DISCLAIMER: The information provided here is for educational purposes only and is designed for use by qualified physicians and other medical professionals. In no way should it be considered as offering medical advice. By referencing this material, you agree not to use this information as medical advice to treat any medical condition in either yourself or others, including but not limited to patients that you are treating. Consult your own physician for any medical issues that you may be having. By referencing this material, you acknowledge the content of the above disclaimer and the general site disclaimer and agree to the terms.

TRACHEOTOMY HEMORRHAGE

Overview
The majority of tracheostomy bleeds originate from the stomal region or are related to suctioning trauma and are self-limiting. Nevertheless, more serious causes of bleeding such as tracheoinnominate fistula (TIF) must always be considered and ruled out. Upon consultation, the current status of bleeding (active bleeding or previously bleeding) as well as volume of blood loss should first be determined. In cases of substantial bleeding (whether active or previously), the patient should be evaluated immediately as TIF has a high mortality rate if not addressed immediately. Of note, TIFs may present with a “sentinel bleed” which is a self-limiting initial episode of bleeding that is later followed by an episode of massive bleeding. Additional helpful information obtained from the patient’s history include timing and reason for tracheostomy, tracheostomy type and size, anticoagulation status, ability to intubate/ventilate from above, and relevant comorbidities such as pulmonary disease and coagulopathies.  

Key supplies for tracheostomy hemorrhage consultation

  • Appropriate PPE including masks, eye protection, gloves, gown

  • Headlight

  • Flexible fiberoptic endoscope with defogger solution (Fred)

  • Suction x2 with Yankauer tip

  • Army/navy or band retractors

  • Nasal speculum or tracheostomy spreader

  • Cric hook

  • Endotracheal tubes (cuffed, sizes 6 & 7)

  • Replacement tracheostomy tubes (Shiley and Bivona of the same size or smaller, cuffed and uncuffed nonfenestrated)

  • Trach ties or Dale collar

  • Empty syringe

  • Gauze, Fibrillar/SurgicelSilver nitrate

  • Tranexamic acid or Topical 1:1000 epinephrine

Management
It is prudent to see all tracheostomy bleed consults as soon as feasible. Bleeding at the trach site can lead to aspiration and pulmonary compromise. If you are called for a large volume bleed or hemorrhage, go to the patient’s room as quickly as possible and inform your senior resident as you make your way to the room. When talking to the team with the patient, ask for a crash cart, endotracheal tubes, and supplies mentioned above to be set up while you make your way to the patient.

Large Volume Hemorrhage

  • Upon arrival, assess patient status and ABCs

  • Set up one or two large suctions if possible

  • If large volume active hemorrhage, compression to stop bleeding while transport to OR

  • If patient has a cuffed tracheostomy in place, consider overinflating the cuff, which in many cases will compress the vessel temporarily

  • If the patient does not have a cuffed tracheostomy tube in place, place one or a cuffed endotracheal tube (usually size 7 will work), then overinflate the cuff. Doing a trach change during massive bleeding can be challenging, and a second set of hands is helpful

  • If overinflating the cuff is not helpful, it is possible that the cuff is not directly sitting over the bleeding site within the trachea. Manipulating the tracheostomy tube either slightly deeper or more shallow may place the cuff over the bleeding site. The cuff may need to be inflated within the stoma tract to compress the vessel

  • If the above fails to stop the bleeding, finger compression can be effective, but partially obstructs the airway. Insert digit via tracheal stoma and compress innominate against sternum anteriorly (hook around anteriorly with your finger). The patient can be ventilated from above with mask, ET tube, or LMA if there is no anatomic difficulty preventing this and skilled colleagues are available

  • Arrange for definitive treatment, have a colleague work on arranging for immediate OR or IR transfer for exploration and ligation of bleeding artery versus endovascular management

  • The patient should ultimately be orotracheally intubated, however, this is preferably done in a more controlled setting in the OR when possible. (Remember, patients with laryngectomies cannot be orotracheally intubated)

  • Though TIF only makes up 0-1% of all trach bleeds and 10% of severe bleeds, a true TIF can be fatal within minutes, and only 25% of patients who make it to the OR survive

  • Be on guard for TIF in all patients, but especially those with neuromuscular hypotonia, kyphosis, long term ventilation/high airway pressures (often necessitates high pressure within cuff, tracheal mucosal breakdown), sepsis, radiation, steroids, malnutrition, diabetes

  • TIF can occur early after tracheostomy placement but peak incidence is 2-3 weeks post op

