Complications of Tracheostomy

There are many immediate or late complications that can occur from tracheostomy.  Tracheostomy may be associated with numerous rare acute, perioperative complications.  Although complications are rare, the rate of death for all causes is high (22%) in this population (Halum, 2012).   There are also numerous late complications as well, including those due to anatomic and physiologic changes.  It is imperative that clinicians are aware of these complications because they effect the management and treatment of these patients.  

Immediate Complications

Bleeding

Bleeding from the actual tracheotomy procedure is common, in small amounts.  Injury to the anterior jugular venous system is a typical source of bleeding, which if encountered is ligated and divided (Cipriano, 2015).  A patient with severe bleeding should undergo bronchoscopy for suspected laryngotracheal stenosis or tracheoesophageal fistula (Mitchell, 2013).  

Bleeding can also occur from frequent or improper suctioning. If bleeding occurs, the clinician may still need to suction the patient. Use of a red rubber suction may reduce trauma from suctioning.

NOTE: Suction pressures should be set no more than -80 to -100 mmHg when suctioning the adult tracheostomy patient.

Pneumothorax

Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.
Right sided pneumothorax (left in the image)

Pneumothoraxcommonly referred to as a collapsed lung, occurs when air leaks into the space between the chest wall and the lung, called the pleural space .  It may be partial or complete collapse of the lung.  Incidence has been reported as up to 17% with an increased incidence in children possibly due to the higher position of the pleural dome (Cipriano et al., 2015).   Pneumothorax is a potentially life threatening complication and can occur from direct injury to the pleura or the cupola of the lung (especially in children) or from high negative inspiratory pressures of patients who are awake and distressed on mechanical ventilation.  COPD  patients are particularly high risk because intrinsic air-trapping causes their chest to be barrel shaped, and the apex of the lung is much higher in the chest cavity.

Early recognition is critical, and routine postoperative chest radiography is often routinely performed to ensure proper tracheostomy placement and rule out pneumothorax.  “Chest X-rays are not routinely required if tube placement has been confirmed endoscopically and the procedure has been uneventful.  There is little likelihood of either displacement or pneumothorax without obvious clinical signs” (ICS, 2015).

Subcutaneous Emphysema

Subcutaneous emphysema  is the result of air or gas trapped under the skin, typically seen in the chest walls and neck regions.  It can develop rapidly, and may be the first clinical sign of a pneumothorax.  It can result from trauma during the tracheotomy procedure or tracheal intubation.  The most common sign is swelling around the neck and chest pain.  Other signs and symptoms include tender sore throat, aching neck, difficulty in swallowing, breathlessness, wheezing, and distension.  Subcutaneous emphysema has a characteristic crackling feel when palpating the skin, which is termed subcutaneous crepitation.  

Injury to the Recurrent Laryngeal Nerve

Damage to the recurrent laryngeal nerve resulting in vocal cord paralysis, is also a potential immediate complication of tracheostomy.  Damage can cause hoarse or breathy vocal quality, dysphagia and aspiration pneumonia.  If midline is properly maintained during dissection, the nerves should not be encountered, except for cases where significant misplacement of the tracheostomy tube has occurred.  

Tracheostomy itself may be needed when bilateral recurrent laryngeal nerve injury has occurred during another procedure (ie., total thyroidectomy).  Bilateral recurrent laryngeal nerve injury results in the vocal folds paralyzed medially and causing difficulty breathing past the closed vocal folds, requiring emegent intubation or tracheostomy. 

Blocked Tracheostomy Tubes

Maintaining a patent airway is vital to the safety of the patient and a blocked tracheostomy tube is potentially life threatening if not managed properly.  A blocked tracheostomy tube is typically secondary to a mucus plug or blood clot.  This  can be prevented with proper suctioning of the airway, adequate humidification, and frequent changing or cleaning of the inner cannula when working with a double lumen tube. The use of dual cannula tubes lessens the potential of mucus plugging because the inner cannula can be removed for cleaning while the outer cannula safely maintains patency of the fresh tract.  Inner cannulas should be cleaned daily if non-disposable, or changed daily if disposable in order to avoid mucous plugging (Mitchell, 2013). 

