Tracheostomy Crises

Loss of Airway

Tracheo-Innominate Fistula

Fistula between trachea and innominate artery occurring due to erosion from the tracheostomy tube or cuff, leading to catastrophic:

The Utley Manoeuvre involves digital compressing the innominate artery against the manubrium to reduce bleeding.

  • Place finger through stoma
    This may require lateral and inferior extension of the incision to gain access. Consider inserting a Foley catheter as an alternative.
  • Blunt dissect anterior to the tracheal wall to create a plane between the trachea and the innominate artery
  • Compress artery against manubrium
    Artery can be identified by pulsation.
Utley Manoeuvre

  • Airway soiling with arterial haemorrhage
  • Air entrainment and embolism
  • Death
    In over 90% of cases.

Tracheo-innominate fistula is a crisis. Priorities are:

  • Control haemorrhage and reduce airway soiling
    Methods:
    • Overinflate the tracheostomy cuff
    • Intubate from above
      May not be an option if the patient has had the laryngectomy.
    • Digital compression
  • Call a surgeon

A tracheo-innominate fistula is:

  • Rare, ~0.1-1%
  • Occurs between 3 days and 6 weeks following insertion
    Peak incidence 7-14 days.
  • Associated with various risk factors:
    • Procedural
      • Low insertion site or mediastinal tracheostomy
        Innominate artery at level of 9th tracheal ring.
      • Surgical tracheostomy
      • Hyperextension during insertion
    • Equipment
      • Over-inflated cuff
      • Anteriorly-curved tracheostomy tube
    • Patient
      • Poor wound healing
  • Proceeded by a herald bleed in 50% of cases1

Definitive management will be surgical:

  • May require a sternotomy, and cardiac surgery involvement
  • The innominate artery will usually be ligated due to the high risk of recurrent bleeding
  • Stenting the innominate may be an option, but is centre and skill-mix dependent
  • Aim SBP 120-140 post-operatively to minimising rebleeding

References

  1. Ailawadi, Gorav. “Technique for Managing Tracheo-Innominate Artery Fistula.” Operative Techniques in Thoracic and Cardiovascular Surgery 14, no. 1 (March 1, 2009): 66–72. .
    This has the excellent figure used in the margin note above.
  2. Donaldson, Lachlan, and Raymond Raper. “Successful Emergency Management of a Bleeding Tracheoinnominate Fistula.” BMJ Case Reports 12, no. 12 (December 2019): e232257. https://doi.org/10.1136/bcr-2019-232257.

  1. This terrifying case report begins:
    “Thirty days following the insertion of the original tracheostomy, small amounts of blood-stained secretions and tracheal aspirates were noted for the first time.

    Later that evening, spontaneous massive haemorrhage via the tracheostomy stoma, the tracheostomy tube and the mouth occurred.”↩︎