Surgical airways carry inherent risks, and managing potential complications is essential for successful outcomes. Anesthesia providers must be prepared to identify and manage these complications in real time to ensure patient safety.
Bleeding
Bleeding is one of the most common complications associated with surgical airways due to the highly vascularized structures in the neck. While minor bleeding can be controlled with direct pressure, more significant hemorrhage may require surgical intervention or transfusion. Early bleeding usually comes from the anterior jugular veins, the thyroid isthmus, or the cricothyroid artery. Late bleeding, typically one to six weeks after tracheostomy, raises concern for a tracheoinnominate artery fistula: a brief sentinel bleed may precede exsanguinating hemorrhage, and the immediate response is to overinflate the cuff or pass a finger through the stoma to compress the artery against the sternum while the patient goes for definitive repair.
Clinical Example: A patient undergoing percutaneous tracheostomy develops bleeding from the incision site. The bleeding is managed with direct pressure, and the patient’s coagulation profile is reassessed to rule out any underlying clotting abnormalities.
Infection
Infections are a potential risk following surgical airway placement, particularly in patients with prolonged tracheostomy tubes. Strict adherence to sterile technique during the procedure and meticulous post-procedure care are critical to minimizing the risk of infection.
Clinical Example: A patient with a tracheostomy develops fever and purulent drainage from the surgical site. Cultures are taken, and broad-spectrum antibiotics are initiated pending the results. The tracheostomy site is cleaned and redressed regularly to prevent further infection.
Subcutaneous Emphysema
Subcutaneous emphysema occurs when air leaks into the tissue surrounding the surgical airway site. This can result from incorrect placement of the tracheostomy tube or obstruction of the tube itself. Subcutaneous emphysema is identified by palpation of crepitus in the neck and must be addressed immediately to prevent further complications.
Clinical Example: A patient with a tracheostomy presents with subcutaneous emphysema, evidenced by swelling and crepitus in the neck. The tracheostomy tube was found to be malpositioned and corrected, resolving the issue.
Tracheal Stenosis
Tracheal stenosis is a long-term complication associated with tracheostomy tubes. The narrowing of the trachea can result from prolonged mechanical ventilation and pressure from the tracheostomy tube or an overinflated cuff. Keeping cuff pressure between 20 and 30 cm H2O preserves mucosal perfusion while still sealing the airway; pressures above about 30 cm H2O cause mucosal ischemia that heals with scar and stenosis. Tracheal stenosis may require surgical intervention if it impedes the patient’s ability to wean from mechanical ventilation.
Clinical Example: A patient with a prolonged tracheostomy develops difficulty weaning from mechanical ventilation due to suspected tracheal stenosis. A bronchoscopy confirms the diagnosis and surgical correction is scheduled to address the stenosis and facilitate weaning.
