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

Purpose 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). Methods Relevant literature from 2000–2025 was reviewed using PubMed and surgical databases, focusing on studies describing tracheostomy-related hemorrhage and TIF. Results 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. Conclusions 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.