Tracheostomy-associated bleeding: prevention, recognition, and management of a potentially fatal complication

Tracheostomy-associated bleeding is an uncommon but potentially fatal complication. This review outlines its incidence, risk factors, diagnostic approach, management, and prevention, emphasizing early recognition of tracheo-innominate artery fistula (TIF).

Relevant literature from 2000-2025 was reviewed using PubMed and surgical databases, focusing on studies describing tracheostomy-related hemorrhage and TIF.

Post-tracheostomy bleeding occurs in 0.6-5% of patients, most often from minor stomal sources. TIF, though rare (<1%), remains the deadliest complication, with mortality over 60%. Major risk factors include low tracheostomy placement, excessive cuff pressure, infection, radiation, and anticoagulant use. Sentinel bleeding precedes 30-50% of TIF events and signals impending catastrophe. Diagnosis relies on prompt bronchoscopy and CT angiography. Management ranges from local control to endovascular or surgical repair. Preventive strategies-meticulous technique, cuff pressure monitoring, and multidisciplinary tracheostomy care-significantly reduce risk.

Early identification of sentinel bleeds, rapid airway control, and adherence to standardized protocols are crucial to prevent fatal hemorrhage. Continuous vigilance and team-based care can markedly improve outcomes in tracheostomy management.