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. (refer/LINK to book 1 A&P) The care path or plan you implement in your institution will greatly impact the overall outcomes for these critically complex patients. From insertion to decannulation, it will be the well educated, multi-disciplinary team that will have the most impact on quality of life, and length of stay
Immediate Complications of Tracheostomy
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Pneumothorax is a potentially life threatening complication caused when the the pleura is punctured during the tracheostomy procedure, followed by partial or complete collapse of the lung. COPD patients are particularly high risk because their intrinsic air-trapping causes their chest to be barrel shaped, and the apex of the lung is much higher in the chest cavity.
This is a postoperative chest x-ray to confirm tracheostomy tube placement. There is a large left sided pneumothorax (arrows on the patient’s left). The curved arrow is pointing to air that has begun to track around the heart area, called pneumomediastinum. Subcutaneous air is beginning to track along the pectoralis major muscles bilaterally. Subcutaneous emphysema can develop rapidly, and may be your first clinical sign of a pneumothorax. Subcutaneous emphysema is detected by palpating crepitus over the neck that may radiate out over the chest wall. (crepitus feel like Rice Krispies Cereal crunching under your fingers when you press on the skin)
Bleeding from the actual procedure is common, in small amounts. 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.
Infection at the stoma site usually responds well to local treatment. Because the area around the stoma stays wet, it is quickly colonized by many organisms (pseudomonas, e-coli, etc). An important part of tracheostomy care is frequently inspecting the stoma site for any signs of infection, skin breakdown, redness, foul smells, etc.
Damage to the laryngeal nerve causing vocal cord paralysis, and trauma to the esophagus are also potential immediate complications of tracheostomy.
This is a postoperative chest x-ray to confirm tracheostomy tube placement. There is a large left sided pneumothorax (arrows on the patient’s left). The curved arrow is pointing to air that has begun to track around the heart area, called pneumomediastinum. Subcutaneous air is beginning to track along the pectoralis major muscles bilaterally. Subcutaneous emphysema can develop rapidly, and may be your first clinical sign of a pneumothorax. Subcutaneous emphysema is detected by palpating crepitus over the neck that may radiate out over the chest wall. (crepitus feel like Rice Krispies Cereal crunching under your fingers when you press on the skin)
Bleeding from the actual procedure is common, in small amounts. 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.
Infection at the stoma site usually responds well to local treatment. Because the area around the stoma stays wet, it is quickly colonized by many organisms (pseudomonas, e-coli, etc). An important part of tracheostomy care is frequently inspecting the stoma site for any signs of infection, skin breakdown, redness, foul smells, etc.
Damage to the laryngeal nerve causing vocal cord paralysis, and trauma to the esophagus are also potential immediate complications of tracheostomy.
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Accidental displacement of the tube soon after surgery requires intervention by a surgeon to recannulate the patient, due to the immature tract. This is an airway EMERGENCY! If you are caring for a fresh tracheostomy patient who becomes accidentally decannulated, you must cover the surgical stoma site with a gloved hand or gauze pads, and begin to bag-mask ventilate this patient until intubation or recannulation of the patient occurs. Do NOT attempt to reinsert the tube, as reinsertion of the tube into a false tract could lead to respiratory and/or cardiac arrest. Whenever you are concerned about tube placement, a complete airway assessment is indicated: you should hear bilateral breath sounds anteriorly, an end tidal CO2 device should change to the appropriate color, and you should be able to pass a suction catheter without resistance.
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Difficulty swallowing immediately post operatively, as well as long term, may be due to the patient’s medical condition, poor laryngeal elevation during the swallow, improper cuff management, poor pharyngeal sensation secondary to a lack of airflow, pain at the site, and the loss of subglottic pressure. (see/link to chapter on swallowing)
Tube obstruction secondary to a mucus plug or blood clot can be managed with proper suctioning of the airway, adequate humidification, (see/link to section of airway care/humidification) and frequent changing or cleaning of the inner cannula, when working with a double lumen tube. (see/link to double lumen tube, and changing an inner cannula)
Tube obstruction secondary to a mucus plug or blood clot can be managed with proper suctioning of the airway, adequate humidification, (see/link to section of airway care/humidification) and frequent changing or cleaning of the inner cannula, when working with a double lumen tube. (see/link to double lumen tube, and changing an inner cannula)
Long term complications of tracheostomy:
The late postprocedural complication rate is as high as 65%, but this rate is significantly affected by injury which occurred as a result of translaryngeal intubation (Engels, 2009).