  • Preserving the integrity of the tracheal mucosa and tracheal cartilage with appropriate tube size and length, neutral tracheostomy tube positioning, minimizing cuff pressure, good patient nutrition, and close monitoring in patients with predisposing conditions can minimize risk of TIF


Small Volume Bleeding

  • Bleeding is generally from tissue breakdown/irritation at the stomal site, or suctioning trauma of the posterior tracheal wall or carina, or in the setting of anticoagulation or coagulopathy

  • Inflate cuff to prevent blood from running down the trachea

  • Scope through the tracheostomy tube and examine the entirety of the trachea itself, carina, and proximal bronchi. Sometimes pulling the tracheostomy tube back slightly will help expose the area of erosion within the trachea

  • If posterior or lateral tracheal wall irritation/erosion is noted, can address by repositioning tracheostomy tube, exchanging for a tracheostomy tube that will be better contoured for the patient’s airway, or establishing a plan with nursing/RT for suctioning that avoids trauma

  • If proximal anterior erosion, consider CTA neck to evaluate fat plane between trachea and innominate artery

  • Knowledge of tracheostomy tubes available can be very useful in these situations

    • Shiley

      • Inner cannula can be exchanged

      • Very useful for patients with large secretion burden

      • Rigid shaft, more right angled

      • Cuffed and cuffless option

      • Cuff is floppy and takes up more space when deflated, more difficult to talk/breathe around

      • Proximal and distal XLT to extend more horizontally or vertically

      • Air cuff allows direct measurement of cuff pressure

    • Bivona

      • No inner cannula

      • Tracheostomy tubes without inner cannulas are at risk for plugging, which can lead to an airway emergency

      • Flexible shaft, more of a smooth curvature

      • Cuff is “tight to shaft” when deflated

      • Much smaller profile within the airway, easier to talk/breathe around

      • Fill cuff with sterile water, not air or saline

      • Smaller external flange, less peristomal irritation

      • Available in adjustable length

      • Water cuff pressures cannot be measured directly

    • Jackson

      • Metal tracheostomy with inner cannula

      • Small outer diameter, as metal is thinner than plastic used for Shileys

      • Reusable, patients will clean Jackson tracheostomy tubes

      • Twist and lock mechanism for inner cannula may not be familiar for nursing staff, and hospital worker education around this may be required

  • If airway is clear, turn attention to stoma. If patient can tolerate temporary decannulation, can cautiously remove trach, and examine the external stoma, tract, and tracheal wall concealed by tracheostomy tube. (A flexible scope is helpful for this task)

  • If stomal bleeding is seen

    • Address as needed with pressure, gauze, Fibrillar/Surgicel. If placing hemostatic agent (such as Surgicel) within the stoma, leave a tail externally over the skin to discourage the packing from falling into the airway and allowing for easy removal if necessary

    • Do not remove scab/clotted blood over wounds/breakdown

    • It is important to chart these items and communicate to nursing and respiratory therapy that they are in place, as to avoid being dislodged into the airway

    • Tranexamic acid or 1:1000 epinephrine can be very useful adjuncts

    • Granulation tissue can be addressed with silver nitrate         

Example Procedural Note
I was called to the bedside of the patient for tracheostomy bleeding. Upon arrival, the vital signs of the patient were ___. He/she appeared stable/unstable. I proceeded to inflate the cuff of the tracheostomy tube, and then examined the full length of the tracheal mucosa, carina, and proximal primary bronchi utilizing a flexible fiberoptic laryngoscope. The tracheal mucosa was noted to be intact, without erosion, erythema, or bleeding. The carina was normal in appearance with well-appearing mucosa. No pooling of blood or excessive secretions were noted in the primary bronchi. The tracheostomy tube was withdrawn slightly and the same findings noted. The scope was removed atraumatically and attention was turned to the stoma. Minor mucosal bleeding was noted just within the proximal tracheostomy tract. This was controlled with Surgicel and application of pressure. The tracheostomy tube was then replaced, trach collar attached, and the patient tolerated the procedure well. Oxygen saturation remained >90% throughout the duration and the patient was left in stable condition.

References

  1. Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013;148(1):6-20. doi:10.1177/0194599812460376

  2. Kraft SM, Schindler JS. Tracheotomy. In P.W. Flint, et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 95-103). Philadelphia, PA: Elsevier.

  3. Durbin CG Jr. Tracheostomy: why, when, and how?. Respir Care. 2010;55(8):1056-1068.