If the patient has any of the following clinical signs then tube occlusion should be considered:
  • Blood/tissue/phlegm visualized in the tracheostomy tube
  • Difficult or labored breathing
  • Noisy breathing
  • Use of accessory muscles
  • No or limited air expired from the tracheostomy
  • Patient complaining of being unable to breathe
  • Patient agitation, decreased conscious level
  • Increased pulse and respiratory rate
  • Collapsed patient
  • Deteriorating gas exchange
  • Difficulty in ventilating using an ambubag
  • Difficulty in passing a suction catheter
Partial blockage is indicated by resistance to the passage of the suction catheter over the first 10 cm or when the inside of the tracheostomy tube feels roughened by accumulated dried secretions. A completely blocked tube is indicated by the inability to pass suction catheter down the tracheostomy tube.
 

See the Emergency Tracheostomy Algorithm provided by the National Tracheostomy Safety Project in the UK, which is available for free download.   

Accidental Displacement/Dislodgement of the Tracheostomy Tube

Misplacement of the tracheostomy tube can occur during initial insertion of the tracheostomy tube  or at any time when the tracheostomy tube is present.  Although uncommon, the situation can be life threatening as the airway is essentially lost with a displaced tube and thus this complication has a high mortality rate.  The tracheostomy tube can be displaced into a false passage, usually in the pretracheal space.  

Signs of a displaced tracheostomy tube include difficult ventilation, difficulty passing the suction catheter, subcutaneous emphysema or pneumothorax.  Patients with thicker necks are at greater risk due to the distance from skin to trachea which provides more subcutaneous tissue for the tube to become displaced.  

The following may prevent accidental displacement: Sedation, suturing the flanges of the tracheostomy to the skin, specialized tracheostomy dressings, ties around the neck and connection of the tube to the ventilator with flexible tubing (Mirza, C, 2011).

Bronchoscopy during the tracheostomy procedure is used to confirm appropriate placement of the tracheostomy tube. It should be available and its routine use is beneficial.  Routine postoperative chest radiography is often routinely performed to ensure proper tracheostomy placement and rule out pneumothorax.  “Chest X-rays are not routinely required if tube placement has been confirmed endoscopically and the procedure has been uneventful.  There is little likelihood of either displacement or pneumothorax without obvious clinical signs” (ICS, 2015).

Any careprovider should be aware of the presentation of a displaced tracheostomy tube and be able to manage it rapidly.  

See the Emergency Tracheostomy Algorithm provided by the National Tracheostomy Safety Project in the UK, which is available for free download.

Late Complications of Tracheostomy

Tracheal Stenosis

Tracheal stenosis is an abnormal narrowing of the trachea that can develop from prolonged intubation causing scarring due to pressure injury.  It can also occur due to high cuff pressures from either the tracheostomy tube or the endotracheal tube cuff.  Tracheal stenosis commonly develops at the stoma site or at the level of the cuff. When stenosis occurs at the stoma, it is usually due to bacterial infection and chondritis.  Granulation tissue can develop at the stoma site and may obstruct the airway at the stoma site.  The tissue can cause difficulty with replacing the tracheostomy tube (Epstein, 2005).  

Overinflation of the cuff can result in scarring and narrowing of the trachea and it is preventable by managing cuff pressures.  The development of high-volume low-pressure tracheostomy-tube cuffs has led to a significant reduction in tracheal stenosis at the cuff site (Epstein, 2005).  Appropriate tracheostomy tube size and providing cuffless tracheostomy tubes as soon as feasible are also ways to reduce tracheal stenosis.  

Diagnosis of tracheal stenosis is often delayed.  It may present as increased cough or difficulty clearing secretions.  If the individual is on mechanical ventilation, the presentation may be difficulty weaning with intermittent high peak airway pressures, 

There are several ways to image the tracheal air column, including chest radiography, tracheal tomography, CT, and magnetic resonance imaging.  However, bronchoscopy is indicated in patients with suspected tracheal stenosis (Mitchell, 2013).  

An extra long distal tracheostomy tube can be used to bypass the tracheal stenosis.  In a retrospective study by Rosenbeck, he reviewed 37 patients who had tracheally obstruction, confirmed by bronchoscopy.  They all initially failed to wean, had difficulty in breathing and developed intermittent high peak airway pressures either early or during the weaning process or just on being ventilated. The insertion of a longer tracheal tube bypassed the obstruction, reestablished the airway, decreased peak airway pressures, and allowed the patient to breathe more easily. Treatment consisted of either placement of a longer tracheal tube (34 of 37 patients) or placement of a tracheal stent. All but two of the patients (5.4%) were able to be weaned within a week.  This study shows the importance of identifying tracheal stenosis.  

