Tracheostomy-related bleeding and stomal complications: a literature review

Abstract

Background and Objective

Tracheostomy is one of the most commonly performed procedures in critically ill patients, with bleeding representing the most frequent early complication. Stomal bleeding and granulation tissue formation create ongoing management challenges that can complicate patient care. Other complications include stomal infection, subcutaneous emphysema, focal airway stenosis, and tracheoinnominate fistula (TIF), which differ in clinical severity and management. Current management relies on reactive measures, yet no standardized approach exists for preventing or managing persistent minor bleeding around the tracheostomy site. This study aims to review the incidence, pathophysiology, risk factors, and current management of tracheostomy-related bleeding and stomal complications, with emphasis on identifying gaps in prevention and treatment strategies.

Methods

We conducted targeted literature searches using PubMed/MEDLINE for English-language human studies published between January 1, 2000 and September 17, 2026 involving adults aged 19 years or older. Search terms included “tracheostomy”, “tracheotomy”, “bleeding”, “hemorrhage”, “granulation tissue”, “tracheoinnominate fistula”, “stomal infection”, “cellulitis”, “abscess”, “decannulation”, “dislodgement”, “subcutaneous emphysema”, “tracheal stenosis”, “ECMO”, “transplantation”, “immunosuppression”, “tranexamic acid”, “epinephrine”, and “cautery”. We extracted data on incidence rates, management approaches, and clinical outcomes.

Key Content and Findings

Bleeding is the most common early complication of tracheostomy procedures, occurring in 0.6–5.0% of cases overall, with rates reaching 5.7% for major or minor bleeding and up to 40% in high-risk populations such as patients on extracorporeal membrane oxygenation (ECMO). Stomal infections, airway complications, and early accidental decannulation is also important to consider in tracheostomy patients. Subcutaneous emphysema was primarily associated with early mechanical complications, whereas focal airway stenosis represented a later consequence of granulation. Management of minor superficial bleeding generally consisted of direct pressure, packing, correction of reversible coagulopathy, and selected topical or cautery-based interventions. TIF remained distinct from these complications because even limited or transient bleeding may precede catastrophic hemorrhage, necessitating urgent recognition and escalation when a vascular source is suspected.

Conclusions

Tracheostomy-related bleeding and stomal oozing represent common complications with limited preventive options. Current management is reactive, relying on manual pressure application, packing materials, and procedural interventions. Particular attention should be made to distinguish minor superficial bleeding from sentinel or life-threatening hemorrhage. Novel approaches could potentially reduce bleeding complications, minimize granulation tissue formation, and improve patient comfort during the critical early post-tracheostomy period.

Introduction

Tracheostomy is a commonly performed procedure in intensive care settings, particularly for patients who require prolonged ventilatory support or airway protection. Although generally considered safe, it is associated with a range of complications that may arise either early or later in the clinical course (1,2). Bleeding, misplacement of the tube, pneumothorax, posterior wall injury, tracheal stenosis, infection, and tracheoesophageal fistula are some of the common complications with tracheostomies, with bleeding as the most frequently encountered early complication. Reported rates of bleeding typically range from 0.6% to 5.0%, although this likely underestimates the true incidence since minor bleeding is often managed without formal documentation (3,4). When both minor and major bleeding are considered, the rate approaches around 5.7% (5). In higher-risk populations, especially patients requiring extracorporeal membrane oxygenation (ECMO), the incidence increases significantly, with some reports approaching 40% (6). Clinically, bleeding presents across a broad spectrum. Some patients experience mild but persistent oozing that complicates routine care, while others may develop severe complications such as tracheoinnominate artery fistula, which carries a high mortality rate even with intervention (7,8).

Between these extremes lies a substantial group of patients with ongoing low-grade bleeding that is difficult to manage but not severe enough to require immediate surgery. The timing of bleeding can offer insight into its cause. Early bleeding, generally within 48–72 hours, is often related to superficial venous injury, incomplete hemostasis, or early granulation tissue formation. As perioperative vasoconstriction subsides, previously compressed vessels may begin to bleed (3,9). At the same time, the presence of the tracheostomy tube triggers an inflammatory response, leading to early granulation tissue formation, which is highly vascular and can result in bleeding (10,11). Later bleeding, occurring after several days, raises different concerns, including persistent granulation tissue, infection, and tracheoinnominate fistula (TIF), which is a surgical emergency. Notably, many cases are preceded by a “sentinel bleed”, a brief episode that may initially appear benign but can signal impending catastrophic hemorrhage (7,8). One of the key contributors to bleeding is granulation tissue. Although part of normal healing, excessive granulation can contribute to persistent bleeding and airway-related issues (10-13). Current treatments are largely reactive and may themselves contribute to additional tissue irritation. In other areas of medicine, controlled compression is a well-established method for promoting hemostasis and supporting wound healing. However, this concept has not been systematically applied to tracheostomy care.

