Tracheostomy emergencies

Background
Patients with tracheostomies may present to the emergency department
with a number of issues, the most serious being tube obstruction, tube
displacement and bleeding.

Tube displacement Tube obstruction Bleeding

 Accidental dislodgement  Secretions  Erosion into major
 Migration due to cuff deflation or  Blood blood vessel
poorly secured tube  Lodged foreign body  Granuloma
 Erosion into tissues  Malfunctioning formation
 Lodged in false passage humidification device  Trauma from
suctioning

Tracheostomy assessment
Patients with a tracheostomy should be assessed using an ABCDE approach
with attention to detecting any 'red flags' for a tracheostomy or
laryngectomy emergency. These are summarised below:

Category Red flag

Airway flags  No gas should escape a cuffed correctly sited tracheostomy. If audible air
leaks or bubbles of saliva are seen or heard at the mouth or nose, then gas
is escaping past the cuff.
 Grunting
 Snoring
 Stridor

Breathing flags  Apnoea (clinical or on capnography)

 Difficulty breathing (or with ventilation) reported by patient or observed
 Accessory muscle use
 Tachypnoea
 Higher airway pressures
 Lower tidal volumes
 Hypoxia
 Noisy breathing

Tracheostomy  Visibly displaced tracheostomy tube

flags  Blood or blood-stained secretions around the tube (note a recently
performed or changed tracheostomy bleeds a little)
 Increased discomfort or pain
 Increased air required to keep the cuff inflated indicating the cuff is
damaged or has an air leak or the tube is displaced and the cuff needs
more air to maintain seal
 Category Red flag
General flags  Tachypnoea
 Tachycardia
 Hypotension or hypertension
 Decreased level of consciousness
 Anxiety, restlessness, agitation and confusion

Tracheostomy algorithms for obstruction or displaced tube

The green algorithm for patients with who may have a patent upper airway Click on
image to enlarge
The red algorithm is for patients who have had laryngectomy and have an end stoma so
cannot be oxygenated by face or mouth Click on image to enlarge

If there is any uncertainty as to whether the patient has had a laryngectomy

oxygen should be delivered to the face and stoma or tracheostomy tube
until this can be determined.
Tracheostomy bleeding
Bleeding causes are usually classified as early or late relative to time since
tracheostomy insertion.

Causes of early bleeding Causes of late bleeding

Direct arterial or venous injury e.g. thyroid vessels Arterial erosion e.g. innominate artery*
Anticoagulation Mucosal injury e.g. suctioning
Mucosal or tracheal injury Granulation tissue

*Note: Major bleeding may occur if a tracheostomy tube erodes into a

major vessel.

Tracheo-innominate fistula (TIF)

The innominate artery (or brachiocephalic artery) is the first branch of the
ascending aorta. It ascends anteriorly and to the right of the trachea,
branching into the right common carotid and subclavian arteries.

Erosion into the innominate (brachiocephalic) artery by a tracheostomy

tube cuff or tip may result in life-threatening haemorrhage. Although rare,
estimated incidence of 0.1-1% post-tracheostomy, this complication is
typically fatal without prompt surgical intervention.
Tracheo-innominate fistula (TIF) pre and post op, highlighting relevant anatomy of the
anterior neck showing relationship between trachea and innominate (brachiocephalic)
artery. Click on image to enlarge

Bleeding from 3 days to 6 weeks post-insertion should be considered

as TIF until proven otherwise.

Minor transient bleeding or a ‘sentinel bleed’ occurs in 50% of patients and

may precede the onset of more severe bleeding.

ED clinicians practitioners should have a high index of suspicion for this

diagnosis even with minor bleeding from a tracheostomy. Urgent referral
for surgical review is advised.

Management of tracheostomy bleeding

General resuscitation measures:

 Sit the patient up

 Administer high flow oxygen
 Urgent anaesthetic and ENT review
 Large bore IV access
 Crossmatch blood (consider major haemorrhage protocol)
 Consider anticoagulant reversal

Specific measures:

 If tube cuff is inflated DO NOT deflate the cuff until expert help has
arrived (maintain any tamponade effect from cuff)
 Hyper-inflate tube cuff to increase any tamponade effect
 Bronchoscopy to assess patency of bronchi and examine bleeding
point
 If ongoing severe bleeding perform endotracheal intubation and
advance tube to just above the carina
 Temporise bleeding pending transfer to theatre by applying direct
digital pressure by inserting a finger into the stoma and compressing
the innominate (brachiocephalic artery) against the posterior wall of
the manubrium. If this requires removal of the tracheostomy tube,
 only perform this after successful endotracheal intubation and with
expert help present.

Digital pressure being applied to innominate (brachiocephalic) artery via the

tracheostomy stoma. Click on image to enlarge

Key Points

 Any bleeding from a tracheostomy tube should be considered

potentially life-threatening.
 Emergency surgical intervention is the only definitive treatment for
TIF