otolaryngology , CRSwNP , FESS , revision surgery

1. Complications of
Tracheostomy
Presented by : Dr. Khalil Elkahlout
MBBS , R2 resident ENT department
Alshifa medical complex

2. There are many complications associated with performing a
tracheostomy.
Most of them can be avoided with a meticulous surgical approach and
dedicated
post-operative care, administered by a multidisciplinary
team.
The most crucial members of this team are usually the nurses who will
be responsible for the management of the patient in the first 48 hours.
More important is to identify in advance possible characteristics of the
procedure that increase the chances of events, such as tracheostomies
in obese patients or pediatric patients, and retracheostomy .

3. The complications can be :
- Intra-operative (including the first 24 h)
- Early postoperative (1–14 days)
- Late > 14 days

5. Complication rates in the literature range between 4 and 31 percent for
percutaneous tracheostomy and between 6 and 66 percent for surgical
tracheostomy depends on individual departments.
The most commonly occurring complications are haemorrhage , tube
obstruction and tube displacement.
Death occurs in 0.5 – 1.6% and is most often the result of tube
displacement.
Emergency tracheostomy carries a two to five fold increase in the incidence
of complications over an elective procedure.

6. Intra-operative complications
Primary haemorrhage
Coagulation disorders must be corrected pre-operatively.
Significant bleeding can occur from the anterior jugular veins & thyroid isthmus .
The surgeon needs to be meticulous when tying off these vessels and the divided
ends of the thyroid isthmus.
By not dissecting lateral to the trachea, damage to the internal jugular vein and the
carotid artery are avoided.

8. Airway fires
Fires usually arise when diathermy is used in the presence of an open airway.
It is essential a dry field to be obtained prior to opening the trachea.
If there is heavy bleeding from the tracheal wall, the anesthetist should be
informed so that ventilation can momentarily be suspended before using
diathermy.
Bipolar diathermy is said to be safer because of less arcing, but this possibility
still exists so care must be taken whatever method is used.
If an airway fire should occur, empty a bowl of saline into the wound, stop
ventilating the patient and use a carbon dioxide fire-extinguisher if the fire
continues .

10. Injury to the trachea and larynx
Careful haemostasis and good exposure will help to minimize the risks of
damage to these structures.
The most important sites of damage to recognize are the posterior tracheal
wall , the cricoid and 1st cartilage ring.
If the damage is recognized at the time of surgery careful apposition of the
edges of the cartilage is necessary to minimize the risk of post-operative
stenosis of the trachea and larynx.
Injury to the posterior tracheal wall must be avoided, as a tracheo-
oesophageal fistula is the ultimate result if this injury goes unrecognized.

11. Injuries to paratracheal structures
Do not dissect lateral to the trachea.
This will avoid damage to the recurrent laryngeal nerves, carotid artery,
jugular vein and vagus nerve.
Also avoid placing the tracheostomy too low or hyper-extending the
neck, as the left brachiocephalic vein and right brachiocephalic trunk
could be damaged ,this is especially so in children.

12. Air embolism
This rare complication will also be avoided by keeping to the midline and
avoiding damage to the internal jugular vein.
Apnoea
This may occur in patients with very high PaCO2 levels because of prolonged
expiratory airway obstruction. When a tracheostomy tube is inserted, there is a
sudden drop in the PaCO2 level, which results in apnoea. The reason for this is
the respiratory drive, which is maintained by the high PaCO2, is cut off and the
patient stops breathing. The anaesthetist needs to be aware of this possibility
and may need to use 5% CO2
in oxygen to prevent this problem occurring.

13. Cardiac dysrhythmias and cardiac arrest
Patients may arrest intra-operatively because of other co-morbidity factors or
the sudden swings in acid base balance, which occur with respiratory
obstruction
and its subsequent rapid correction.
Displacement or blockage of the tube, tension pneumothorax or
pneumomediastinum
can also result in a cardio-respiratory arrest.

14. Mechanism of false passage between the sternum (S) and the trachea (T).

15. Early post-operative complications
Subcutaneous emphysema
It is most commonly caused by too tight a closure of the tracheostomy
wound or an incorrectly sized tube allowing air to escape esp. in PPV .
So leave the wound loosely closed and make sure the tube is the correct
size for the patient.
If the situation does arise then address the above two points and cover the
patient with antibiotics as cellulitis may develop.
The air will be re-absorbed spontaneously.

16. Pneumomediastinum and pneumothorax
This occurs with dissection low in the neck and damage
to the pleural domes.
This condition should always be suspected and
postoperative chest X-ray performed.
This condition usually requires chest tube .

17. Tube displacement
It may occur at any time and is potentially fatal.
_ Patient factors : obesity, excessive coughing, and agitation.
_ Physical factors : incorrect placement of the opening into the trachea, creating a false passage, loosening of
the tapes as a result of resolution of subcutaneous emphysema, inadequately tied tracheostomy tapes, and
use of bulky dressings. It is preventable by suturing the neck plate to the skin surrounding the tracheostoma.
It should be suspected when a patient with recent tracheostomy develops respiratory distress or is
suddenly able to speak. Management by traction sutures should be pulled gently ,retract the skin and bring the
stoma into the wound. The tracheostomy tube is then inserted and adequate ventilation verified.
If this procedure fails or in difficult anatomy, it may be best to reintubate the patient and find the
tracheostomy tract once the airway is secured.
Identifying the stoma with suction tubing and inserting the tracheostomy tube into the trachea is an
alternative method of restoring the airway.