Stomal infection represents another important complication of tracheostomy. The tracheostomy wound is considered clean-contaminated and is continuously exposed to respiratory secretions, increasing susceptibility to local infection (2,8). Superficial infection commonly presents as cellulitis with erythema, edema, induration, tenderness, and sometimes purulent drainage; local wound care and antimicrobial therapy are generally used, with cultures helping guide treatment when drainage is present (2,8). Deeper infectious complications, including abscess formation, are less common but should be considered when there is fluctuance, progressive swelling, systemic illness, or failure of superficial infection to improve; these cases may require drainage or other source control in addition to antimicrobial therapy (2,8,14). Severe infection can rarely progress to necrotizing soft-tissue infection and require aggressive antimicrobial therapy and surgical debridement (2,8). Distinguishing uncomplicated cellulitis from a deeper abscess or progressive infection is therefore important when evaluating a painful, erythematous, or draining tracheostomy stoma (2,8,14).

Other important early and late complications include accidental decannulation, subcutaneous emphysema, and focal airway stenosis. Early decannulation is particularly concerning before maturation of the tracheostomy tract because attempted reinsertion may create a false passage and result in loss of a secure airway (2,9,15). Subcutaneous emphysema can occur when air dissects into surrounding soft tissues, including with tube malposition, obstruction, or tissue injury, and progressive cases should prompt assessment of tube position and associated thoracic complications (2,9,12). Focal tracheal or airway stenosis is generally a later complication related to granulation, scarring, or pressure-related mucosal injury and may present with progressive dyspnea, stridor, or difficulty with decannulation (2,9,11).

Beyond the immediate issue of blood loss, tracheostomy-related bleeding has broader implications. It can increase patient discomfort and anxiety, complicate care, and place additional demands on healthcare staff. Frequent dressing changes and monitoring increase workload, while blood tracking into the airway raises the risk of aspiration and respiratory complications (15-18).

Despite its frequency, management remains inconsistent. Most approaches rely on clinician judgment and available tools, including manual pressure, packing, and topical agents (3). These methods can be effective in the short term but are often labor-intensive and provide only temporary control. Importantly, management depends on the underlying etiology and severity of bleeding, and minor superficial stomal oozing must be distinguished from sentinel or life-threatening hemorrhage requiring urgent evaluation (7,8). The lack of standardized approaches to the evaluation and management of tracheostomy-related bleeding and associated stomal complications represents a significant gap in current care. This review summarizes the incidence, pathophysiology, risk factors, clinical presentation, and current management of tracheostomy-related bleeding and associated stomal complications, including granulation tissue, stomal infection, early decannulation, subcutaneous emphysema, focal airway stenosis, and TIF, while highlighting current limitations and opportunities for improved treatment strategies. We present this article in accordance with the Narrative Review reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1891/rc).

Methods

A structured narrative literature review was conducted using PubMed/MEDLINE for English-language human studies published between January 1, 2000 and September 17, 2026 and involving adults 19 years or older. Eight targeted searches were performed using combinations of terms including “tracheostomy”, “tracheotomy”, “bleeding”, “hemorrhage”, “granulation tissue”, “tracheoinnominate fistula”, “stomal infection”, “cellulitis”, “abscess”, “decannulation”, “dislodgement”, “subcutaneous emphysema”, “tracheal stenosis”, “ECMO”, “transplantation”, “immunosuppression”, “tranexamic acid”, “epinephrine”, and “cautery” (Table 1). The searches yielded 547 records and 515 unique records after removal of 32 duplicates. Following relevance assessment and supplementary reference review, 27 sources were included in the final narrative synthesis.

Table 1. Search strategy summary.

Items	Specification
Date of search	February 11–14, 2026 and September 17, 2026
Databases searched	PubMed/MEDLINE
Search terms used	“Tracheostomy”, “tracheotomy”, “bleeding”, “hemorrhage”, “granulation tissue”, “tracheoinnominate fistula”, “stomal infection”, “cellulitis”, “abscess”, “decannulation”, “dislodgement”, “subcutaneous emphysema”, “tracheal stenosis”, “ECMO”, “transplantation”, “immunosuppression”, “tranexamic acid”, “epinephrine”, and “cautery”
Timeframe	January 1, 2000–September 17, 2026
Inclusion and exclusion criteria	Inclusion: English-language studies and adults aged 19 years or older were included. Original studies, observational studies, reviews, and guideline or consensus publications addressing tracheostomy-associated bleeding, risk factors, complications, evaluation, or management were included
	Exclusion: pediatric-only studies, non-English publications, studies before 2000, and publications without relevance to tracheostomies or bleeding
Selection process	Titles and abstracts were identified through literature search and potential articles were assessed for inclusion. The authors of this manuscript screened through the articles

ECMO, extracorporeal membrane oxygenation.

