It is estimated that late complications occur in up to 2/3 of patients with a tracheostomy tube.  Accidental decannulation may have either no consequences (the patient was ready for decannulation and is able to maintain their own airway) or may have life threatening consequences (respiratory failure).  In either case being prepared and assessing the patient is important to know which path of action to take.

Extra equipment should be available at the bedside in case the primary tracheostomy tube is unable to be replaced back into the stoma. A tracheostomy tube that is 1 size smaller than the indwelling tracheostomy tube should be available.

Aspiration

Often aspiration is a silent event meaning that it is not recognized  immediately by care givers.  Pneumonia can occur as a result of aspiration.  Patients with tracheostomy tubes are predisposed to aspiration.  Cuff overinflation can be a cause of aspiration if the overinflation compresses on the esophagus.  A formal swallow study should be performed if oral nutrition is contemplated.  Continued close monitoring and swallow precautions should happen with oral intake.

Bleeding

There are a few sites where bleeding can occur.  Stomal bleeding can be caused by movement of the tracheostomy tube inside the stoma.  Bleeding from trauma such as during a tracheostomy tube change can occur.  Vigorous suctioning has to potential to cause bleeding from the carina. Take care to properly measure and gently suction.

Tracheosophageal fistula

Tracheosophageal fistula is another complication that can occur due to an over inflated cuff and the excessive cuff pressure or tip of the tracheostomy but causing posterior tracheal wall injury.  Over time and tracheal wall can erode causing a communication between the trachea and the esophagus.  A surgical fix or a double stent (trachea and esophagus) are the possible repairs.

Tracheoinnominate-artery fistula

Erosion of the tracheoinnominate-artery is due to an over inflated cuff or a distal end of a tracheostomy tube with excessive movement or placed too low in the trachea.  Mortality of this condition is close to 100% in individuals who develop this condition.  Suspicion and monitoring are ways to avoid this condition.  If a patient has fresh bleeding from the trachea site one should proceed with further investigation.  This will usually involve transfer to a hospital and bronchoscopy.

Stenosis

Granulation tissue can form at the level of the stoma and also develop in and around fenestrated tracheostomy tubes causing significant difficulty with tracheostomy tube changes and decannulation.

There are a number of risk factors are associated with stomal stenosis:

1. Sepsis
2. Stomal infection
3. Hypotension
4. Advanced age
5. Male sex
6. Steroids
7. Tight-fitting or oversized cannula
8. Excessive tube motion
9. Prolonged placement
10. Disproportionate excision of anterior tracheal cartilage during the creation of the tracheostomy

Tracheal stenosis its at the site of tracheal-tube cuff is caused by over inflation of the cuff over a long period of time.  The cuff exceeds the perfusion pressure in the trachea and causes decreased tracheal blood flow and ischemia. Prolonged ischemia may bring mucosal ulceration, chondritis, and cartilaginous necrosis.  Pooled secretions or gastroesophageal reflux may be exacerbate this process.  Granulation tissue forms over time leading to airway obstructions.

The risk factors associated with Tracheal-tube cuff related stenosis are:

1. Female sex
2. Advanced age
3. Prolonged tube placement
4. Excess cuff pressure

Tracheomalacia

Tracheomalacia (softening of the trachea) is a weakening of the tracheal wall.  Ischemic injury followed by chondritis and subsequent destruction and necrosis of the sporting tracheal cartilage. Once the cartilage is weakened the supporting structure of the trachea is lost and normal pressures exerted through breathing can collapse the trachea.  Tissues around the trachea may also push against the weakened area and cause obstruction.

Tracheal stenosis and tracheomalacia develop over time.  Post acute settings afford the luxury of time for patients to develop these processes.  The vigilant daily cares and strict routines can help to avoid these conditions.  Attentiveness to slight changes in the respiratory status may give clues to the development of tracheal stenosis and tracheomalacia. Further diagnostic work will confirm the presence of either one with bronchoscopy.