Formation of granulation tissue is the most frequent late complication of tracheostomy occurring in 58% of long term tracheostomies (Law et al., 1993) . It happens when the trachea becomes damaged by the pressure and friction of a moving cuff/tube, or an infection at the stoma site causes scar tissue to proliferate. Tracheal granulomas are of significant concern, and may cause airway occlusion or result in airway stenosis. Fenestrated tracheostomy tubes are commonly associated with this complication. (P Siddharth, L Mazzarella - The American journal of surgery, 1985 - Elsevier) Earlier and more frequent tube changes has been associated with decreased potential for granular tissue formation (Yaremchu, K., 2003).
Granulation tissue can be removed several ways, but the most popular procedures are via endoscopy with forceps and suction, or vaporized with a CO2 laser. When endoscopic techniques fail, the patient must have an open procedure. Open reduction of granular tissue is a last resort.
Tracheomalacia is caused when the cartilaginous structure of the tracheal wall softens, and erosion of the tracheal rings occurs. 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. When this loss of cartilage is replaced by granular or fibrotic tissue, narrowing and/or collapse of the airway at or above the site can occur. Collapse of this structure occurs during expiration, and may necessitate placement of a tracheostomy tube. 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.
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.
Tracheal stenosis is narrowing of the airway that can cause significant respiratory distress. It can be congenital, or secondary to radiation or trauma to the airway. In regards to tracheostomized patients, stenosis is usually secondary to trauma to the tracheal rings at the area of the cuff and distal tip of the tube, and damage at the stoma is usually a result of constant motion (i/e tugging on ventilator tubing), or a bacterial infection. Bronchoscopy is indicated in patients with suspected tracheal stenosis
Prevention of tracheal stenosis should be incorporated into every clinical pathway. Whether you use air filled high volume, low pressure cuffs (see/link to that cuff section), or water filled high pressure, low volume cuffs, (see/link to TTS) incorporating a routine cuff pressure management system is the first step. The tube should be appropriately sized, and a cuffless tube should be considered when the patient no longer requires mechanical ventilation, or when the patient tolerates continuous cuff deflation. Great care should be taken to minimize motion of the tracheostomy tube, for it is that friction with movement that causes a great deal of tracheal damage.
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). The most common procedures to treat tracheal stenosis are tracheal resection and reconstruction, tracheal dilation, laser bronchoscopy, and surgical placement of a silicone or metal airway stent to hold the trachea open.
Treatment of Tracheal Stenosis
Tracheoesophageal (T-E) and tracheoinnominate (T-I) fistulas can be very serious, but are extremely rare complications of tracheostomy. T-E fistulas develop when a connection is made between the tracheal and the esophageal walls. Causes of T-E fistulas could include: congenital deformities, over inflated cuffs, or a malpositioned tracheostomy tube. Erosion through the wall creates the connection. Clinical symptoms of a T-E fistulas are: excessive secretions, chronic aspiration, and distended abdomen secondary to excess air in the stomach. There should be a high suspicion for a T-E fistula if tube feedings are noted in the tracheostomy tube or around the stoma. If a T-E fistula is suspected, a bronchoscopy is indicated (Mitchell, 2013). In most cases, the fistula must be surgically repaired.
T-I fistula is an extremely rare and life threatening airway emergency that presents as massive tracheal bleeding. It occurs more commonly if the tracheostomy is placed at or below the 3rd and/or 4th 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 rubbing of the distal tip of the tracheostomy tube and high pressures in the 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.
