Tracheostomy Emergency 003
Author: Chris Nickson
Reviewers: Andrew Udy, Chris Hebel
You are asked to review a 36 year-old woman as she has coughed up some blood. She has a tracheostomy tube in situ and is undergoing rehabilitation for a traumatic brain injury.
Her SpO2 is 96% on air and she is otherwise undistressed.
Q1. What are the important causes of haemoptysis and/or haemorrhage around a tracheostomy site in a patient with a tracheostomy?
A patient with a tracheostomy can have any of the causes of haemoptysis that can affect non-tracheostomised patients. It is also important to consider if there is an underlying bleeding diathesis in any patient with bleeding (e.g. anticoagulant drugs or a bleeding disorder).
Most bleeding early after a tracheostomy performed is benign. This may be due to:
- suction/ manipulation of tracheostomy tube, or
- bleeding from a nearby surgical site that tracks to the tracheostomy site
Bleeding occurring late (e.g. after a couple of weeks) is usually due to:
- granulation tissue, or
- infection at the stoma site
However, a tracheo-innominate fistula is also a potential cause.
- This is a connection between the trachea and the innominate artery due to erosion from pressure from the tracheostomy, infection or other factors.
- It is potentially life-threatening.
- Massive bleeding may follow hours-to-days after a small, apparently insignificant, sentinel bleed.
Q2. What are the important components of assessment of a tracheostomy patient?
As always assess ABCs and get help early Assess the bleeding: Important information to gather when assessing any tracheostomy patient includes:
As always assess ABCs and get help early
Assess the bleeding:
Important information to gather when assessing any tracheostomy patient includes:
Q3. What is your management plan?
If there is profuse bleeding from the tracheostomy (especially if tracheo-inominate fistula is suspected), this may be temporarily reduced or stopped by:
- applying finger pressure to the root of the neck in the sternal notch, or by
- optimising tracheostomy tube position and inflating the tracheostomy tube cuff (if present) with a 50ml syringe of air. Inflation should be done slowly and steadily to inflate the balloon to a maximum volume without bursting it, usually 10 to 35 mL depending on the type and size of the tracheostomy tube
- With any bleeding patient it is important to identify and correct any underlying bleeding diathesis
- Investigation of other causes of haemoptysis (e.g. pulmonary causes) may be warranted
Notify the consultant, even if the bleeding appears minor.
- The external ICU Consultant at The Alfred ICU should be notified of potential emergencies affecting patients with tracheostomies at Caulfield ABI unit
- Surgical exploration may be required, especially if the bleeding is a suspected sentinel bleed from a tracheo-innominate fistula
Document the events, your assessment and the plan.
References and links
- Hess DR. Tracheostomy tubes and related appliances. Respir Care. 2005 Apr;50(4):497-510. Review. PubMed PMID: 15807912.[Free Full Text]
- LITFL CCC — Bleeding tracheostomy
- LITFL CCC — Respiratory distress in a tracheostomy patient
- LITFL CCC — Tracheostomy tubes
- UK National Tracheostomy Safety Project at www.tracheostomy.org.uk (see the emergency flowcharts)
All case-based scenarios on INTENSIVE are fictional. They may include realistic non-identifiable clinical data and are derived from learning points taken from clinical practice. Clinical details are not those of any particular person; they are created to add educational value to the scenarios.