Table 3 Early and late post-PDT complications and management

Early (days 1–7)

Paratracheal placement and posterior wall injury (ventilation problems and high pressure alarms)

Reposition the tube

Avoid excessively deep introduction of the dilator into the airway, excessive downward force when advancing the tracheostomy-loaded dilator, and maintaining a flush fit of the tracheostomy tube to the dilator

Malpositioned tubes causing airway obstruction (possible with tapered percutaneous tube tips) manifests as pressure alarms or acute dyspnoea and may be indistinguishable from mucus plugging (ventilation problems and high pressure alarms)

Exchanging the tube for another with a blunt tip opening

Rotation of the tube to bring the distal tip away from contact with the tracheal wall

Pneumothorax; errant needle puncture and barotrauma due to alveolar overdistention during the procedure are the most common causes

Immediate tube thoracostomy

-

Subcutaneous emphysema

Typically disappears within 24 hours

-

Bleeding (minor venous oozing)

Increased frequency of dressing changes; if bleeding persists, then silver nitrate can be applied to the wound edge for chemical cauterization

Preoperative correction of coagulopathy, and careful identification and control of bleeding points during the procedure; avoid overdilatation and creation of large stoma

Late (beyond day 7)

Subglottic stenosis

Interventional bronchoscopic techniques (cryoprobe therapy, Nd:YAG and argon plasma coagulation)

Maintain cuff pressure <30 cmH₂O

Unplanned decannulation

Keep decannuled or replace the tube. If airway is needed urgently, then perform immediate translaryngeal intubation. If there is no urgent need to secure the airway then the tracheostomy tube may either be guided into the trachea by bronchscopically observing the introduction from a translaryngeal vantage point, or the scope itself may be used as an introducer

Careful patient mobilization

Stomal infection

-

Limited disruption of tissue and minimal bleeding

Infections of lower respiratory tract

Early appropriate antibiotic

Early tracheostomy when indicated; reduction in bacterial colonization (aggressive aseptic tracheostomy care, proper nutrition, early treatment of infections)