Formation of granulation tissue is the most frequent late complication of tracheostomy occurring in 58% of long term tracheostomies (Law et al., 1993) . It happens when the trachea becomes damaged by the pressure and friction of a moving cuff/tube, or an infection at the stoma site causes scar tissue to proliferate. Tracheal granulomas are of significant concern, and may cause airway occlusion or result in airway stenosis. Fenestrated tracheostomy tubes are commonly associated with this complication. (P Siddharth, L Mazzarella - The American journal of surgery, 1985 - Elsevier) Earlier and more frequent tube changes has been associated with decreased potential for granular tissue formation (Yaremchu, K., 2003).
Granulation tissue can be removed several ways, but the most popular procedures are via endoscopy with forceps and suction, or vaporized with a CO2 laser. When endoscopic techniques fail, the patient must have an open procedure. Open reduction of granular tissue is a last resort.
Tracheomalacia is caused when the cartilaginous structure of the tracheal wall softens, and erosion of the tracheal rings occurs. 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. When this loss of cartilage is replaced by granular or fibrotic tissue, narrowing and/or collapse of the airway at or above the site can occur. Collapse of this structure occurs during expiration, and may necessitate placement of a tracheostomy tube. 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.
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.
Tracheal stenosis is narrowing of the airway that can cause significant respiratory distress. It can be congenital, or secondary to radiation or trauma to the airway. In regards to tracheostomized patients, stenosis is usually secondary to trauma to the tracheal rings at the area of the cuff and distal tip of the tube, and damage at the stoma is usually a result of constant motion (i/e tugging on ventilator tubing), or a bacterial infection. Bronchoscopy is indicated in patients with suspected tracheal stenosis
Prevention of tracheal stenosis should be incorporated into every clinical pathway. Whether you use air filled high volume, low pressure cuffs (see/link to that cuff section), or water filled high pressure, low volume cuffs, (see/link to TTS) incorporating a routine cuff pressure management system is the first step. The tube should be appropriately sized, and a cuffless tube should be considered when the patient no longer requires mechanical ventilation, or when the patient tolerates continuous cuff deflation. Great care should be taken to minimize motion of the tracheostomy tube, for it is that friction with movement that causes a great deal of tracheal damage.
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). The most common procedures to treat tracheal stenosis are tracheal resection and reconstruction, tracheal dilation, laser bronchoscopy, and surgical placement of a silicone or metal airway stent to hold the trachea open.
Treatment of Tracheal Stenosis
Tracheoesophageal (T-E) and tracheoinnominate (T-I) fistulas can be very serious, but are extremely rare complications of tracheostomy. T-E fistulas develop when a connection is made between the tracheal and the esophageal walls. Causes of T-E fistulas could include: congenital deformities, over inflated cuffs, or a malpositioned tracheostomy tube. Erosion through the wall creates the connection. Clinical symptoms of a T-E fistulas are: excessive secretions, chronic aspiration, and distended abdomen secondary to excess air in the stomach. There should be a high suspicion for a T-E fistula if tube feedings are noted in the tracheostomy tube or around the stoma. If a T-E fistula is suspected, a bronchoscopy is indicated (Mitchell, 2013). In most cases, the fistula must be surgically repaired.
T-I fistula is an extremely rare and life threatening airway emergency that presents as massive tracheal bleeding. It occurs more commonly if the tracheostomy is placed at or below the 3rd and/or 4th 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 rubbing of the distal tip of the tracheostomy tube and high pressures in the 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.
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The cuff is the balloon that surrounds the shaft of the tracheostomy. (See/link to types of cuffs later in this book) Complications of the cuff are: laryngeal lesions, tracheal stenosis, granulomas, tracheal erosion, tracheomalacia, trauma and subsequent necrosis of the tracheal wall, and T-E or T-I fistula. Esophageal impingement may also occur with cuff over-inflation. Most of these can be avoided today with the proper management of cuff pressures, and by stabilizing the tracheostomy tube.
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