Tracheostomy Emergency 003

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.

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?

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.