How do you manage a tracheostomy (tracheal opening with a tube for breathing) bleed in a patient?

Management of Tracheostomy Bleeding

Immediately assess the severity and source of bleeding, as life-threatening hemorrhage from a tracheoinnominate artery fistula requires emergent surgical intervention, while minor bleeding from granulation tissue or suction trauma can be managed conservatively. 1, 2

Initial Assessment and Immediate Actions

Determine Bleeding Severity and Source

• Minor bleeding (blood-tinged secretions, small amounts with suctioning) is typically from granulation tissue, suction trauma, or stomal irritation 1, 3
• Moderate bleeding (persistent oozing, clots) may indicate infection, erosion, or early vascular injury 1
• Massive bleeding (pulsatile, bright red blood filling the airway) suggests tracheoinnominate artery fistula (TIAF) until proven otherwise 2

Critical History Elements for TIAF Risk

• Tracheostomy placed within the last 3-4 weeks (75% of TIAF cases occur in this timeframe) 2
• Percutaneous tracheostomy technique 2
• History of sentinel bleed (brief self-limited bleeding episode occurring in 50% before massive hemorrhage) 2
• Prior neck radiation, chronic steroid use, or chest/neck deformity 2

Immediate Stabilization

• Apply high-flow oxygen to both the face and tracheostomy stoma using two separate oxygen sources 1, 4
• Establish large-bore IV access and send type and crossmatch 2
• Monitor vital signs continuously with pulse oximetry and waveform capnography 1, 4

Management Algorithm Based on Bleeding Severity

Minor Bleeding (Blood-Tinged Secretions)

• Assess for suction trauma by performing flexible endoscopy through the tracheostomy tube to visualize the tracheal mucosa 1
• Counsel caregivers on proper suctioning technique to avoid traumatic injury 1
• Continue routine tracheostomy care with humidification 3
• Monitor for progression 5

Early Post-Procedural Hemorrhage (First 24-48 Hours)

• Keep the cuff inflated to provide tamponade effect, as this may reduce bleeding in up to 5% of early post-tracheostomy hemorrhages 1
• Avoid deflating the cuff unless absolutely necessary for airway patency 1
• Obtain urgent ENT/surgical consultation 6
• Monitor closely in ICU setting 3

Suspected Tracheoinnominate Artery Fistula (Massive Bleeding)

This is a surgical emergency with 50-70% mortality requiring immediate operative repair. 2

Immediate Bedside Interventions

1. Hyperinflate the tracheostomy cuff with 30-50 mL of air to compress the bleeding vessel against the anterior tracheal wall 2

2. If bleeding continues, perform the Utley Maneuver: 2

   • Remove the tracheostomy tube completely
   • Insert a gloved finger through the stoma
   • Apply direct anterior pressure against the innominate artery by compressing it against the posterior sternum
   • Maintain pressure until the patient reaches the operating room

3. Alternative to Utley Maneuver: Insert a cuffed endotracheal tube orally (if upper airway is patent) and advance it beyond the stoma, then hyperinflate the cuff to tamponade the bleeding site 2

Critical Actions

• Activate massive transfusion protocol immediately 2
• Emergently consult otolaryngology AND cardiothoracic surgery for operative repair 2
• Transport directly to operating room for median sternotomy and vascular repair 2
• Do NOT attempt fiberoptic evaluation or temporizing measures beyond cuff hyperinflation and Utley Maneuver 2

Airway Management Considerations During Bleeding

When Upper Airway is Patent

• Oral endotracheal intubation with a long, uncut tube advanced beyond the stoma is the preferred approach for definitive airway control 4
• This bypasses the bleeding site and allows surgical access to the neck 4
• Confirm placement with waveform capnography 4

When Upper Airway is Obstructed or Unknown

• Do NOT attempt oral intubation blindly in patients with known difficult airways or laryngeal pathology 4
• Maintain oxygenation via the tracheostomy route 4
• Use cuff hyperinflation for hemorrhage control 2

Common Pitfalls to Avoid

• Never dismiss a sentinel bleed as minor—50% of patients with TIAF present with a brief self-limited bleeding episode before catastrophic hemorrhage 2
• Never delay surgical consultation for suspected TIAF while attempting conservative measures 2
• Never deflate the cuff in early post-procedural bleeding, as this removes the tamponade effect 1
• Never use vigorous suctioning if bleeding is suspected from suction trauma, as this worsens mucosal injury 1
• Never attempt blind tube changes during active bleeding, as this can worsen hemorrhage and lose airway control 5

Special Circumstances

Bleeding from Granulation Tissue

• Suprastomal granulomas are common and may bleed with manipulation 1
• These can be managed electively with surgical removal, though recurrence is common as they represent a foreign body reaction 1
• Not an emergency unless causing airway obstruction 1

Recurrent Tracheitis/Bronchitis with Bloody Secretions

• Colonization of tracheostomy tubes is universal 1
• Empiric antibiotics are commonly used for suspected infection with bloody secretions 1
• Cultures of tracheostomy secretions are not always helpful due to colonization 1