Post-Tracheostomy Complications

Complications associated with tracheostomy can be divided into two categories: immediate surgical complications and late complications. The most frequent causes of death in tracheostomy patients are obstruction and hemorrhage. Many of the early complications have already been mentioned elsewhere in this text and we will now consider the late complications that are frequently encountered.

Hemorrhage

Massive bleeding may occur a few days to several weeks after a tracheostomy. The most common cause of delayed hemorrhage is erosion of the anterior tracheal wall and a major vessel crossing it (frequently the innominate artery) by the tip of the tube. Predisposing factors may include a low tracheal incision, tube size selection, an excessively long or curved tube, and infection.

Wound Infection

Minor infection of an open tracheostomy site is common and usually responds to local treatment. If it fails to respond, a wound culture and sensitivity should be obtained and the appropriate systemic antibiotic administered. Serious mediastinitis can result from an untreated tracheostomy wound infection.

Tracheitis

A dry tracheitis will develop if humidification of the airway is inadequate. Treatment of any secondary infections will require administration of antibiotics. Instillation of normal saline during suctioning procedures may help to keep the airway moist.

Pneumonia

The development of pneumonia or lung abscess is prevented by employing aseptic technique during the surgery and postoperative care of the tube. It is especially important to avoid bacterial contamination of the respiratory tract by contaminated suction catheters. The use of sterile disposable catheters or closed suction systems will prevent many of the associated problems.

 

Subglottic Edema

If the surgical opening into the trachea is made through the first or second tracheal cartilage, edema of the subglottic area can develop. The swelling of the mucosa will restrict the airway above the tube and may lead to difficult decannulation. This is especially true in infants and small children.

Tracheal Stenosis

Narrowing of the trachea by stenotic granular tissue (scar tissue) may occur at the tracheal orifice, cuff site, or at the position of tube tip. In children and infants stenosis at the tracheal orifice can be avoided by not removing any tracheal cartilage,- in adults this problem is most frequently associated with a high position of the opening, through the first or second tracheal ring. Frequently, granulation may occur at the cuff site if careful attention is not paid to cuff inflation volumes and design. This problem is best avoided by monitoring the inflation volume and by using a tracheostomy tube with a high-volume cuff such as the Portex Profile8 cuff. Erosion of the tracheal wall by the tip of the tube, which will lead to stenosis, is avoided by selection of a tracheostomy tube that is of proper length, size, and curvature. Tubes that soften slightly at body temperature and have movable neck plates conform better to the trachea. Portex Blue Line, D.I.C.™, and Flexible D.I.C. tracheostomy tubes incorporate all of these features.

Tracheoesophageal Fistula

Erosion of the posterior wall of the trachea can be caused by a poorly fitted tube or by excessive cuff volume. A communicating channel between the esophagus and trachea can result. This complication is potentially fatal but is fortunately rare. It is treated by inserting a longer cuffed tube with surgical correction when the patient's condition permits. Monitoring and recording cuff volumes will help reduce this possibility. Minimizing torque transmission of connections to the distal tip of the tracheostomy tube is also clinically significant.