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
References and Links
CCC Airway Series
Emergencies: Can’t Intubate, Can’t Intubate, Can’t Oxygenate (CICO), Laryngospasm, Surgical Cricothyroidotomy
Conditions: Airway Obstruction, Airway in C-Spine Injury, Airway mgmt in major trauma, Airway in Maxillofacial Trauma, Airway in Neck Trauma, Angioedema, Coroner’s Clot, Intubation of the GI Bleeder, Intubation in GIH, Intubation, hypotension and shock, Peri-intubation life threats, Stridor, Post-Extubation Stridor, Tracheo-esophageal fistula, Trismus and Restricted Mouth Opening
Pre-Intubation: Airway Assessment, Apnoeic Oxygenation, Pre-oxygenation
Paediatric: Paediatric Airway, Paeds Anaesthetic Equipment, Upper airway obstruction in a child
Airway adjuncts: Intubating LMA, Laryngeal Mask Airway (LMA)
Intubation Aids: Bougie, Stylet, Airway Exchange Catheter
Intubation Pharmacology: Paralytics for intubation of the critically ill, Pre-treatment for RSI
Laryngoscopy: Bimanual laryngoscopy, Direct Laryngoscopy, Suction Assisted Laryngoscopy Airway Decontamination (SALAD), Three Axis Alignment vs Two Curve Theory, Video Laryngoscopy, Video Laryngoscopy vs. Direct
Intubation: Adverse effects of endotracheal intubation, Awake Intubation, Blind Digital Intubation, Cricoid Pressure, Delayed sequence intubation (DSI), Nasal intubation, Pre-hospital RSI, Rapid Sequence Intubation (RSI), RSI and PALM
Post-intubation: ETT Cuff Leak, Hypoxia, Post-intubation Care, Unplanned Extubation
Tracheostomy: Anatomy, Assessment of swallow, Bleeding trache, Complications, Insertion, Insertion timing, Literature summary, Perc. Trache, Perc. vs surgical trache, Respiratory distress in a trache patient, Trache Adv. and Disadv., Trache summary
Misc: Airway literature summaries, Bronchoscopic Anatomy, Cuff Leak Test, Difficult airway algorithms, Phases of Swallowing
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC