When A, B, and C Collide: Tracheoinnominate Fistula Management

Case presentation:

62 y.o man with history of proximal paraesophageal mass compressing trachea, status post tracheostomy 1 month ago, presents to the ED with massive hemoptysis.

Question: How do you know where the bleeding is coming from and how do you manage the airway?

Summary of Evidence:

Anatomy refresher:
The innominate artery (also known as brachiocephalic artery) comes off the aortic arch and runs just superficial to the trachea and is deep to the left subclavian vein.
A tracheostomy is a hole created in the trachea and is indicated for a variety of reasons (5):
Bypassing upper airway stenosis/obstruction
Respiratory toilet
Prolonged mechanical ventilation
Airway protection
It takes about 7 days for tracheostomies to fully mature (5)
Like any surgical procedure, the tissue requires time to recover after trauma. In the case of a tracheostomy, the patency of the nascent stoma is supported by the presence of the trach tube itself while the tissue heals. Eventually the tissue heals enough to keep the stoma patent without the support of a trach.
The maturation stage of the tracheostomy is important as it helps the provider assess what potential complications may be present.
A nascent stoma has very friable tissue, leading to superficial bleeding. Conversely, a tracheostomy that has been in place chronically can lead to local structural damage that accrues slowly over time.
Common complications:

A tracheo-innominate fistula is an abnormal connection between the innominate artery and the trachea.
Due to the artery’s high pressure, large diameter, and difficult accessibility, the blood loss from the fistula puts the patient at high risk for rapid exsanguination and massive aspiration.
Risk factors (3, 4):
High tracheo-innominate artery
High cuff tracheal pressures leading to pressure necrosis and erosion through trachea
Prolonged intubation
Mucosal damage or breakdown
Incidence of tracheo-innominate fistula is 0.1-1% 7-14 days post procedure (1,3, 6)
Neck and airway anatomy is often difficult or distorted because of the pathology that necessitated tracheostomy in the first place, or because of surgical distortion of normal structures (4)

Recommendations:

Call for help from surgical specialties (ENT, cardiothoracic, and/or general surgery)
Evaluate ABC’s
Ask how long since the tracheostomy operation?
This will help you determine potential complications for which the patient is at risk (see table above)
For example, if immediately post-op, the trach could have lacerated the posterior soft tissue of the trachea
Conversely, if this patient has had the tracheostomy for a week or so, the site has had time to begin healing and the bleeding might be due to granulation tissue damage.
Is it a tracheostomy ONLY or is it a laryngectomy?
A laryngectomy is a procedure where the larynx is removed and obliterates any connection between the upper and lower airways.

This identifies if the airway is in continuity from the mouth to the trachea, and whether you will be able to salvage the airway from the oropharynx or not. The presence of a laryngectomy precludes the ability to intubate from the oropharynx because there simply is no connection between the oropharynx and the lower airway!
Thus, your only option to manage the airway is through the stoma.
Where is the bleeding coming from?
Look into the mouth, nose, upper airway
If possible, pass suction tubing through the stoma to suction out blood and assess for patency of the trach itself.
If there is a large amount of bleeding, suspect tracheo-innominate fistula until proven otherwise.
Management of tracheo-innominate fistula:
Step 1a: Hyperinflate the cuff of the trach to attempt tamponade of tracheo-innominate artery
Step 1b: If the trach is uncuffed or if bleeding does not stop, remove trach, replace with endotracheal tube with cuff maximally inflated, and attempt tamponade of brachiocephalic artery with your finger through the stoma.
Your finger must pass between the sternum and the trachea itself in order to adequately tamponade the innominate artery.

Ultimately, tracheo-innominate fistula requires surgical intervention - hence why you had better have called your surgical colleagues early!
If the bleeding is minimal and around the stoma site, exchange trach for a smaller size[JJ6] and manage bleeding as necessary while keeping potential for aspiration to a minimum.
The smaller trach size removes any pressure or friction imparted on the stoma that could be causing irritation and damage.

References:

1. Bradley PJ. Bleeding around a tracheostomy wound: What to consider and what to do? J Laryngol Otol. 2009;123(9):952-956.

2. Espeel B, Buron F, Lismonde M, Lambot D, Frederickx Y. Massive bleeding due to a brachiocephalic trunk erosion during a percutaneous tracheotomy. Intensive Care Med. 2006;32(6):943-944.

3. Grant CA, Dempsey G, Harrison J, Jones T. Tracheo-innominate artery fistula after percutaneous tracheostomy: Three case reports and a clinical review. British Journal of Anaesthesia. 2006;96(1):127-131. doi: https://doi.org/10.1093/bja/aei282.

4. Long B, Koyfman A. Resuscitating the tracheostomy patient in the ED. Am J Emerg Med. 2016;34(6):1148-1155. https://search-proquest-com.proxy.campbell.edu/docview/1797125170?accountid=146941. doi: http://dx.doi.org.proxy.campbell.edu/10.1016/j.ajem.2016.03.049.

5. McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary guidelines for the management of tracheostomy and laryngectomy airway emergencies. Anaesthesia. 2012;67(9):1025-1041.

6. Pilarczyk K, Haake N, Dudasova M, et al. Risk factors for bleeding complications after percutaneous dilatational tracheostomy: A ten-year institutional analysis. Anaesth Intensive Care. 2016;44(2):227.

7. Pool C, Goyal N. Operative management of catastrophic bleeding in the head and neck. Operative Techniques in Otolaryngology-Head and Neck Surgery. 2017;28(4):220-228. doi: https://doi.org/10.1016/j.otot.2017.08.006.