How can tracheostomy complications be minimized and managed?

Minimizing and Managing Tracheostomy Complications

Establish a multidisciplinary tracheostomy team with the least number of highly experienced providers, ensure bedside emergency equipment is always available, and implement systematic protocols for routine care and emergency management to prevent the most life-threatening complications: tube obstruction, displacement, and hemorrhage. 1, 2

Prevention Through Team Structure and Expertise

Form a dedicated multidisciplinary team consisting of intensivists, otolaryngologists, respiratory therapists, nurses, and speech-language pathologists to optimize care delivery and reduce complications. 1 Implementation of such teams has demonstrated a marked decrease in major complications from 25.4% to 4.9% and reduced wait times for procedures from 2.6 to 1.3 days. 1 The team should include the fewest number of providers with the highest level of experience to minimize both procedural risks and exposure during care. 1

Essential Bedside Safety Equipment

Maintain complete emergency supplies at every bedside including: 3, 2

• Functional suctioning system with appropriate catheters
• Oxygen source
• Manual resuscitation bag
• Complete tracheostomy kit with replacement tubes (same size and one half-size smaller)
• These supplies must accompany the patient wherever they go in the hospital 3

Routine Care Protocols to Prevent Complications

Implement rigorous secretion management as the suction catheter is the most critical tool for preventing tube obstruction, which represents one of the three greatest life threats. 3, 2 Effective mobilization of secretions prevents the most common short-term complication of tube blockage. 1

Perform regular endoscopic evaluation of the airway during spontaneous breathing to assess anatomic and functional patency, identify granulation tissue early, and detect tracheomalacia or stenosis before they become critical. 1, 4

Select appropriate tube size, diameter, length, and curvature based on individual patient anatomy to minimize suprastomal collapse and granuloma formation, particularly in pediatric patients. 4, 5

Managing Specific Complications by Timeline

Immediate Complications (During/Immediately Post-Procedure)

• Hemorrhage and loss of airway are the primary immediate threats 1
• Emergency tracheostomies carry significantly higher complication rates (54%) compared to elective procedures (46%), so plan electively whenever possible 6
• Meticulous surgical technique combined with careful perioperative management avoids the majority of complications 7

Short-Term Complications (Days to Weeks)

• Tube displacement or complete/partial dislodgement requires immediate recognition 1
• If accidental decannulation occurs, attempt replacement with the same size tube first; if unsuccessful, use a tube one half-size smaller 5
• Tube obstruction from secretions or blood requires aggressive suctioning protocols 3, 2
• Infection represents 43% of all complications and requires strict postoperative management and regular follow-up 6

Long-Term Complications (Weeks to Months)

• Tracheomalacia and tracheal stenosis develop with prolonged cannulation, with complications occurring in 11% of patients cannulated <100 days, 55% for 101-500 days, and 80% for >500 days 1
• Late complications occur in up to 68.8% of all pediatric tracheostomies, particularly in children with neurological disorders (22% of complications) 4
• Tracheoesophageal fistula, tracheal stenosis, and tracheocutaneous fistula require ongoing surveillance 3, 2
• Skin breakdown around the stoma necessitates meticulous wound care 3

High-Risk Patient Populations Requiring Enhanced Vigilance

Children under 3 years of age, premature infants, and patients with neurological disorders have significantly higher complication rates and require more intensive monitoring. 1, 4 Young children experience proportionately larger increases in airway resistance with tube downsizing and face increased risk of mucous plugging in smaller tubes. 1

Patients with COVID-19 or pandemic illness face heightened risks including highly tenacious secretions increasing occlusion risk and elevated bleeding risk from aggressive prophylactic anticoagulation. 1 These patients require modified care protocols with appropriate personal protective equipment during all aerosol-generating procedures. 1

Emergency Management Algorithm

When confronting tracheostomy emergencies, address the three greatest life threats systematically: 2

1. Decannulation: Replace tube immediately using bedside emergency kit
2. Obstruction: Suction aggressively; if unsuccessful, remove and replace tube
3. Hemorrhage: Apply direct pressure; prepare for surgical intervention if massive

Training and Quality Improvement

Ensure comprehensive training of all multidisciplinary team members as inadequate training has been associated with adverse outcomes and significant medicolegal consequences. 4 The overall complication rate exceeds 50%, though serious complications remain relatively uncommon when proper protocols are followed. 2 Regular simulation training and protocol review prevent reliance on individually acquired skills or lessons learned from previous errors. 1

Critical Pitfalls to Avoid

• Never allow patients to leave their room without complete emergency equipment accompanying them 3
• Avoid overly conservative approaches to decannulation that unnecessarily prolong tracheostomy duration, as complications increase dramatically with time 1
• Do not perform percutaneous tracheostomies without experienced physicians present, as operator experience directly correlates with complication rates 8
• Never discharge patients requiring long-term tracheostomy without teaching home-care and establishing regular follow-up 6