What are the treatment options for redness around the tracheostomy site?

Management of Redness Around Tracheostomy Site

Redness around a tracheostomy site requires immediate assessment for infection, bleeding, or tube displacement, as these are recognized "red flags" that may signal life-threatening complications requiring urgent intervention. 1

Initial Assessment Approach

When evaluating redness around the tracheostomy site, you must systematically determine whether this represents:

• Local infection/inflammation - Most common cause of isolated redness 2
• Bleeding or blood-stained secretions - May indicate trauma, granulation tissue, or rarely tracheo-arterial fistula 1
• Tube displacement or malposition - Redness may accompany mechanical irritation from improper positioning 1
• Increased discomfort or pain - Another red flag requiring assessment 1

The multidisciplinary guidelines from Anaesthesia emphasize that tracheostomy-specific red flags include blood or blood-stained secretions around the tube and reports of increased discomfort or pain, both of which may present with visible redness. 1

Treatment Algorithm

Step 1: Rule Out Emergency Conditions

First, exclude life-threatening causes before treating simple inflammation:

• Check for active bleeding - If moderate bleeding is present with pulsation of the tube, suspect tracheo-arterial fistula and hyperinflate the cuff immediately while preparing for emergency surgical intervention 1
• Assess tube position - Visibly displaced tubes require immediate tube change, not local wound care 1
• Evaluate airway patency - Ensure the suction catheter passes freely through the tracheostomy 1
• Monitor vital signs - Changes in respiratory rate, heart rate, blood pressure, or consciousness may indicate airway compromise rather than simple local infection 1

Step 2: Manage Stomal Infection

If emergency conditions are excluded and redness suggests infection:

• Clean the stoma site with appropriate antiseptic solution 2
• Assess for purulent drainage - Stomal infection occurs in approximately 3-5% of cases 3, 4
• Initiate local wound care with regular cleaning and dressing changes 2
• Consider systemic antibiotics if cellulitis extends beyond the immediate stoma or if systemic signs of infection are present 2

Step 3: Address Mechanical Causes

Redness from mechanical irritation requires:

• Verify proper tube positioning - The tube should extend at least 2 cm beyond the stoma and remain 1-2 cm above the carina 5
• Check tube security - Ensure the tube is not moving excessively, causing friction and inflammation 2
• Assess for skin breakdown - A recognized complication that presents with redness and requires protective barrier application 2
• Evaluate for granulation tissue - May cause bleeding and redness, requiring cauterization or surgical management 1

Step 4: Ongoing Monitoring

After initial treatment:

• Reassess within 24-48 hours to ensure improvement 2
• Escalate care immediately if redness worsens, bleeding develops, or respiratory status changes 1
• Maintain bedside emergency equipment including complete tracheostomy kit, suction, oxygen, and manual resuscitation bag 2

Critical Pitfalls to Avoid

Never dismiss isolated redness as benign without systematic assessment - The guidelines emphasize that a recently performed or changed tracheostomy bleeds a little, but "if in doubt, you should get it assessed." 1

Do not attempt blind manipulation of the tube if displacement is suspected - This has resulted in harm and should only be performed by trained personnel with proper equipment 1

Avoid delaying specialist consultation for moderate bleeding - A sentinel bleed precedes fatal hemorrhage in approximately 50% of tracheo-arterial fistula cases 1

Never assume infection is the only cause - Redness may be the first sign of tube malposition, skin breakdown, or developing tracheomalacia 2

When to Summon Emergency Assistance

Call for immediate multidisciplinary team assistance if: 1

• Redness is accompanied by any airway or breathing red flags
• Active bleeding beyond minimal blood-stained secretions
• Patient reports sudden increase in pain or discomfort
• Any physiological deterioration (vital sign changes, altered consciousness, respiratory distress)
• Tube appears displaced or suction catheter will not pass

The bedhead sign should clearly display who to call in an emergency, agreed upon at admission or tube insertion. 1