Depending on the location and severity of the stenosis, surgery may be necessary. Approximately 3 to 12% of all tracheostomized patients will develop clinically significant stenosis that will require intervention (Epstein, S., 2005). Common  options include tracheal resection and reconstruction, bronchoscopic tracheal dilation, laser bronchoscopy, or tracheal broncial airway stent.  

Tracheomalacia

Tracheomalacia is a weakening of the tracheal wall. In adults, this is usually secondary to trauma of some kind to the tracheal wall, including recurrent infections, where the tube and/or cuff rubs against it, or with over inflation of the cuff.  Signs and symptoms of tracheomalacia include: shortness of breath, hoarse voice, chronic cough, difficulty swallowing, recurring respiratory tract infections, and during mechanical ventilation there is often the presence of a cuff leak, or the need to overinflate the cuff in order to maintain control of mechanical ventilation (Morris, L. et al 2013). Prevention of tracheomalacia includes maintaining cuff pressures and limited movement of the tracheostomy tube.

If tracheomalacia is suspected, bronchoscopy or a dynamic CT scan of the trachea can reveal excessive expiratory collapse of the trachea.  Treatment options depend on the severity and include insertion of a longer tracheostomy tube to bypass the region of trachomalacia, stenting, trachoplasty, or tracheal resection. 

Treatment options for tracheomalacia are tracheal dilatation with surgical stent  placement, t-tube placement,  tracheal resection, tracheal replacement, or surgical attachment of a polyethylene or polypropylene mesh onto the trachea at the area of the malacia.

Tracheoesophageal Fistula

A tracheoesophageal (T-E) fistula is an abnormal communication between the trachea and fistula.  It is a rare complications that occurs in less than 1% of individuals with tracheostomy (Epstein, 2005).  Individuals with tracheostomy may develop a tracheoesophageal fistula due to injury of the posterior tracheal wall.  The perforation can occur during percutaneous insertion of the tracheostomy tube, malpositioning of the tube, or from excessive tracheostomy tube cuff pressures.  The presence of a nasogastric tube, especially wide-bore, can aggravate the tissue and contribute to the development of a T-E fistula (Sanwal, M et al, 2012).   

The use of high-volume, low-pressure endotracheal and tracheostomy cuffs has reduced the incidence of this complication.  Tracheostomy tube cuff management is important for preventing a tracheoesophageal fistula with emphasis on daily cuff measurements not to exceed 30 cm H2O.

The main symptoms of an acquired tracheoesophageal fistula are copious secretions and recurrent aspiration of secretions, food and/or liquids, which can lead to life threatening pulmonary complications.  There should be a high suspicion for a T-E fistula if tube feedings are noted in the tracheostomy tube or around the stoma.  Additional manifestations include increasing dyspnea, a persistent cuff leak, or severe gastric distention (due to excess air in the stomach). The diagnosis of tracheoesophageal fistula is made by, high resolution CT scan, barium or water soluble esophagography, or endoscopy.

 If a T-E fistula is suspected, a bronchoscopy is indicated (Mitchell, 2013). While smaller T-E fistula may heal spontaneously, in most cases, the fistula must be surgically repaired.  For patients who are not able to tolerate surgery, treatment includes esophageal or double (tracheal and esophageal) stenting using self-expanding metallic stents (Sanwal et al, 2012). 

Tracheoinnominate fistula

Tracheoinnominate (T-I) artery fistula is an extremely rare and life threatening airway emergency that presents as massive tracheal bleeding, often presenting in the first three weeks after tracheotomy..  It occurs more commonly if the tracheostomy is placed below the 3rd tracheal ring (Engels, 2005; Grant, 2006).  This placement leaves the distal end of the tracheostomy tube in close proximity to the innominate artery.   Tissue necrosis from excessive movement of the distal tip of the tracheostomy tube and high pressure (or overinflated) cuff are also risk factors that can cause a life threatening hemorrhage (Grant, 2006). Tracheal bleeding and pulsation of the tracheostomy tube that is synchronous with the heartbeat may be an indication that the tube is pressing on the innominate artery.

