What to do if a tracheostomy (trach) site is bleeding, how to stop it?

Management of Tracheostomy Bleeding

For bleeding tracheostomy sites, immediately identify the severity of bleeding and apply direct pressure to stop minor bleeding, while for moderate to severe bleeding, hyperinflate the tracheostomy tube cuff if present or intubate the stoma with a cuffed tube to tamponade the bleeding site. 1

Assessment of Bleeding Severity

Tracheostomy bleeding can be categorized as:

1. Minor bleeding: Small amounts that can be managed conservatively
2. Moderate bleeding: Requires more aggressive intervention
3. Severe/life-threatening bleeding: Potentially fatal, especially from tracheo-arterial fistulae

Management Algorithm

For Minor Bleeding:

• Apply direct pressure to the bleeding site
• Identify potential causes:
  • Traumatic suctioning
  • Granulation tissue
  • Local infection
  • Bleeding disorders
• Conservative management with careful observation is usually sufficient 1

For Moderate to Severe Bleeding:

1. Immediate actions:

   • If tracheostomy tube has a cuff, hyperinflate it to tamponade bleeding 1
   • If no cuff present or bleeding continues, intubate the stoma using a cuffed tracheal tube (one half-size smaller than original tube) 1
   • Position the tube tip distal to the suspected bleeding site
   • Apply digital pressure directly to bleeding site or to the innominate artery site if tracheo-arterial fistula is suspected

2. Assess for tracheo-arterial fistula:

   • Watch for pulsation of the tracheostomy tube
   • Note that sentinel bleeds occur in approximately 50% of tracheo-arterial fistula cases 1
   • This is a life-threatening emergency with mortality approaching 10% 1

3. Resuscitation measures:

   • Call for emergency surgical assistance immediately
   • Start standard resuscitation protocols
   • Prepare for possible emergency surgical intervention (arterial ligation) 1

Warning Signs of Serious Bleeding

• Pulsation of the tracheostomy tube
• Sentinel bleed (small bleeding episode preceding major hemorrhage)
• Moderate bleeding from stomal site
• Thick, clotted blood in airway

Prevention of Bleeding Complications

• Avoid traumatic suctioning techniques
• Ensure proper tube size and positioning
• Manage anticoagulation carefully, especially in COVID-19 patients who may require higher levels of anticoagulation 1
• Regular stoma care and inspection
• Proper tube securement to prevent movement and trauma 1

Pitfalls to Avoid

• Do not delay calling for surgical assistance if moderate bleeding occurs
• Do not mistake bleeding from suctioning trauma for a sentinel bleed from arterial erosion
• Do not attempt multiple tracheostomy tube changes during active bleeding
• Do not ignore even small amounts of bleeding, as they may indicate a sentinel bleed 1
• Never rely solely on pulse oximetry during bleeding episodes, as readings may be inaccurate 2

Equipment to Keep at Bedside

Every tracheostomy patient should have immediate access to:

• Functional suctioning system
• Oxygen source
• Manual resuscitation bag
• Complete tracheostomy kit with replacement tubes (including one half-size smaller) 3

Prompt recognition and appropriate management of tracheostomy bleeding is critical to prevent potentially fatal outcomes, particularly in cases of tracheo-arterial fistula which requires immediate surgical intervention.