Question 14

1. Contributing factors
   • High pressure cuff (ideally < 20mmHg
   • Low tracheostomy – below the 3rd or 4th tracheal ring
   • Prolonged tracheostomy duration
   • Neck/chest deformity
   • Anomalous/high anatomic location of innominate artery
   • Prolonged use of steroids/immunosuppression
   • Localised infection

2. Clinical features
   • Bloody secretions/haemoptysis/haemorrhagic shock
   • Sentinel bleeding occurs in approximately 50% of patients, often pulsatile
   • Time frame is usually > than 48 hours since tracheostomy insertion Confirm diagnosis
   • Bronchoscopy –> bleeding from right anterior wall at site of 6/7 tracheal rings
   • Angio/CTA reveal blush from artery into trachea if appropriate to perform

3. Management of TIF (combination of call for help, resuscitate and try and stop bleeding awarded marks)
   • Call for senior assistance including ENT/Cardiac surgeon as appropriate for institution
   • Activate MTP/ensure blood products available
   • Secure airway and compress artery with cuff
     • Bronchoscopy to position tracheostomy (if able to advance) or replacement with ETT are acceptable
     • Adjust the depth of the tracheostomy/ETT to put cuff pressure over the bleeding site
     • Hyperinflate the cuff
   • If unable to compress artery with tube cuff, position ETT distal to bleeding to secure airway and provide digital pressure through the tracheostomy opening against the sternum to try and compress
   • Endovascular stenting or surgical ligation as definitive management

Examiners Comments:

This was not well answered overall with a poor knowledge of this complication demonstrated.

Discussion

Contributing factors to the formation of tracho-innominate fistula: 

• A particularly low tracheostomy
• Surgical tracheostomy where excessive dissection interrupts the blood supply
• Mediastinal tracheostomy
• Excessive tension on the tracheostomy (eg. where the tube selected is too short for the pre tracheal tissues)
• Unusual patient anatomy or behaviour, eg. an abnormal ectatic or tortuous trachea, or unusual patient posturing with frequently extreme neck extension (eg. cerebral palsy)
• Hyperextension of the neck during tracheostomy:  marked retraction of the head brings the innominate vessels closer to the level of the suprasternal notch
• A propensity towards poor wound healing: 
  • Prolonged episodes of hypotension
  • Extensive use of vasopressive agents
  • Radiation therapy to the neck
  • Steroid therapy
  • Protein malnutrition 
  • Localised infection at the insertion site
• Problems with the tracheostomy device:
  • Overinflated high pressure cuff
  • A tracheostomy tube which is excessively curved anteriorly (eg. a fixed 90 degree bend), or one which is tied or sutured in a way which angles it anteriorly.

Clinical features of tracheo-innominate fistula

• Airway bleeding is clearly the main feature. 
• A pulsatile tracheostomy tube is occasionally reported
• Infection around the site is an associated feature

Management of tracheo-innominate fistula

• First, overinflate the tracheostomy cuff. In their 2006 review, Grant et al  recommended overinflating the tracheostomy cuff as the optimal first line management, while waiting for the cardiac surgical team to prepare for theater. 
• Next, as the bleeding should be controlled well enough for you to set up for it, intubate the patient orally.  It may be necessary to do this in an emergency anyway, particularly if the blood is coming from the tracheostomy itself, rather than around it. To intubate the patient from above prevents soiling of the lower respiratory tract. Somebody should remove the tracheostomy just as you're advancing the ETT, i.e. at the very last minute. 
• Next, gain control of the haemorrhage by digital compression. This "Utley manoeuvre" (Utley et al, 1972) requires you to stick your index finger into the tracheal stoma, blunt-dissect down along the tracheal wall to separate the artery and the trachea, and put pressure on the innominate artery, compressing it up against the posterior wall of the manubrium. Just like this:
  
• Obviously, this is not going to be a particularly long-term solution. The person with their finger in the patient's mediastinum should get themselves into a comfortable position. They will remain in place until theatres are ready, and then they will escort the patient there. A full median sternotomy will usually follow. Most often, repair is not attempted, and the innominate artery is ligated and resected where it overlies the trachea, so that the arm is now perfused by retrograde flow from the right carotid.