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Fig. 12 Patient positioning can be hampered by venous access and cardiac monitor electrodes.
Notice the deformity that the shoulder roll causes on the mattress. It may increase as the procedure
lengthens and jeopardize the procedure
J.G.M. da Paixão et al.
instruments and disposable materials that will be used in the procedure, making it difcult to access them. Another challenge is patient positioning (Fig.12), which can
change throughout the procedure by deformation of the mattress on the ICU bed, which
is made to avoid areas of high pressure—a fact that may jeopardize the procedure.
Bedside or Operating Room Tracheostomy?
Deciding where to do a tracheostomy depends fundamentally on two factors: available resources and patient conditions.
It should be assessed if there is a trained professional available to use the desired
technique, and if there is availability of resources to perform it (operation room
time, safe transport for a ICU patient, a well-established bedside procedure protocol, an intensive care team experienced in organizing the appropriate materials and
assisting a tracheostomy, a PT kit, etc.). Finally, the patient’s clinical condition must
be assessed with regard to laboratory tests, cardiorespiratory stability, possibility of
cervical hyperextension, and access to the airway.
Considering these points, the surgeon is then able to decide, on a case-by-case basis,
where is the best place to do the tracheostomy.
“Informed consent was obtained from any individual participant for whom identifying information is included in this article.”
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J.G.M. da Paixão et al.
Tracheostomy Complications
Gabriel Manfro, Fernando Luiz Dias,
and Terence Pires de Farias
Tracheostomy is a frequently performed procedure. The variety of indications and
different characteristics of the patients makes attention necessary to avoid complications The decision regarding the performance of tracheostomy should consider
the risks and benets of this procedure [1].
More important than knowing the possible complications of the tracheostomy,
making the diagnosis early, and treating them, 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 [2].
G. Manfro, M.D., Ph.D. (*)
Department of Head and Neck Surgery, Santa Teresinha University Hospital, Universidade do
Oeste de Santa Catarina, UNOESC, Joaçaba, Santa Catarina, Brazil
e-mail: manfro1976@gmail.com
F.L. Dias, M.D., Ph.D., M.Sc., F.A.C.S.
Head and Neck Surgery Department, Brazilian National Cancer Institute—INCA,
Rio de Janeiro, RJ, Brazil
Head and Neck Department, Pontical Catholic University of Rio de Janeiro,
Rio de Janeiro, RJ, Brazil
T.P. de Farias, M.D., Ph.D., M.Sc., Researcher
Department of Head and Neck Surgery, Brazilian National Cancer Institute—INCA,
Rio de Janeiro, RJ, Brazil
Department of Head and Neck Surgery, Pontical Catholic University,
Rio de Janeiro, RJ, Brazil
© Springer International Publishing AG 2018
T.P. de Farias (ed.), Tracheostomy, https://doi.org/10.1007/978-3-319-67867-2_18
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308
G. Manfro et al.
Transoperative Complications
Bleeding
This is the most frequent complication, affecting between 1% and 37% of cases [3].
Most of the time the bleeding is minor, without hemodynamic repercussions for the
patient (Fig. 1). it usually occurs due to failure of vessel exposure and exacerbated
traction on these structures, especially the anterior jugular veins and inferior thyroid
veins (Fig. 2).
The treatment of this kind of bleeding normally is done with hemostatic maneuvers with suturing or electrocauterization.
Pneumothorax
This occurs by inadvertent injury of the apical pleura (Fig.3), which is more easily
exposed in patients who are on mechanical ventilation. In addition, this pleural segment is more exposed in children, which increases the risk of this complication from
4% in adults to up to 17% in children [3, 4].
To diagnose this complication, it is necessary to perform a chest X-ray after the
tracheostomy [3, 4].
Another cause of pneumothorax is the placement of the cannula on a false path
anteriorly and laterally to the trachea (Fig.4).
Fig. 1 A small bleeding posttracheostomy treated with surgical re-exploration and bleeding suture
Tracheostomy Complications
Fig. 2 Red arrow: inferior thyroid vein;
yellow arrow: anterior jugular vein (anterior
jugular arch)
309
Fig. 3 (a) Brachiocephalic trunk.
(b) Trachea. (c) Right carotid common
artery. (d) Right subclavian artery.
(e) Right apical pleura
310
Fig. 4 (a) Trachea.
(b) Brachiocephalic trunk.
(c) Brachiocephalic vein.
(d) Tracheal cannula (false
path between brachiocephalic
trunk and brachiocephalic vein)
G. Manfro et al.
Esophageal Perforation
This iatrogenic lesion is rare, occurring in fewer than 1% of cases, and should be
treated immediately, with suturing in two planes, in addition to diversion of food
intake with nasoenteric feeding. Late diagnosis of this complication signicantly
worsens the prognosis, based on the risk of mediastinitis [3, 4].
