Tracheostomy Complications

OVERVIEW

Tracheostomy complications can be:

  • immediate
  • delayed
  • late

IMMEDIATE

Tracheostomy tube dysfunction

  • cuff herniation
  • equipment failure
  • incorrect size

Malposition

  • pretracheal dilation and placement
  • endobronchial placement
  • occlusion of tip by carina or tracheal wall
  • transfixed trachea with oesophageal placement

Damage to local structures

  • cricoid cartilage damage
  • tracheal laceration
  • haemorrhage
  • hematoma causing local compression
  • nerve injury
  • vascular injury
  • thyroid injury

Air-related complications

  • surgical emphysema
  • pneumothorax
  • air embolism
  • pneumomediastinum

Death

DELAYED

Infection

  • infection (tracheostomy site, larynx, tracheobronchial tree, mediastinum)

Trachesotomy tube migration and displacement

  • accidental decannulation
  • twisting of tube
  • protraction/ retraction

Ulceration

  • mucosal
  • tracheo-innomiate fistula
  • tracheo-esophageal fistua

Mechanical complications of tracheostomy tube

  • obstruction with secretions
  • dysphagia due mechanical compression of oesophagus (requires NG or PEG for enteral nutrition)

LATE

Bleeding

  • tracheal granulomata
  • trache-innominate fistula (life threat)

Trachea

  • tracheal or laryngeal stenosis
  • persistent sinus at tracheostomy site
  • tracheomalacia
  • tracheal dilatation

Other

  • aphonia/dysphonia (recovery of voice, laryngeal or cord dysfunction)
  • scar and cosmetic effects
  • psychological effects

COMPLICATIONS CAUSED BY WRONG SIZE OF TRACHEOSTOMY TUBE

Too long

  • Trauma caused by tube tip or suction catheter catching on carina
  • Collapsed lung due to unilateral ventilation
  • Patient discomfort
  • Convulsive or excessive coughing due to irritation of the carina

Too short

  • Tube displacement — loss of tracheostomy tract, respiratory arrest and/or death — causing ventilation into pre-tracheal space leading to surgical emphysema
  • Ulceration and/or erosion of the posterior tracheal wall, from poorly positioned/angled tube in trachea
  • Ineffective ventilation from a poorly positioned/angled tube within the trachea

Too wide

  • Tracheal ulceration
  • Tracheal erosion
  • Granulation tissue caused by shearing effect of TT against tracheal wall
  • Discomfort
  • Difficulty swallowing
  • Inability to achieve voice
  • Tracheostomy stoma site stenosis
  • Difficult tube changes
  • Subcutaneous emphysema caused by shearing and tearing of the trachea wall
  • Trachoesphageal fistula caused by the TT and/or cuff pressing against the posterior wall of the trachea

Too narrow

  • Inadequate ventilation
  • Increased respiratory effort
  • Ventilator indicates leakage via nose and mouth
  • Ineffective clearance of secretions

COMPLICATIONS CAUSED BY TRACHEOSTOMY TUBE CUFF OVER/UNDER-INFLATION Over inflated cuff

  • Tracheal mucosal ischaemia causing ulceration and erosion
  • Tracheo-oesophageal fistula, caused by cuff pressing on the posteriortracheal wall
  • Tracheo innominate fistulae, necrosis of the tracheal mucosa and artery wall; this can lead to a potentially fatal bleed

Under inflated cuff

  • Laryngotracheal stenosis
  • Difficulty in swallowing as oesophagus is impacted

The intracuff pressure should be high enough to achieve a closed respiratory system and be between 20- 30cmH2O


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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