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Massive Airway Bleeding and a Recent Tracheostomy
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Larry Mellick, MD, MS, FAAP, FACEP
Professor of Emergency Medicine
Medical College of Georgia
Ryan Johnson, MD
Emergency Medicine Resident
Medical College of Georgia
Pearl: In patients presenting with a tracheostomy and hemoptysis, consider this potentially fatal cause of airway bleeding.
Presentation: A 64 year old male and long-term care facility resident secondary to a cerebrovascular accident (CVA) and tracheostomy presents to the emergency department for evaluation of dyspnea and hemoptysis. His initial vital signs are heart rate 120 beats per minute, blood pressure 100/80 torr, respiratory rate 26 per minute, Temperature 37.1 Celsius and SaO2 was 93% on a FiO2 of 30%. The physical examination demonstrates bloody secretions coming from the tracheostomy tube. Assisted by the respiratory therapist, you begin to suction out the bloody secretions eminating from the tube. Upon closer examination of the stoma created 45 days ago, you observe that the gauze around the stoma is saturated with fresh blood. Unfortunately, the bleeding source is not easily or immediately localized. The patient's condition progressively worsens and decompensates with worsening hypoxia, tachycardia, hypotension and increased bleeding from inside and around the tracheostomy tube. You decide to orotracheally intubate the patient, but despite your attempts the patient has massive hemoptysis and succumbs with pulseless electrical activity (PEA). What was the source of the massive hemoptysis and what could have been done to stabilize this patient?
Diagnosis: Tracheoinnominate Artery Fistula
Discussion: Bleeding is the chief complaint in 20% of tracheostomy related emergency department visits and up to 10% of these visits are related to massive bleeding.1 Sources of tracheostomy bleeding include; superficial blood vessels at the tracheostomy site, granulation tissue, thyroid vessels, jugular veins, bleeding from the GI tract through a tracheoesophageal fistula, and innominate artery fistula.
The innominate artery is the first branch off of the aorta and divides distally into the right internal carotid and right subclavian artery. (For an illustration see source.) At the area of the superior thoracic inlet it crosses from left to right as it moves superiorly and lies anterior to the trachea.
Tracheoinnominate (TI) artery fistula occurs in up to 2% of patients with tracheostomies and has a mortality rate of up to 75%.1,2 Interestingly, 85% of all fistula bleeds occur within the first month after placement of a tracheostomy.3 Brisk bleeding, a "sentinel" or "herald" bleed, any history or evidence of 10 mL or more of blood, and hemoptysis should raise the clinical suspicion for an arterial fistula. (See Management of Tracheoinnominate Artery Fistula.)
Risk factors for development of this fistula include placement of a tracheostomy stoma below the 3rd or 4th tracheal ring, migration of the tracheostomy tube inferiorly because of pressure on the tube and high cuff pressures.4 All of these factors are believed to contribute to fistula development by compressing the anterior trachea into the innominate artery along with subsequent erosion and bleeding.
Emergency department management consists of slowing and controlling the hemorrhage until the fistula can be definitively managed in the operating room. If the patient is stable, visualization of the bleeding source can be attempted. Visualization is best accomplished by a fiberoptic nasopharyngoscope and even a pediatric laryngoscope blade can be inserted into the stoma. One method of controlling bleeding from a tracheoinnominate artery fistula is to compress the artery by hyperinflating the cuff of the tracheostomy tube. (Click here for an illustration.) If this fails, orotracheal intubation should be performed and the cuff of the tube should be positioned at the level of the upper sternum before hyperinflation. If these first two measures fail, hemostasis is attempted by inserting the index finger into the stoma (pointed caudally) and then putting traction against the anterior tracheal wall while compressing the anterior neck by "pinching" with the thumb. This method known as the Utley maneuver will still allow a partially open airway as the index finger does not totally obstruct the trachea. This method has been shown to be the most reliable method to control hemorrhage until definitive management can be accomplished.5
References:
- Hackeling T, Triana R, Ma OJ, Shockley W. Emergency Care of patients with tracheostomies: A 7 year review. Am J Emerg Med 1998;16(7):681-685.
- Lewis R. Tracheostomies: indications, timing, and complications. Clin Chest Med 1992(1):137-149. Review.
- Tayal V. Tracheostomies. Emerg Med Clin North Am 1994;12(3):707-727.
- Throp A, Hurt TL, Kim TY, Brown L. Tracheoinnominate artery fistula: a rare and often fatal complication of indwelling tracheostomy tubes. Pediatr Emerg Care 2005;21(11):763-766.
- Utley JR, Singer MM, Roe BB, Fraser DG, Dedo HH. Definitive management of innominate artery hemorrhage complicating tracheostomy. JAMA. 1972;220(4):577-579.
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