Management – tracheostomy bleeding

Bleeding can be classified as early or late, relating to time since tracheostomy insertion.

Causes of early bleeding:

• Direct arterial or venous injury  e.g. thyroid vessels, skin
• Anticoagulant medication effects
• Mucosal or tracheal injury

Causes of late bleeding:

• Erosion into an artery e.g. innominate artery
• Mucosal injury e.g. suctioning
• Granulation tissue

Major bleeding may occur if a tracheostomy tube erodes into a major vessel.

Tracheo-innominate fistula (TIF)

The innominate artery (or brachiocephalic artery) is the first branch of the ascending aorta. It ascends anteriorly and to the right of the trachea, branching into the right common carotid and subclavian arteries.

Erosion into this vessel by a tracheostomy tube cuff or tip can cause profuse, life-threatening bleeding.

The incidence is 0.1-1% post-tracheostomy^6,7 and it is generally fatal without emergency surgical management.⁹

It has been suggested that any bleeding from 3 days to 6 weeks post-insertion should be considered as TIF until proven otherwise.¹⁰ Minor, transient bleeding or a ‘sentinel bleed’ occurs in 50% of patients, and may precede the onset of severe acute bleeding.^11,12

In practice, this indicates that emergency department practitioners faced with even minor bleeding from a tracheostomy, should have a high suspicion for this diagnosis and should obtain urgent surgical review.

Management

Management of tracheostomy bleeding^9,13

General resuscitation measures:

• Sit the patient up
• Administer high flow oxygen
• Urgent anaesthetic and ENT support
• Ensure large bore IV access
• Group and crossmatch blood – consider major haemorrhage protocol
• Consider anticoagulant reversal

Specific measures^9,13-15

• If the tube cuff is inflated do not deflate the cuff until expert help has arrived; the rational being to maintain any tamponade effect the cuff may be exerting on the bleeding point.
• Hyper-inflate the tube cuff to augment any tamponade effect.
• Bronchoscopy should be used to assess the source and severity of bleeding and to evaluate the patency of the main bronchi.
• If there is ongoing severe bleeding, endotracheal intubation should be performed and the tube advanced to just above the carina.
• Apply direct digital pressure by inserting a finger into the stoma and compressing the brachiocephalic artery against the posterior wall of the manubrium. If this requires removal of the tracheostomy tube, only perform this after successful endotracheal intubation and with expert help present.
• This may act as a temporising measure pending transfer to theatre for immediate surgical intervention.

Learning bite

• Any bleeding from a tracheostomy tube should be considered potentially life-threatening.
• In the case of a tracheo-innominate fistula, hyper-inflating the tracheostomy tube cuff may act as a temporising measure until expert help arrives.
• Emergency surgical intervention is the only definitive treatment for tracheo-innominate fistula