Tracheostomy complications: Difference between revisions
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==Background== | ==Background== | ||
{{Tracheostomy background}} | {{Tracheostomy background}} | ||
*Critical distinction: Tracheostomy (tracheal stoma, upper airway intact) vs laryngectomy (stoma is ONLY airway — cannot be ventilated from above)<ref>Mitchell RB, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013 Jan;148(1):6-20. PMID 22990518</ref> | |||
*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== | ==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== | ==Differential Diagnosis== | ||
| Line 8: | Line 28: | ||
==Evaluation== | ==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 | ==Management== | ||
*Call for airway expert help | ===Stepwise Emergency Algorithm=== | ||
*Sit patient up or | *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 speaking valve or cap | *Remove inner cannula and attempt suction | ||
*Remove inner cannula | *If unable to pass suction catheter: | ||
*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== | ==Disposition== | ||
*Admit all patients with significant tracheostomy emergencies | |||
*Low threshold for admission of patients with immature tracts | |||
==See Also== | ==See Also== | ||
*[[Medical device complications]] | *[[Medical device complications]] | ||
*[[Surgical airways]] | *[[Surgical airways]] | ||
*[[G-tube complications]] | |||
*[[Ostomy complications]] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:ENT]] | [[Category:ENT]] | ||
[[Category:Surgery]] | [[Category:Surgery]] | ||
[[Category:Pulmonary]] | [[Category:Pulmonary]] | ||
[[Category:Critical Care]] | |||
Latest revision as of 10:57, 22 March 2026
Background
Tracheostomy Sizes
- Average size:
- Adult: 5-10mm
- Peds: 2.5-6.5mm
Tracheostomy vs laryngectomy
It is important to differentiate between tracheostomy vs laryngectomy
- If laryngectomy[1]:
- 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)[2]
- 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
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
References
- ↑ https://www.ccam.net.au/handbook/tracheostomy/ Date accessed: 4/24/2018
- ↑ Mitchell RB, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013 Jan;148(1):6-20. PMID 22990518