Background: Many patients with advanced illness have tracheostomies, which require specialized care and management. Common indications for tracheostomies in patients seen by generalists and palliative care/hospice clinicians include chronic long-term ventilation, aid with ventilation weaning, and upper airway obstruction (e.g., head and neck cancer). A working knowledge of tracheostomy equipment and the basic handling procedures can avoid complications and improve a patient’s comfort.

Tracheostomy equipment 101: At its most basic level, a tracheostomy appliance consists of a cannula (or tube), cuff, obturator, and ties. The cannula maintains the patency of the stoma and airway. It facilitates movement of air into the trachea, facilitates deep suctioning, and can help provide comfort for patients who would otherwise be dependent on an endotracheal tube for long-term ventilation. Tracheostomy cannulas can be cuffed or uncuffed. The inflatable cuff, typically filled with air by a syringe, surrounds a portion of the trachea, allowing for greater degrees of positive pressure ventilation. Hence, patients on positive pressure ventilation (e.g., mechanical ventilation) usually require that their tracheostomies are inflated and cuffed. Cuffs require monitoring to maintain a pressure in the range of 20-25 mmHg since higher pressures can produce tracheal ischemia and mucosal injury while lower pressures are associated with aspiration (1-3). Obturators are inserted into the lumen of the cannula and provide increased rigidity during placement of the tracheostomy tube. Tracheostomy ties secure the tracheostomy tube to the patient and typically wrap around the back of the patient’s neck.

Effect on aspiration risk: Aspiration occurs in up to 87% of those with tracheostomies (4), of which, 82% were silent aspiration (5). Beyond common patient-related factors (e.g., delirium and sedation are common in chronic critical illness), a tracheostomy contributes to this risk by decreasing laryngeal elevation, reducing subglottic pressure, desensitizing the larynx, disrupting the vocal fold function, and compromising the cough reflex (6,7). Somewhat counterintuitively, aspiration risks are exacerbated with a cuffed vs uncuffed tracheostomy in patients who are not on positive pressure ventilation. Secretions tend to pool above the cuff and because the cuff is not airtight, secretions can then pass around it and into the lower airway (8). Therefore, for those patients not on positive pressure ventilation, an uncuffed tracheostomy is often preferred.

Complications of tracheostomy placement Short-term complications include bleeding from surgical site (~5%), wound infection, subcutaneous emphysema, pneumothorax, tracheostomy tube obstruction, recurrent laryngeal nerve damage, and posterior tracheal wall injury (9,10). Long-term complications include dysphagia, airway obstruction from secretions, infection, rupture of the innominate artery, tracheo-innominate artery fistula (<0.7%), tracheoesophageal fistula, tracheal dilation, tracheal stenosis (1-2%), granuloma formation, and tracheal ischemia and necrosis (9,10).

Approach to complications and emergencies: In hospital settings, ENT and pulmonary specialists can be instrumental in managing acute tracheostomy-related care issues, even for patients with comfort-focused goals of care.  However, in other settings (e.g., home, long-term care facility), these specialists may not be readily available. Hence, the following clinical pearls may be helpful to clinicians.

• Acute Dyspnea.  If a patient with a tracheostomy becomes acutely dyspneic, it may be due to partial or complete blockage by retained secretions. Ask the patient to cough and then attempt to suction the tracheostomy in place with a flexible suction catheter. If the tracheostomy stoma and tract is not fully matured, do not attempt to remove the cannula as it may be difficult to re-insert (3).
• Bleeding. Bleeding from the surgical site is a common early complication. Treatments include packing around the edges of the stoma with gauze, correction of coagulopathies, and cautery or suturing of site of bleeding (3,5). Massive pulsatile bleeding may indicate erosion of the innominate artery, which can occur days to weeks after a tracheostomy procedure. This can rapidly lead to airway compromise and/or exsanguination. To minimize bleeding, place a gloved finger in the stoma, feel for a pulsatile mass, and apply forward motion on the backside of the upper border of the sternum thereby compressing the pulsatile artery against the posterior surface of the sternum (8). Other techniques include overinflating the cuff. If the patient’s goals of care allow this, the patient should be transported emergently to the operating room for management (3).  See Fast Fact #251 for further details about caring for hemorrhaging patients who do not want further invasive treatments.
• Accidental decannulation. Reassure the patient and yourself.  Don’t panic. If the tube has been in place less than 5 days, consider endotracheal intubation (10). If the tube has been in place for 5 days or more, the tract should be well formed and should not suddenly close (2). To reinsert the tracheostomy tube, insert the obturator (if applicable) into the cannula. Slowly insert the cannula with obturator into the tracheostomy, following the path of the airway. When reinserting, be mindful of any resistance. If met with resistance, it is possible to create a false passage, and one should reevaluate the entry approach. After insertion, remove the obturator while keeping the cannula in place. Listen for and feel for air movement through the tracheostomy tube and ensure that there is no subcutaneous emphysema, which may indicate improper placement.

