What are the potential complications of a tracheostomy (tracheal opening with a tube) and how are they managed?

Tracheostomy Complications and Management

Immediate Life-Threatening Complications

The three greatest life threats requiring immediate recognition and intervention are tube displacement/decannulation, tube obstruction, and hemorrhage, with displacement and blockage accounting for the majority of serious incidents in both adult and pediatric populations. 1, 2

Tube Displacement/Decannulation

• Most common serious complication, particularly in the first 7-10 days before stoma maturation when reinsertion through the tract is unreliable 1
• In pediatric patients, displacement represents the most frequently reported incident, with higher risk in children with neurological conditions and those under 3 years of age 1, 3
• Management priority: secure the upper airway first rather than attempting blind reinsertion, which can create false passages and worsen the emergency 1, 4
• Emergency response requires immediate removal of the displaced tube, assessment of both the native upper airway and stoma, and use of waveform capnography to confirm ventilation 1

Tube Obstruction

• Mucus plugging is the most common cause requiring rapid response activation, resulting from inadequate humidification after loss of natural upper airway moisture 4, 5
• Presents with absent or changed capnograph waveform, increasing airway pressure, reducing tidal volume, and inability to pass a suction catheter 1
• Never use stiff introducers or bougies to assess patency as they create false passages if the tube is displaced 4
• Management requires immediate tube removal if obstruction cannot be cleared, followed by upper airway assessment 1

Hemorrhage

• Immediate perioperative bleeding occurs from surgical site vessels, while late catastrophic hemorrhage suggests tracheoinnominate artery fistula 1, 6, 7
• Blood in tracheal secretions may precede catastrophic hemorrhage and demands immediate evaluation 8
• Tracheoinnominate fistula typically occurs 3 days to 6 weeks post-procedure, presenting with sentinel bleeding followed by massive hemorrhage 6, 2
• Emergency management involves hyperinflating the cuff, digital compression of the innominate artery against the sternum, and immediate surgical consultation 2

Early Complications (First Week)

Surgical Site Issues

• Bleeding, pneumothorax, pneumomediastinum, and subcutaneous emphysema occur during or immediately after placement 1, 7
• Surgical emphysema indicates air tracking into tissues and may signal tracheal injury or tube malposition 1
• Damage to adjacent structures including recurrent laryngeal nerve, esophagus, and thyroid gland can occur during placement 7

Airway Loss During Placement

• Emergency tracheostomy in "cannot intubate, cannot ventilate" situations carries high risk of complications and mortality 1
• Surgical cricothyroidotomy is preferred over emergency tracheostomy in life-threatening airway emergencies, as classical tracheostomy takes too long and has higher complication rates 1

Late Complications (Beyond One Week)

Tracheal Stenosis

• Most frequent late complication, occurring in up to 68.8% of pediatric tracheostomies, caused by prolonged intubation, excessive cuff pressure, large tube size, and diabetes 3, 8, 4, 6
• Presents as failure to wean from ventilator, progressive dyspnea, or stridor after decannulation 6
• Management requires multidisciplinary approach using bronchoscopy, laser therapy, airway stents, and potentially tracheal surgery 6

Tracheomalacia

• Results from cuff over-inflation causing cartilage weakening and airway collapse 8, 4, 6
• Manifests as difficulty weaning, expiratory stridor, or recurrent respiratory infections 6

Tracheoesophageal Fistula

• Rare but serious complication from posterior tracheal wall erosion, often related to excessive cuff pressure or nasogastric tube trauma 6, 2
• Presents with recurrent aspiration, coughing with feeding, or gastric distension during ventilation 2

Granulation Tissue Formation

• Develops at stoma site or within trachea, potentially causing obstruction or bleeding 6, 5
• Requires endoscopic evaluation and removal if symptomatic 6

Infection-Related Complications

• Infective complications represent 43% of all tracheostomy complications, including stomal infection, tracheitis, and ventilator-associated pneumonia 9, 5
• Risk increases due to loss of natural airway defense mechanisms including filtration, humidification, and mucociliary clearance 4
• Prevention requires strict aseptic technique, appropriate humidification, and regular stoma care 5

Critical Management Principles

Essential Bedside Equipment

• Every tracheostomy patient must have immediately available: appropriately sized replacement tubes (same size and one size smaller), suction equipment, oxygen source, manual resuscitation bag, and complete emergency kit 1, 3, 5
• Equipment must accompany the patient throughout the hospital 1, 8

Monitoring Requirements

• Waveform capnography is central to monitoring, recognition, and management of tracheostomy emergencies 1
• Continuous assessment of respiratory rate, oxygen saturation, work of breathing, and secretion characteristics 4
• Bedhead signs must display essential airway details including tube type, size, and whether upper airway is patent 1, 8

Humidification Strategy

• Heat and moisture exchangers (HME) with viral filters are the preferred method, providing adequate moisture while maintaining a closed circuit 4
• Inadequate humidification directly causes mucus plugging and airway emergencies 4

Emergency Response Algorithm

1. Assess using "red flags": absent/changed capnograph waveform, absent/changed chest movement, increasing airway pressure, inability to pass suction catheter 1
2. Remove tube immediately if patient deteriorating - do not delay attempting to troubleshoot 4
3. Assess both upper airway and stoma separately 1
4. In first 7-10 days post-percutaneous tracheostomy, focus on securing native upper airway rather than stoma reinsertion 1
5. Use capnography to confirm successful ventilation regardless of route 1

Special Population Considerations

Pediatric Patients

• Complication rate doubles in preterm infants compared to full-term infants 1
• Catastrophic events occur more than one week after insertion, including at home 1, 3
• Children with neurological disorders have 22% complication rate with higher risk of displacement 3
• Subglottic stenosis and granulomas assume greater importance due to small airway caliber 1

Ventilator-Dependent Patients

• Worse outcomes following incidents compared to spontaneously breathing patients 1
• Require continuous monitoring and immediate access to ventilation equipment 5

Common Pitfalls to Avoid

• Never attempt blind reinsertion of displaced tubes, especially in immature stomas - secure upper airway first 1, 4
• Never use rigid instruments to assess tube patency as they create false passages 4
• Avoid inadequate staff training, which is associated with adverse outcomes and significant medicolegal consequences (median award $2,000 USD) 1, 3
• Do not rely on absence of symptoms to rule out complications - many serious issues develop insidiously 6
• Ensure multidisciplinary team training is comprehensive and standardized across all care settings 1