What are the management steps for a tracheostomized patient experiencing bleeding during suctioning?

Management of Bleeding During Tracheostomy Suctioning

Immediate Assessment and Risk Stratification

Stop suctioning immediately and assess the severity of bleeding to determine if this represents minor trauma versus life-threatening hemorrhage from a tracheoinnominate artery fistula (TIAF). 1, 2

Classify Bleeding Severity:

• Minor bleeding: Blood-tinged secretions or small amounts with suctioning, typically from granulation tissue, suction trauma, or stomal irritation 1
• Moderate bleeding: Persistent oozing or clots, which may indicate infection, erosion, or early vascular injury 1
• Severe bleeding: Pulsatile hemorrhage, massive bleeding from stoma or tube, or "sentinel bleed" (occurs in 50% of TIAF cases before catastrophic hemorrhage) 2

High-Risk Features for TIAF:

• Recent tracheostomy within 3 weeks 2
• Pulsation of the tracheostomy tube 2
• Percutaneous tracheostomy technique 2
• History of radiation therapy or chronic steroid use 2

Management Algorithm Based on Bleeding Severity

For Minor Bleeding (Blood-Tinged Secretions):

Review and correct your suctioning technique first, as traumatic suctioning is the most common cause of minor bleeding. 2

• Ensure suction catheter is measured to pre-determined depth and passes easily beyond the tube tip 3, 2
• Use appropriate negative pressure (100-200 cmH₂O) 3
• Avoid instilling saline before suctioning, as this increases coughing and aerosolization with little benefit 3
• Examine the stoma for signs of local infection and change dressing with physiological saline 2
• Monitor for hemorrhagic signs every 3 hours in the immediate post-tracheostomy period (days 0-4) 2

For Moderate Bleeding (Persistent Oozing/Clots):

Apply high-flow oxygen to both the face and tracheostomy stoma using two separate oxygen sources, and keep the cuff inflated to provide tamponade effect. 1

• Monitor vital signs continuously with pulse oximetry and waveform capnography 1
• The inflated cuff may reduce bleeding in up to 5% of early post-tracheostomy hemorrhages 1
• Consider anticoagulation status, as COVID-era practices and routine anticoagulation have greatly increased bleeding frequency and volume 3
• Assess for thick, tenacious secretions that may have caused tube occlusion requiring aggressive suctioning 3

For Severe Bleeding (Suspected TIAF):

This is a life-threatening emergency requiring immediate airway control, bleeding tamponade, and activation of surgical team for sternotomy. 2

Immediate Actions (Simultaneous):

1. Hyperinflate the existing tracheostomy tube cuff or insert a cuffed tracheal tube via the stoma with tip placed distal to the fistula 2, 4

2. Apply digital pressure directly through the stoma to the innominate artery site (Utley Maneuver) 2

3. Activate massive transfusion protocol and prepare for emergency operative intervention 2

4. Consider oral endotracheal intubation with a long, uncut tube advanced beyond the stoma for definitive airway control, as this bypasses the bleeding site and allows surgical access to the neck 1

Definitive Management:

• Emergency operative intervention in the operating room with personnel capable of performing sternotomy 2
• Division and ligation of both ends of the innominate artery is the definitive management 2
• This provides immediate control and eliminates risk of rebleeding 2

Critical Safety Considerations

Never attempt vigorous hand ventilation via the tracheostomy if you cannot confirm tube patency with a suction catheter, as this can cause massive surgical emphysema and worsen the situation. 3

• If suction catheter will not pass and patient is stable, deflate the cuff to allow potential airflow around the tube 5
• If patient is deteriorating and tube cannot be confirmed patent, remove the tube immediately 5
• Use soft suction catheters rather than gum-elastic bougies, as stiffer devices can create false passages 3

Prevention Strategies

Use closed-circuit suctioning systems to minimize trauma and aerosolization risk. 3

• For mechanically-ventilated patients, use inline suction catheter with closed circuit 3
• For non-ventilated patients, use T-connector or Kelley Circuit with inline suction catheter 3
• Avoid saline instillation before suctioning 3
• Ensure proper humidification to prevent thick secretions 3

Common Pitfalls to Avoid

• Do not dismiss a "sentinel bleed" - any bleeding from a tracheostomy site warrants serious concern for TIAF 2
• Do not delay surgical consultation for moderate-to-severe bleeding, as mortality approaches 10% with significant hemorrhage 3
• Do not perform routine tracheostomy tube changes if minor bleeding is present until the source is identified and resolved 3
• Do not over-inflate cuffs for prolonged periods, as this causes tracheal ischemia and subsequent stenosis 3

Equipment Requirements at Bedside

Essential equipment must be immediately available: 2

• Suction with appropriate catheters
• Spare tracheostomy tubes (same size and one size smaller)
• Emergency airway equipment
• Waveform capnography
• Fiberoptic scope for visualization