Bleeding Tracheostomy

Originally adapted from Cliff Reid’s Resus.ME post on Bleeding Tracheostomy

OVERVIEW

Haemorrhage from, or around, a tracheostomy site is both relatively common and potentially life-threatening

• ‘early’ peri-operative bleeding is more common and usually benign
• ‘late’ bleeding is potentially a life-threatening emergency

CAUSES

Early

• suction/ manipulation of tracheostomy tube
• bleeding from a nearby surgical site that tracks to the tracheostomy site (e.g. tracheostomy created at the time of oral reconstruction and neck dissection for cancer)
• operative injury to a significant vessel (e.g. anomalous vasculature)

Late (e.g. >72 hours)

• granulation tissue
• infection at the stoma site
• tracheo-innominate fistula
• erosion of an adjacent vessel

Also note that:

• An underlying bleeding diathesis may be present
• Usual causes of hemoptysis may be responsible for bleeding from a tracheostomy

CLINICAL FEATURES

Haemorrhage (any of these features may be absent!)

• aspiration of blood
• bleeding beside the tracheal cannula
• bleeding from the tracheostomy tube lumen
• may appear to be naso-oropharyngeal haemorrhage, especially where the contact between the tissue and the cannula is tight
• massive, lethal bleeding may follow a small, apparently insignificant, sentinel bleed in the preceding hours in the case of a tracheo-innominate fistula

Other

• pulsation of the cannula (may be absent)

INVESTIGATIONS

Laboratory

• FBC and coags (check for bleeding diathesis)
• crossmatch (may require transfusion, especially if surgical intervention required)

Imaging

• angiography (may be negative)
• bronchoscopy (may be negative)

Urgent surgical intervention, without delay for investigation, may be warranted

MANAGEMENT

Assess for life-threats and call for help

• ABC approach
• enlist senior medical and nursing staff, other health professionals with tracheostomy care skills (e.g. respiratory therapist, physiotherapist)

Clear airway

• blood clots may need to be suctioned +/- bronchoscopy if sufficiently stable
• provide high flow oxygen via tracheostomy tube and facemask (if tracheostomy tube is cuff down or removed)

Bleeding (especially if tracheo-innominate fistula is suspected) 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 is required in an adult depending on the type and size of the tracheostomy tube
• Correct coagulopathy and replace blood products as required
• ensure adequate IV access

Urgent referral for surgical exploration and repair

• ENT or maxillofacial surgeon and a vascular surgeon
• ligation and resection of the pathological segment of artery, rather than reconstruction, is generally preferred
• sometimes, surgical repair requires cardiopulmonary bypass, and so a cardiothoracic surgeon may also be needed
• if patient stabilises, angiography may help identify the source of bleeding +/- allow angioembolisation

Consider palliation

• this situation may be rapidly fatal
• it may be the mode of death for some patients with head and neck cancers

If settles and is easily controlled, investigate for other causes (e.g. pulmonary causes of hemoptysis)

References and Links

FOAM and web resources

• Resus.ME — Bleeding Tracheostomy (2011)

Journal articles

• Bradley PJ. Bleeding around a tracheostomy wound: what to consider and what to do?. J Laryngol Otol. 2009;123(9):952-6
• Bontempo LJ, Manning SL. Tracheostomy Emergencies. Emerg Med Clin North Am. 2019;37(1):109-119.
• Hafez A, Couraud L, Velly JF, Bruneteau A. Late cataclysmic hemorrhage from the innominate artery after tracheostomy. Thorac Cardiovasc Surg. 1984;32(5):315-9
• Long B, Koyfman A. Resuscitating the tracheostomy patient in the ED. Am J Emerg Med. 2016;34(6):1148-55.
• Richter T, Gottschlich B, Sutarski S, Müller R, Ragaller M. Late life-threatening hemorrhage after percutaneous tracheostomy. Int J Otolaryngol. 2011;2011:890380.
• Singh N, Fung A, Cole IE. Innominate artery hemorrhage following tracheostomy. Otolaryngol Head Neck Surg. 2007;136(4 Suppl):S68-72.