, 2021.
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