Troublesome Tracheostomies

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Troubles with tracheostomy tubes can be some of the most anxiety provoking complaints we see in the Emergency Department.  Airway master and Dr. IC Cordes himself, Dr. Steven Carleton, MD PhD joined me on the podcast to help demystify 2 common tracheostomy related complaints - the bleeding trach site and the displaced tracheostomy tube.

What to do about the Bleeding Tracheostomy?

Bleeding from tracheostomy sites account for 20% of ED tracheostomy visits (1).  

Many of these presentations are for relatively minor bleeding but the specter of the tracheo-innominate (TI) fistula looms large in these patients.  TI fistulas occur in about 2% of patients with a tracheostomy and 85% of these bleeds occur in the first post-operative month.  Even with prompt identification and management, there is a 50-75% mortality when this condition is present.  Anatomically the innominate artery lies in close approximation to where the tip of the tracheostomy tube sits in the patient’s airway.  Usually these patient’s present with a brisk amount of bright red bleeding.  If >10 ml of bright red blood is present on exam, one should assume that the source of the patient’s bleeding is arterial in origin.  Ultimately aortic angiography may be needed to diagnose the presence of a TI fistula (if it is already not obvious based on the patient’s presentation).

Less dramatic sources of bleeding in these patients includes bleeding from incisional sites as well as bleeding from granulation tissue.  A thorough examination in these patients (including fiberoptic endoscopy) is essential to definitively rule out a bronchial source of bleeding, tracheitis, and tracheal ulcerations. Typically, bleeding from incisional sites or granulation tissue can be controlled through direct pressure, silver nitrate, packing, or a host of other local bleeding wound management strategies.

What about the dislodged tracheostomy tube?

The patient presenting with a chief complaint of “displaced tracheostomy tube” can either be exceptionally easy or exceptionally difficult.  First, it is important to obtain some crucial bits of historical information from these patients (or from ancillary sources of information if the patient is unable to provide it).

  • Did the patient have a tracheostomy or a tracheotomy? (if it is the latter, then the stoma is the only connection between the patient’s lungs and the environment)
  • How long ago was the tracheostomy performed? (usually these stoma are considered mature after 7-14 days)
  • Why was the tracheostomy/tracheotomy performed? (was it due to prolonged vent weaning, sleep apnea, Pickwickean syndrome, laryngeal cancer, etc.)
  • Does the patient have the tracheostomy tube with them?
  • What was the size and nature of the tracheostomy tube that was previously in place? (cuffed/uncuffed, fenestrated/non-fenestrated, size, etc)
  • When did the tracheostomy tube fall out?
  • Have there been any recent size changes or tracheostomy tube changes?

For the recently displaced tracheostomy tube from a mature tracheostomy site, where you can find an identical tracheostomy tube, replacing the tube is relatively straight forward. The process is generally to:

  • Generously lubricate the tip of the tracheostomy tube with the obturator in place
  • Start with the tube perpendicular to the patient
  • Insert the tip of the tube into the stoma, advance and rotate into a parallel plane
  • Remove the obturator, replace the inner cannula
  • Confirm placement with a flexible endoscope

Unfortunately the process is not always so simple.  For a tracheostomy tube that has fallen out some time ago, the stoma can quickly become stenotic making it impossible to pass the original tracheostomy tube.  For these patients, you need to undertake a process of sequentially dilating the stoma site with a series of endotracheal tubes until you are able to pass an endotracheal tube of equivalent outer diameter to the original tracheostomy tube.  To undertake this process:

  • First prepare the patient with aqueous lidocaine to provide analgesia to the tracheal mucosa
  • Advance the largest cuffed endotracheal tube that can fit into the stoma site
  • Sequentially advance ever larger endotracheal tubes. During this process you can also gently and partially inflate the endotracheal tube cuff.  As you withdrawal the ET tube from the stoma, the stoma will gradually dilate allowing you to pass an ET tube of equivalent outer diameter to the original tracheostomy tube.
  • Finally pass the tracheostomy tube over a flexible endoscope and visually confirm placement.

References

1.) Neacy, K. Tracheostomy Care. Roberts and Hedges. Chapter 7. pp 124-137.