What are the immediate steps to manage bleeding in a patient with a tracheostomy cannula?

Management of Blood in Tracheostomy Cannula

Immediately assess the severity of bleeding and suspect tracheoinnominate artery fistula (TIAF) if there is moderate to severe bleeding, pulsation of the tracheostomy tube, or any sentinel bleed—this is a life-threatening emergency requiring immediate hyperinflation of the cuff and preparation for surgical intervention. 1

Risk Stratification and Initial Assessment

Determine bleeding severity immediately:

• Suspect TIAF if moderate to severe bleeding from the stomal site, pulsation of the tracheostomy tube, or sentinel bleed (occurs in approximately 50% of TIAF cases before massive hemorrhage) 1
• High-risk features include recent tracheostomy within 3 weeks, percutaneous technique, history of radiation therapy, or chronic steroid use 1
• Monitor for hemorrhagic signs every 3 hours in the immediate post-tracheostomy period (days 0-4) 2

Emergency Management for Suspected TIAF (Moderate to Severe Bleeding)

This is a surgical emergency with high mortality—act immediately:

1. Immediate airway control and tamponade:

   • Hyperinflate the existing tracheostomy tube cuff to tamponade bleeding 1
   • If unsuccessful, insert a cuffed tracheal tube via the stoma with the tip placed distal to the fistula 1
   • Apply digital pressure directly through the stoma or externally to the innominate artery site (Utley Maneuver) 1

2. Simultaneous resuscitation:

   • Activate massive transfusion protocol 1
   • Call for immediate surgical backup capable of performing sternotomy 1

3. Definitive surgical management:

   • Emergency operative intervention in the operating room with personnel capable of performing sternotomy 1
   • Division and ligation of both ends of the innominate artery is the definitive treatment 1
   • Intensive monitoring post-procedure is crucial 1

Critical pitfall: A sentinel bleed may precede massive hemorrhage—any pulsatile or moderate bleeding must be treated as TIAF until proven otherwise. 1

Conservative Management for Minor Bleeding

If bleeding is minor (small amounts of blood-tinged secretions without hemodynamic compromise):

• Careful observation and identification of the underlying cause 1

• Common causes of minor bleeding:

  • Traumatic suctioning technique 1
  • Granulation tissue at the stoma 1
  • Local infection 1
  • Recent tube change or manipulation 2

• Review suctioning technique if traumatic injury is suspected—ensure suction catheter is measured to the pre-determined depth (down to the carina, up one centimeter) 2

• Examine the scar for signs of local infection and change dressing with physiological saline 2

Equipment and Monitoring Requirements

Essential bedside equipment must be immediately available:

• Suction with appropriate catheters 2
• Spare tracheostomy tubes (same size and one size smaller) 2
• Emergency airway equipment including laryngoscopes, self-inflating bags, and oral/nasal airways 2
• Waveform capnography for immediate assessment 2
• Fiberoptic scope for visualization if available 2

Post-Emergency Considerations

After managing bleeding:

• Intensive monitoring for recurrent bleeding, especially after innominate artery ligation 1
• Assess for other tracheostomy complications including infection, tracheomalacia, or false tract formation 1
• Continue monitoring for hemorrhagic signs every 3 hours if within the first 4 days post-tracheostomy 2

Key distinction: The management algorithm diverges sharply based on bleeding severity. Minor bleeding warrants conservative management with observation and correction of technique, while any suspicion of TIAF demands immediate aggressive intervention with surgical backup. The presence of a sentinel bleed (even if self-limited) should trigger preparation for potential massive hemorrhage. 1