Prevention is key and includes appropriate management of the tracheostomy cuff, lightweight ventilator tubing, limiting movement of the tracheostomy tube, and avoid hyper-extending the neck.  Treatment involves digital or tube cuff occlusion of the fistula while transferring the patient to immediate surgical repair.  

 

Pneumonia

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Physiologic Complications of Tracheostomy

Airway cutout with an inflated tracheostomy tube

The cuff itself may cause complications including: tracheal stenosis, granulomas, tracheal erosion, tracheomalacia, trauma and subsequent necrosis of the tracheal wall, and T-E or T-I fistula.   Since the trachea and esophagus share a common wall, if the cuff is over-inflated, there may also be esophageal impingement. Most of these complications can be avoided with proper management of cuff pressures, and by appropriate positioning of the tracheostomy tube.  

The tracheostomy tube is placed below the level of the vocal folds and larynx.  Placement of a tracheostomy tube causes airflow to bypass the upper airway.  Instead of air flowing through the upper respiratory tract, air is redirected in and out of the tracheostomy tube.  Therefore many physiological complications occur, even if cuff management is done appropriately.  

Physiologic Changes after Tracheostomy
Impaired Voicing Impaired smell and taste Impaired secretion management Impaired swallowing Loss of physiologic PEEP Altered body image

Impaired Voicing

Voicing requires airflow through the vocal folds.  Aphonia, or loss of speech, occurs in patients with a cuffed tracheostomy tube. This is because airflow is redirected in and out through the tracheostomy tube instead of through the vocal folds and through the upper airway. The inability to speak can result in agony, fear, panic and frustration for the patient. 

There are many communication options for patients with tracheostomy including writing, gestures, mouthing words, leak speech, speaking valves,  talking tracheostomy tubes.  Check out the section on communication options for an in-depth look at the pros and cons of each method.  

Patients with communication disorders have a higher rate of medical complications and errors (Barlette et al., 2008) and are at increased risk of preventable adverse events (JACHO, 2010). Adverse events lead to poorer patient outcomes, unnecessary patient suffering and dissatisfaction, longer hospital stays, and extra healthcare spending each year (JACHO, 2011). Hospitals in the US, seeking Joint Commission accreditation, must adhere to standards intended to ensure that health care providers communicate appropriately and effectively with patients.

Joint Commission has provided a Roadmap for Hospitals for Advancing Effective Communication, Cultural Competence, and Patient and Family Centered Care. 

Impaired smell and taste

Lack of airflow through the upper airway also causes reduced ability to smell and taste. This complication can often be overlooked, but can result in reduced oral intake.  In a study of nasal function of patients with tracheostomy, quality of life was significantly reduced due to nasal function compared to the control group.  Loss of smell and taste were identified as the most important (Tsikoudas et al., 2011).  

Impaired secretion management

Secretion management is impaired in patients with tracheostomy.  Inspired air bypasses the nasal cavity, which eliminates natural warming, humidifying and filtering of inspired air before it reaches the trachea and lungs.  This results in drying out of the tracheal and bronchial epithelium, which respond by increasing mucus production.  The presence of a foreign body (tracheostomy tube) in the airway also increases mucus production.  The increased amount and thickness of mucus may enable crusts or mucus plugs to form that can block the tracheostomy tube .  

The normal cough mechanism is also impaired with the tracheostomy tube.  When the cuff is inflated, patients are unable to cough and clear secretions above the cuff.  Even if the cuff is deflated, most secretions are directed out the tracheostomy tube during coughing, instead of up through the upper airway and out the oral cavity.  The strength of the cough is impaired due to a lack of subglottal air pressure.  Subglottic pressure has been measured as 0 cmH2O with an open tracheostomy tube (Eibling & Gross, 1996).  Therefore secretions are difficult for the patient to remove through the cough mechanism with the cuff is inflated or deflated.  To generate sufficient pressure, the tracheostomy must be occluded typically with finger occlusion, speaking valves or capping.  When the tracheostomy tube is occluded on exhalation, secretion will be redirected around the tracheostomy tube and through the upper airway to be swallowed or expelled orally.  

The section on secretion management strategies has more information here.