If you cannot insert a new cannula and the patient cannot breathe comfortably on their own through the stoma, use a bag-valve mask to ventilate the patient through the upper airway. Ventilate gently to prevent air from escaping through the stoma or carefully occlude the stoma with a gloved hand to maximize oxygenation. Next steps depend on the patient’s current indication for a tracheostomy (airway patency vs. ventilation vs. secretion management) and goals of care.  If the patient has a patent airway and is not on a ventilator there may be time to have the patient evaluated by a specialist to replace the cannula.  If the patient is ventilator dependent or has an upper airway obstruction, endotracheal intubation and/or emergency transport is indicated.

• Resuscitation via tracheostomy tube.  Resuscitate the patient as if they did not have a tracheostomy, with the following exceptions: do not remove the tracheostomy; check that the cannula is patent; manually ventilate via a resuscitation bag attached directly to the tracheostomy tube. If you are unable to ventilate, try suctioning, changing the tracheostomy tube, or the last resort is oral intubation.

References

1. Heffner JE, Hess D. Tracheostomy management in the chronically ventilated patient. Clin Chest Med. 2001; 22:55-69.
2. Hess DR. Tracheostomy tubes and related appliances. Respir Care. 2005; 50:497-510.
3. St. John RE and Malen JF. Contemporary issues in adult tracheostomy management. Crit Care Nurs Clin N Am. 2004; 16:413-430.
4. Elpern, E. et al. (1994). Pulmonary Aspiration in Mechanically Ventilated Patients with Tracheostomies. CHEST. Volume 105, Issue 2, 563-566.
5. Leder, S. (2002). Incidence and Type of Aspiration in Acute Care Patients Requiring Mechanical Ventilation via a New Tracheotomy. CHEST, Volume 122, Issue 5, 1721 – 1726
6. Tracheostomy LLC. (2022, February 23). Swallowing management of individuals with tracheostomy. Tracheostomy Education. Retrieved June 26, 2022, from https://www.tracheostomyeducation.com/blog/swallowing-management-of-individuals-with-tracheostomy/ 
7. NFOSDadmin. (2020, September 4). Dysphagia & Patients with Tracheostomy and Mechanical Ventilation. National Foundation of Swallowing Disorders. Retrieved June 26, 2022, from https://swallowingdisorderfoundation.com/dysphagia-patients-with-tracheostomy-and-mechanical-ventilation/ 
8. Hernandez, G. et al. (2013). The effects of increasing effective airway diameter on weaning from mechanical ventilation tracheostomized patients: a randomized controlled trial. Intensive Care Medicine. Jun;39(6):1063-70
9. Conlan AA, Kopec, SE. Tracheostomy in the ICU. J Int Care Med. 2000; 15:1-13.
10. De Leyn P, Bedert L, Delcroix M, et al. Review. Tracheotomy:  clinical review and guidelines. Eu J Cardiothoracic Surg. 2007; 32:412-21.

Author Affiliations:  EK, JS, JK: University of Pennsylvania School of Medicine, Philadelphia, PA; PF, BS: University of Kansas School of Medicine, Kansas City, KS.

Version History: Originally published February 2012; Copy-re-edited August 2015 and again in April 2023.

Conflicts of Interests: none to report.