Normally it happens with lateral traction of the trachea, exposing the anterior
wall of the esophagus, confusing the muscular esophagus wall with the strap muscles, which could resulting in a surgical esophagus injury (Figs.5 and 6).
Recurrent Laryngeal Nerve Injury
This occurs during lateral dissection of the trachea, and happens more easily when
it is deviated. This complication usually is diagnosed after decannulation, with signicant dysphonia and changes in swallowing with aspiration of varied intensity,
and is conrmed by laryngoscopy examination. This neural decit may be denitive
or temporary [5, 6].
Cardiopulmonary Resuscitation
Several factors can result in cardiorespiratory arrest during the performance of a
tracheostomy: delay in airway clearance, cardiac arrhythmia, vagal stimulation,
hypertensive pneumothorax, postobstruction pulmonary edema, and excessive inhalation of oxygen in patients with chronic hypercarbia [3, 7].
Tracheostomy Complications
Fig. 5 Normal exposure
during a tracheostomy. The
trachea is in a central position
311
Fig. 6 Lateral tracheal
retraction with anterior
esophagus wall exposure
312
G. Manfro et al.
Pneumomediastinum
This occurs more often in children and is usually diagnosed on routine chest X-rays.
This complication can be caused by dissection of the paratracheal soft tissues, especially in cases of excessive respiratory effort and also when accompanied by cough.
In most cases, pneumomediastinum is asymptomatic and does not require
treatment [8].
Combustion
This rare complication can be a catastrophic event. The use of electrocautery on a
surface that has received an alcoholic solution, in the presence of oxygen in a high
concentration, may result in ideal conditions for the occurrence of severe burns.
Care should be taken to avoid this complication; however, if it occurs, treatment
should be instituted to minimize the complications of airway burns, such as antibiotics, intravenous uids, and corticosteroids [8].
Late debridement will be necessary in the following days to avoid secondary
infection of the burned tissue.
Early Complications
Cannula Obstruction
The presence of mucous secretions or blood clots can occur frequently and immediately after performing the tracheostomy. This can be avoided by using proper
humidication and frequent aspiration of the tracheostomy. To avoid complete
obstruction of the cannula, the use of a prosthesis with an inner cannula is essential,
otherwise replacement is indicated [8].
Displacement of the Tracheostomy Tube
The earlier this occurrence happens, the more serious a complication it can be. In
the immediate postoperative period, the peritracheal soft tissue does not present
brosis. Then there is no dened path between the skin and the trachea, and immediate recannulation could be difcult to perform. Decannulation more frequently
occurs in patients without favorable anatomy such as obesity, agitated patients, or
those with a severe cough. Incorrect cannula xation and inappropriate dressing
may also facilitate the occurrence of this complication.
One of the clear signs of cannula displacement is the possibility of the patient
speaking even with a tracheostomy.
For the repositioning of the cannula, a suture in the tracheal ring can help in the
exposure of the tracheal orice. In cases where repositioning of the cannula is not
Tracheostomy Complications
313
possible, the orotracheal tube should be replaced, following by posterior repositioning of the tracheostomy cannula [8].
Bleeding
In the early postoperative period the source of bleeding would be the same as that in
the transoperative period (see Sect. 1.1). Cases of major bleeding should be surgically re-explored [8].
Surgical Wound Infection
Colonization of the tracheal wound occurs within the rst 48h after surgery. The
main colonizing germs are Gram positive bacteria, Pseudomonas, and Escherichia
coli. Because it is an open operative wound, colonization is inevitable, but some
maneuvers are important for reducing the risks of major infectious complications,
such as frequent cannula replacement, removal of the tracheal ring suture, and minimal devascularization of peritracheostoma and tracheal tissue, avoiding lateral tracheal dissection.
Necrotizing stoma infection is an uncommon complication; however, it presents
a high rate of serious complications such as exposure of large vessel ruptures
(Fig.7). Treatment should be performed with antibiotic therapy whenever possible,
guided by cultures and debridement of devitalized tissue [8].
Subcutaneous Emphysema
Accumulation of air in the subcutaneous space usually is not very serious, requiring
no treatment at all. The cause of this complication may be excessive cough, a cannula
without a cuff, or near-total obstruction of the skin around the cannula. Usually the
treatment is cannula replacement with a cuffed cannula or correct cuff ination [8].
Fig. 7 Sternotomy approach
for a brachiocephalic trunk
rupture due to tracheostomy
infection