Impaired Swallowing

Individuals with tracheostomy are at high risk of aspiration and silent aspiration.  Many individuals with tracheostomy also receive alternative means of nutrition and hydration such as through nasogastric tubes, gastrostomy tubes, jejunostomy tubes.  General decompensation and medical fragility is part of the reason for the abnormal swallowing.  However, there are also unique complications of the tracheostomy that often lead to difficulty swallowing.   These complications include: impaired laryngeal elevation,  desensitization of the larynx, unproductive cough, decreased subglottal pressure, disruption of vocal fold function, and difficulty with secretion management.  

The section on swallowing management of individuals with tracheostomy has more detailed information. 

Loss of physiologic PEEP

Intrinsic positive end-expiratory pressure (PEEP) is normally mediated by the glottis and is lost with an open tracheostomy tube.   Intrinsic, or physiologic PEEP is the amount of pressure in the lungs at the end of exhalation which helps to keep the alveoli open for gas exchange.  Normal intrinsic PEEP is about 4cmH2O.  The loss of intrinsic PEEP reduces alveolar ventilation, functional residual capacity (FRC) and compliance, and can result in atelectasis (Russell, C. & Matta, B., 2004).

Individuals would also be unable to create intrathoracic air pressure with an open tracheostomy tube.  A Valsalva maneuver occurs when the vocal folds move toward midline to increase intrathoracic pressure. This is required for defecation, heavy lifting as well as for posture and positioning.

Altered Body Image

Altered body image after tracheostomy may have a significant psychological impact.  Some tracheostomy tubes may be permanent.  If the tracheostomy tube is removed, the stoma typically closes and heals within 4-6 weeks with minimal scarring.  

Summary

These many physiological complications of a tracheostomy tube may be reversed by restoring a closed respiratory system to normalize airflow and pressures. A closed respiratory system on a tracheostomized patient can only be achieved by use of the Passy-Muir Speaking valve or a cap. 

 

References:

  • Bartlett G, Blais R, Tamblyn R, Clermont RJ, MacGibbon B. Impact of patient communication problems on the risk of preventable adverse events in acute care settings. Canadian Medical Association Journal. 2008;178(2):1555–1562. doi: 10.1503/cmaj.070690. [PMC free article][PubMed] [CrossRef] []
  • Cipriano A, Mao ML, Hon HH, et al. An overview of complications associated with open and percutaneous tracheostomy procedures. Int J Crit Illn Inj Sci. 2015;5(3):179–188. doi:10.4103/2229-5151.164994
  • Engels, SK (2005). Late Complications of Tracheostomy. Respiratory Care. (4)50; 4; 542-549.  
  • Eibling DE, Gross R. Subglottic air pressure: a key component of swallowing efficiency. Annals of Otology, Rhinology, and Laryngology. 1996 Apr;105(4):253-8.
  • Halum
  • Happ MB, Seaman JB, Nilsen ML, et al. The number of mechanically ventilated ICU patients meeting communication criteria. Heart & Lung. 2015;44:45–49. doi: 10.1016/j.hrtlng.2014.08.010.[PMC free article] [PubMed] [CrossRef[]
  • Rumbak, Mark J. et al. (1999). Significant Tracheal Obstruction Causing Failure to Wean in Patients Requiring Prolonged Mechanical Ventilation. CHEST, Volume 115, Issue 4, 1092 – 1095

  • Russell, C. & Mata, R.  Tracheostomy: A Multiprofessional Handbook. Cambridge University Press. 

  • Sanwal MK, Ganjoo P, Tandon MS. Posttracheostomy tracheoesophageal fistula. J Anaesthesiol Clin Pharmacol. 2012;28(1):140–141. doi:10.4103/0970-9185.92478

  • The Joint Commission. Advancing effective communication, cultural competence, and patient-and family-centered care: A roadmap for hospitals. Oakbrook Terrace, IL: The Joint Commission; 2010.[]

  • The Joint Commission. Summary data of sentinel events reviewed by The Joint Commission.Oakbrook Terrace, IL: The Joint Commission; 2011. []
  • Tsikoudas A, Barnes ML, White P. The impact of tracheostomy on the nose. European Archives of Oto-Rhino-Laryngology. 2011 Jul;268(7):1005-8. doi:10.1007/s00405-011-1522-1. Epub 2011 Feb 17.