Complications

Complications associated with a tracheostomy

Complications can be divided into those associated with insertion of the tracheostomy (surgical or percutaneous), those that arise following the procedure (usually blocked or displaced tracheostomy tubes) or as later complications. These can be serious and sometimes fatal. The following list shows how these complications are usually grouped.

Immediate complications (peri-operative period)

Haemorrhage (usually minor, can be severe if thyroid or blood vessels damaged)
Misplacement of tube—within tissues around trachea or to main bronchus
Pneumothorax
Tube occlusion
Surgical emphysema
Loss of the upper airway.

Delayed complications (post-operative period <7 days)

Tube blockage with secretions or blood—may be sudden or gradual
Partial or complete tube displacement
Infection of the stoma site
Infection of the bronchial tree (pneumonia)
Ulceration and/or necrosis of trachea
Mucosal ulceration by tube migration (because of loose tapes or patient intervention)
Risk of occlusion of the tracheostomy tube in obese or fatigued patients who have difficulty extending their neck
Tracheo-oesophageal fistula formation
Haemorrhage (local tissue trauma or erosion through blood vessels).

Late complications (late post-operative period >7 days)

Granulomata of the trachea may cause respiratory difficulty when the tracheostomy tube is removed
Tracheal dilation, stenosis, persistent sinus or collapse (tracheomalacia)
Scar formation—requiring revision
Blocked tubes may occur at any time, especially if secretions become thick, the secretions are not managed appropriately (suction) and humidification is not used
Haemorrhage.

Potential problems post-placement

Blocked tracheostomy

One role of the upper airway is to moisten and warm inhaled air before it reaches the lungs. Cilia are small hair-like protrusions that line the respiratory tract. Their function is to prevent infection within the respiratory tract, by moving mucus and other particles away from the lungs. Inserting a tracheostomy tube bypasses these natural mechanisms, which means the lungs will receive cool, dry air. Dry air entering the lungs may reduce the motility of the secretions within the lungs and the function of the cilia. In addition, the patient may not be able to cough and/or clear the secretions from the airways through the tracheostomy. This may cause the tracheostomy to become blocked by these thick or dry secretions. Blocked tracheostomy tubes can be minimised by careful humidification, tracheal suction and inner tube care. However, it is necessary to keep emergency equipment at hand at all times, as a blocked tube may lead to respiratory arrest.

Pneumonia

A build-up of secretions may lead to consolidation and even collapse of some areas of the lung, and thus contribute to pneumonia. The presence of a foreign body in the airway will hamper normal physiological defence mechanisms and particulate matter, oral secretions, gastric contents and bacteria can be aspirated past any cuff into the airway. These risks can be minimised by careful humidification, tracheal suction and inner tube care, and may be helped by suctioning above the cuff with specific sub-glottic suction tubes. Aspiration of gastric contents may also lead to pneumonia. This can occur with patients who are unable to swallow safely. Any patient who you suspect may have aspirated will need to have a formal swallowing assessment.

Displaced tracheostomy tube

The tracheostomy tube can become partially or completely displaced. The tube may migrate out of the stoma, or into the soft tissue of the neck. The tube may become displaced by coughing, because of its weight or the weight of attached breathing circuits, or by patient interference. Partial tube displacement is more dangerous, as it is not always visibly obvious that there is a problem with the tube (Figure 6.1). In order to keep tracheostomy tubes in position they must be secured carefully and monitored. Any concerns raised by the patient or nursing staff must be promptly investigated.

Figure 6.1 Tubes can become displaced.

Reproduced with permission of HEE eLfH.