18. Tube blockage/crusts
Due to increase in viscosity and the amount of mucus production with inadequate suction and
humidification of the inspired air over the first few days the mucus will dry out and form very hard
crusts which can block a tube .
Suspected if the patient is experiencing SOB , or the nursing staff are having difficulty passing a
suction catheter.
The first thing to do is to remove the inner cannula of the tracheostomy tube to check for crusts.
Once this is out, a flexible endoscope can be passed down the lumen and an inspection of position
of the tube and any crusts.
If there are crusts then firstly nebulised saline or 5 ml of saline trickled into the trachea to soften
the crusts and allow successful suction clearance.
If this fails the tube may need to be removed and replaced or the crusts may need to
be removed with long nasal packing forceps.

19. Wound infection
The tracheostomy wound always develops a low-grade infection,
usually a self-limiting infection and no treatment is needed. A serious if
there is any pressure necrosis of the skin from ill-fitting tubes.
Sterile dressings should be changed when soiled to prevent prolonged
contact
of wet contaminated dressings with the skin.
The wound should never be packed for a prolonged period to control
bleeding because this provide a culture medium for infection,
& wound breakdown.
Trachiitis may result if the trachea is allowed to dry out and this may
lead to perichondritis then tracheal stenosis.
Adequate humidification and correctly fitting tubes are essential to
prevent this complication.

20. Tracheal necrosis
Result of pressure necrosis by an inappropriately sized tube pressing
on the posterior wall of the trachea or an inappropriately high pressure
within the cuff of the tube.
So it’s important to check the position of the tube and to monitor cuff
pressure.
The pressure necrosis perichondritis a tracheo-oesophageal
fistula or a tracheo-arterial fistula.
The necrosis often leads to long-term tracheal stenosis.

21. Secondary haemorrhage
Minor bleeding from skin easy to control with a pressure dressing to more
serious bleeding can occur from erosion of a vessel by the tube (tracheo-
arterial fistula) or from an area of granulation tissue within the stoma or
trachea.
Therefore, sure adequate humidification, the tube is fitting properly and
prompt treatment of any infection.

22. Tracheoarterial fistulae
They most commonly in previously irradiated patients with a low tracheostomy
, usually occurs within the first 3 weeks after tracheostomy , occurs in 0.4% of
patients.
May be due to :
low tracheostomy , aberrant course innominate artery , long tube , pressure
necrosis by prolonged inflate cuff and trachiitis.
Rupture of the innominate artery is usually heralded by a “sentinel bleed “ may
stop and followed a few days later by a catastrophic hemorrhage.
In the presence of any hemorrhage the cuff of the tracheostomy tube should
immediately be overinflated and suprasternal pressure applied the patient
should be appropriately resuscitated and the wound should be explored to
ligate the bleeding vessel.

23. Mechanism of erosion of the innominate artery (IA) by pressure from the concave surface of the tracheostomy
cannula.
B,
Pressure of the tip of the tracheostomy cannula on the anterior tracheal wall (T) causes erosion into the innominate
artery (IA).

24. Late post-operative complications
Haemorrhage can occur at any time.
Granuloma formation
In ill-fitting tube or a chronic low-grade infection , most commonly at the
stoma but may also in the lumen of the trachea.
They usually cause minor bleeding on suctioning or changing the tube and
may cause difficulty in passing a suction catheter.
Treated firstly removing a tube that is rubbing on the wall of the trachea, and
replacing it with a better fitting tube to removes the stimulus .
They can then be cauterized with a silver nitrate cautery stick and topical
antiseptic ointment applied.
Failing this they can be treated with a CO2 laser via a bronchoscope.

25. Tracheo-oesophageal fistula
primary trauma to the posterior wall of the trachea and the
oesophagus at the time of surgery or pressure necrosis by high
cuff pressure or the tube is pressing on the tracheal wall ,
compounded if NG tube inserted.
Thus, only fine bore feeding tubes should be used and the cuff
pressure regularly checked .
This complication may be suspected if the patient
is coughing on swallowing saliva or eating.
The diagnosis is confirmed endoscopically and repaired by an
open procedure.

26. Tracheocutaneous fistula
In long-term tracheostomies there may be complete
epithelialisation of the stomal tract , which will not close off
spontaneously after removal of the tube.
It is necessary in these patients to excise the stoma and to close
the wound in layers, interposing the strap muscles between the
skin and the trachea.

27. Laryngotracheal stenosis
Damage to the 1st tracheal ring and the cricoid cartilage is the
chief culprit but infection and pressure necrosis can also play a
part.
Tracheostomy scar
Unsightly scars are usually the result of the skin attaching to the
anterior tracheal wall , results in a puckered scar that moves on
swallowing , managed as TC fistula .

28. extensive tracheal stenosis due to cuff hyperinflation

29. Resources
• TRACHEOSTOMY A MULTIPROFESSIONAL HANDBOOK .
• Tracheostomy A Surgical Guide .
• Scott Brown 8th edition Otorhinolaryngology, Head & Neck Surgery .
• Operative Otolaryngology: Head and Neck Surgery Book: 2-Volume
Set.
• European Annals of Otorhinolaryngology, Head and Neck Diseases .
• Atlas of Otolaryngology, Head & Neck Operative Surgery by Johan
Fagan .
• Essential Otolaryngology Head & Neck Surgery 10th E D I T I O N .

30. Any Question ?