What to do for bleeding after tracheostomy (tracheal airway formation)?

From the Guidelines

Bleeding after tracheostomy should be managed with careful observation for minor cases, while moderate to severe bleeding requires immediate intervention, including hyperinflation of the tracheostomy tube cuff, digital pressure, or intubation of the stoma with a cuffed tracheal tube, and preparation for definitive surgical treatment.

Management of Tracheostomy Bleeding

• Minor bleeding can be managed conservatively with careful observation, as most cases settle without surgical intervention 1.
• Moderate to severe bleeding, particularly if suspected to be due to tracheo-arterial fistulae, requires immediate action:
  • Hyperinflation of the tracheostomy tube cuff, if present 1.
  • Intubation of the stoma using a cuffed tracheal tube, with the tube tip placed distal to the fistula 1.
  • Application of pressure via a hyperinflated cuff or digitally, either directly or applied to the innominate artery site 1.
• Standard resuscitation measures should be initiated in tandem with these interventions, and emergency plans should be made for definitive surgical treatment, which typically involves ligation of the innominate artery 1.

Importance of Preparedness and Training

• Institutions should plan for emergencies in advance, including having essential airway equipment immediately available and ensuring that healthcare professionals receive regular training in routine and emergency tracheostomy management 1.
• High- and low-fidelity simulation can play a crucial role in preparing healthcare staff, families, and carers for tracheostomy emergencies 1.

Clinical Context and Outcomes

• Tracheostomy-related hemorrhage is associated with a significantly increased risk of mortality, highlighting the importance of prompt and effective management of bleeding complications 1.
• The most common causes of hemorrhage include bleeding diathesis, granulation tissue, wound breakdown, and mucosal or vascular injury, underscoring the need for a comprehensive approach to managing tracheostomy patients 1.

From the Research

Causes of Bleeding after Tracheostomy

• Bleeding after tracheostomy can be caused by various factors, including tracheoarterial fistula, erosion of the tracheal wall into vascular structures, and damage to small cervical vessels or the carotid artery 2, 3, 4.
• Tracheoarterial fistula is a rare but potentially fatal complication of tracheostomy, occurring with a frequency of approximately 0.7% 4.
• Bleeding from tracheoarterial fistula often occurs late, more than 48 hours post-procedure, and is often preceded by sentinel hemoptysis 4.

Management of Bleeding after Tracheostomy

• The management of bleeding after tracheostomy involves acute stabilization and support, with protection of the airway and restoration of circulating blood volume 4, 5.
• Definitive repair of the bleeding site may be necessary, and measures to prevent tracheal damage by the tracheostomy tube, such as proper surgical technique and proper inflation of the tracheostomy tube cuff, may help avoid this complication 4.
• In cases of tracheo-innominate artery fistula, urgent sternotomy and ligation of the innominate artery may be necessary to control bleeding 5, 6.
• Endoscopic examination of the trachea in an operating theatre environment, with the facility to proceed to exploration of the neck and possibly to sternotomy, may be necessary to diagnose and treat tracheoarterial fistula 6.

Prevention of Bleeding after Tracheostomy

• Careful manipulations with vessels and their isolation from the tracheal anastomosis and tracheostomy channel with the patient's own tissues are obligatory to prevent intraoperative bleeding 3.
• Proper surgical technique and proper inflation of the tracheostomy tube cuff may help prevent tracheal damage and reduce the risk of bleeding 4.
• Early consideration of tracheoarterial fistula and other potential causes of bleeding may help reduce the associated high death rate 4, 6.