Tracheostomy complications

Background

Tracheostomy Sizes

(1) Thyroid cartilage (2) Cricothyroid ligament (3) Cricoid cartilage (4) Trachea (A) Cricothyrotomy site (B) Tracheotomy site

Tracheotomy in situ
1 – Vocal folds
2 – Thyroid cartilage
3 – Cricoid cartilage
4 – Tracheal rings
5 – Balloon cuff

Shiley™ trach tube

• Average size:
  • Adult: 5-10mm
  • Peds: 2.5-6.5mm

Tracheostomy vs laryngectomy

It is important to differentiate between tracheostomy vs laryngectomy

• If laryngectomy:
  • The stoma is the only way to ventilate the patient.
  • Patient cannot be orally intubated
• Critical distinction: Tracheostomy (tracheal stoma, upper airway intact) vs laryngectomy (stoma is ONLY airway — cannot be ventilated from above)
• Complications may be early (<7 days, immature tract) or late (>7 days, mature tract)
• Immature tracts are at high risk for false passage if tube is dislodged

Clinical Features

Obstruction (Most Common Emergency)

• Respiratory distress, increased work of breathing, inability to pass suction catheter
• Causes: mucus plugging, blood clot, granulation tissue, tube displacement

Decannulation/Dislodgement

• Tube falls out or is pulled out
• Immature tract (<7 days): High-risk — tract may close rapidly, reinsertion can create false passage
• Mature tract (>7 days): Usually can be replaced at bedside

Hemorrhage

• Minor: granulation tissue bleeding (common, usually self-limited)
• Tracheo-innominate fistula: Sentinel bleed followed by massive hemorrhage — life-threatening emergency
  • Occurs days to weeks post-placement; innominate artery erosion
  • Temporize with hyperinflation of tracheostomy cuff or digital compression through stoma

Other

• Tracheoesophageal fistula, subcutaneous emphysema, pneumothorax, stomal infection

Differential Diagnosis

Tracheostomy complications

• Tracheostomy obstruction
• Tracheostomy dislodgement
• Tracheostomy infection
• Tracheostomy bleeding

Evaluation

• Determine if tracheostomy vs laryngectomy (if laryngectomy → stoma is the ONLY airway)
• Identify tracheostomy type, size, and whether cuffed or uncuffed
• Assess patency: can suction catheter pass? Can patient be ventilated through trach?
• SpO2, capnography if available

Management

Stepwise Emergency Algorithm

• Call for airway expert help early
• Sit patient up or position of comfort
• Apply high-flow O2 to trach stoma AND to face (unless confirmed laryngectomy)
• Remove speaking valve or cap if present
• Remove inner cannula and attempt suction
• If unable to pass suction catheter:
  • Deflate cuff
  • Consider removing the tracheostomy tube entirely
• If tube removed:
  • Mature tract: Attempt reinsertion (same size or one size smaller); use suction catheter as bougie guide
  • Immature tract: Do NOT blindly reinsert — risk of false passage; cover stoma, ventilate from above (oral intubation)
• If unable to ventilate from either route → emergency cricothyrotomy or surgical airway through stoma

Tracheo-innominate Hemorrhage

• Hyperinflate cuff to tamponade
• If unsuccessful: digital compression of innominate artery through stoma (finger anterior and downward)
• Emergent surgery consult — definitive management is operative

Disposition

• Admit all patients with significant tracheostomy emergencies
• Low threshold for admission of patients with immature tracts

See Also

• Medical device complications
• Surgical airways
• G-tube complications
• Ostomy complications