Tracheostomy Emergency 003

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

  • Fortunately the ABCs are not compromised in this patient. However, in some cases blood clots may need to be suctioned. The main life threat in haemoptysis is asphyxia, not exsanguination.
  • If the tracheostomy tube is obstructed it, it should be managed as described in Tracheostomy Emergency 001 and Tracheostomy Emergency 002.

Assess the bleeding:

  • what amount of blood was coughed up?
  • can you identify whether the bleeding coming from the tracheostomy site (e.g. external bleeding around the tracheostomy tube) or from within the trachea?
  • are there any respiratory complications? (haemodynamic instability is rare, except in rare cases of an exsanguinating lesion e.g. arterial fistula)

Important information to gather when assessing any tracheostomy patient includes:

  • what was the indication for tracheostomy?
  • were there any complications following the procedure?
  • regarding the tracheostomy tube:
    • what type of tracheostomy tube is it?
    • what size?
    • is it cuffed?
    • is an inner cannula present?
  • can the patient be orally intubated? (e.g. has the patient had a laryngectomy?)
  • what are the vital signs?
  • what is the sputum load, the character of the sputum, and the strength of the patient’s cough?

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

Other considerations:

  • 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

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.

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