A tracheostomy is a surgical procedure where an opening is created in the anterior neck that allows direct access to the trachea (windpipe). This opening, called a tracheostomy stoma, allows air to enter the lungs without having to pass through the upper airway. Tracheostomies are performed for a variety of reasons, including to bypass an upper airway obstruction, to facilitate long-term mechanical ventilation, or to facilitate secretion removal in patients who cannot clear secretions effectively. While a tracheostomy can be lifesaving, like any surgical procedure, it also carries risks of complications. Complications can occur during the actual tracheostomy procedure (perioperative complications), in the early postoperative period after tracheostomy placement, or later on after the stoma has matured. Knowing the most common early complications of tracheostomy can help healthcare providers be prepared to recognize and manage them appropriately.
Types of Early Tracheostomy Complications
Some of the most common early complications that can occur after a new tracheostomy include:
- Subcutaneous emphysema
- Tracheomalacia and tracheal stenosis
- Dislodgement and accidental decannulation
- Tracheo-innominate artery fistula
These complications tend to occur within the first 1-2 weeks after tracheostomy tube placement while the stoma is still maturing. Let’s take a closer look at each of these early tracheostomy complications:
Bleeding can occur during the tracheostomy procedure itself if a blood vessel is nicked, or it can occur postoperatively if wound healing at the tracheostomy site leads to erosion of a blood vessel. Significant bleeding is one of the most serious early complications of tracheostomy and can quickly become life-threatening if not recognized and managed emergently.
Tracheostomy stoma sites are at high risk for infection given their direct communication with the trachea and exposure to the external environment. Signs of early stomal infection include purulent drainage, cellulitis, foul odor, and fever. Tracheitis (infection of the trachea itself) may also occur.
Pneumothorax refers to air accumulating in the pleural space between the lungs and chest wall, leading to lung collapse. It is an uncommon but serious complication that can occur if the tracheostomy tube is inadvertently placed too deep and penetrates the parietal pleura.
Subcutaneous emphysema occurs when air tracks up from the tracheostomy site and spreads into the subcutaneous tissues of the neck and chest wall. This can create crepitus and swelling. It may result from a small tear in the tracheal wall or parietal pleura.
Tracheomalacia and Tracheal Stenosis
The tracheostomy tube itself can lead to pressure-related injury, with the cuff possibly causing pressure necrosis. This can lead to weakening of the tracheal rings (tracheomalacia) or narrowing of the trachea (tracheal stenosis).
Dislodgement and Accidental Decannulation
Early on when the stoma is immature, the tracheostomy tube is at higher risk of becoming dislodged or accidentally coming out fully (decannulation). This can lead to acute airway obstruction.
Tracheo-innominate Artery Fistula
This is an uncommon but often fatal early complication in which the tracheostomy tube erodes into the adjacent innominate artery, creating a direct connection. Life-threatening bleeding can ensue.
Most Common Early Complication
Of all the early complications that can arise after a new tracheostomy, the most common is bleeding.
Multiple studies looking at early tracheostomy complications have found bleeding to be the most prevalent, occurring in anywhere from 1.6% to 11.8% of patients in the first 1-2 weeks after tracheostomy:
|Wang et al. 2011||11.8%|
|Dempsey et al. 2006||8.4%|
|Hill et al. 2005||7.9%|
|Stock et al. 2004||5.6%|
|Stelter et al. 1997||1.6%|
While the rates vary between studies, bleeding consistently emerges as the most prevalent of the early complications overall. There are several reasons why bleeding is particularly common:
- Formation of the tracheostomy defect involves cutting through very vascular tissue in the anterior neck.
- Ongoing healing and granulation at the fresh stoma site can lead to erosion of adjacent blood vessels.
- Tracheostomy tubes can exert pressure on the tracheal walls, leading to necrosis and exposure of blood vessels.
- Coughing and tract tension on the tracheostomy can tear delicate granulation tissue.
- Anticoagulants or antiplatelet medications may increase bleeding risk.
Bleeding can range from a minor ooze to a torrential hemorrhage depending on the source and type of vessel involved. Minor bleeding often resolves on its own, but severe bleeds require prompt intervention to stabilize the airway and stem blood loss.
Presentation of Bleeding
Bleeding arising from the tracheostomy stoma site or deeper trachea may present in different ways:
This involves bleeding directly out through the tracheostomy stoma exteriorly. The initial signs may be minor blood-tinged secretions or dripping of frank blood from the stoma. However, brisk bleeding can quickly ensue if a major blood vessel opens up. Saturations may drop if blood loss is severe.
Bleeding originating from the trachea (tracheitis) or a tracheoesophageal fistula may present as hemoptysis – coughing up blood via the tracheostomy tube. Saturations are often well-maintained.
Small warning bleeds may precede a major hemorrhage, especially with tracheo-innominate fistulas. Intermittent minor oozing of blood can occur before sudden torrential bleeding.
Risk Factors for Early Tracheostomy Bleeding
Certain factors can increase risk of bleeding in the early post-tracheostomy period:
- Coagulopathy or antiplatelet/anticoagulant medication
- Infection or tracheitis
- High positive end-expiratory pressure
- Trauma to vascular structures during tracheostomy placement
- High tracheostomy tube cuff pressure
- Forceful suctioning or coughing
- Underlying disease like diabetes mellitus or cancer
Identifying and mitigating modifiable risk factors for bleeding can help reduce risk of this common early tracheostomy complication.
Management of Early Tracheostomy Bleeding
When bleeding occurs in the days and weeks after a new tracheostomy, prompt and targeted management can save the patient’s life. Initial management steps include:
- Maintain ventilation – provide supplemental oxygen as needed.
- Assess for extent and severity of bleeding – is it a minor ooze or torrential hemorrhage?
- Determine if bleeding is internal or external.
- Alert help/rapid response team early.
- Keep suction at bedside to clear airway of blood as needed.
Depending on bleeding severity, additional interventions may include:
- Apply direct pressure to stoma
- Use hemostatic dressings
- Loosen ties to relieve pressure on trachea
- Consider topical agents like silver nitrate
- Inflate cuff if bleeding is intratracheal
- Pack stoma with moist gauze
- Consider emergent tracheal balloon tamponade
- Suspend anticoagulants/antiplatelets if possible
- Give intravenous fluids, blood products, vasopressors as needed
- Surgical exploration may be urgently needed
Preventing and promptly managing bleeding reduces morbidity and mortality associated with this common early tracheostomy complication.
Tracheostomy is an invasive procedure with the potential for various early complications as the stoma heals and matures in the first 1-2 weeks post-placement. Of these, bleeding stands out as the most common, with reported incidence rates ranging from 1.6% to 11.8% in published studies. Bleeding can vary from a minor ooze to severe hemorrhage depending on the source and vessels involved. Risk factors like coagulopathy, infection, trauma, high pressures, and medications can increase chances of bleeding. Close monitoring and prompt targeted management of bleeding when it occurs can improve patient outcomes after tracheostomy. Being aware that bleeding is the most prevalent early tracheostomy complication can help clinicians enhance care.