Studies addressing the incidence, risk factors, presentation, management, or outcomes of tracheostomy-related bleeding and stomal or airway complications were considered. Search filters were limited to humans, adults aged 19 years or older, and English-language publications. Pediatric-only studies and articles without relevant complication data were excluded. Case reports were considered for uncommon complications when higher-level evidence was limited. Additional relevant sources, including older literature, were identified through targeted supplementary searches and reference review. Data on incidence, risk factors, management, and outcomes were extracted. Given heterogeneity in study design and reporting, study quality was considered descriptively, and findings were synthesized narratively rather than through formal meta-analysis.

Results

Bleeding remains the most common early complication following tracheostomy, with reported incidence ranging from 0.6% to 5.0% (3,4). When minor and major events are combined, rates increase to approximately 5.7% (5). These figures likely underestimate the true prevalence, as minor oozing is frequently managed without formal documentation. Rates vary depending on patient population. Risk is influenced by both patient- and procedure-related factors. Anticoagulation, thrombocytopenia, and critical illness may increase bleeding risk, while local factors such as tube movement and pressure can increase bleeding risk as well (5,7). Patients receiving ECMO, for example, experience significantly higher rates, with one study reporting a 40% incidence of bleeding, including both minor and significant cases (6). Most bleeding events are mild and manageable with local measures (3,6). Moderate bleeding requiring procedural intervention occurs in roughly 5% of cases (8). Major bleeding, typically associated with TIF, is rare (<1%) but carries high mortality (7,8).

Granulation tissue formation is common and represents a normal component of wound healing (19). However, in some patients it becomes excessive and clinically problematic. Contributing factors include mechanical irritation, infection, poor wound healing, and prolonged tracheostomy duration (11,12,20,21). Collectively, these findings show that tracheostomy-related bleeding and stomal complications are not uncommon. Bleeding rates can vary substantially according to patient population and clinical setting, with particularly high rates observed in high-risk populations.

The impact extends beyond blood loss. Even relatively minor but persistent oozing can complicate routine care, increase nursing workload, and create anxiety for patients and families. It can also delay planned steps such as tube changes or decannulation. In more serious cases, bleeding may serve as an early warning sign of a larger underlying issue. Granulation tissue adds another layer of complexity by contributing to ongoing bleeding, discomfort, and, in some cases, mechanical obstruction. While current management strategies can be effective, they often require repeated interventions and lack consistency.

Stomal infection

Stomal infection is an important nonhemorrhagic complication and should be distinguished by depth and severity. The stoma is a clean-contaminated wound exposed to respiratory secretions, and superficial cellulitis may present with erythema, induration, tenderness, edema, or purulent drainage (2,8). Uncomplicated cellulitis is generally treated with local wound care and antimicrobial therapy, with culture-directed treatment when purulent drainage is available (2,8). Deeper abscess formation is less common but should be suspected with fluctuance, progressive swelling, systemic toxicity, or failure of superficial infection to improve and may require drainage or other source control in addition to antibiotics (2,8,14). Rare necrotizing infection requires urgent broad antimicrobial therapy and surgical debridement (2,8).

Early or accidental decannulation

Accidental decannulation can rapidly become an airway emergency, particularly during the early post-tracheostomy period before the tract has matured. Reinsertion through an immature tract can create a false passage, leading to ineffective ventilation, soft-tissue air, and loss of the airway (2,9,15). Immediate priorities are oxygenation, recognition of tube displacement, and restoration of a secure airway; management depends on the age of the tract, patient anatomy, and local expertise (2,15).

Subcutaneous emphysema

Subcutaneous emphysema is usually an early complication and reflects escape of air into the cervical soft tissues. It may occur with tube malposition, obstruction, tissue injury, or conditions that prevent adequate egress of air around the tracheostomy (2,9,12). Mild cases may resolve after correction of the underlying problem, whereas progressive emphysema should prompt assessment of tube position and evaluation for associated pneumothorax, pneumomediastinum, or airway injury (2,9,12).

Focal airway stenosis

Tracheal or focal airway stenosis is generally a later complication and may occur at the stoma, cuff site, or tube tip as a consequence of granulation tissue, fibrosis, or pressure-related mucosal ischemia (2,9,11). Patients may develop progressive dyspnea, stridor, difficulty tolerating capping, or failure of decannulation. Evaluation commonly requires airway visualization and/or imaging, while treatment depends on severity and may include endoscopic management or surgical reconstruction (2,9,11).

TIF

While much of the discussion focuses on minor and moderate bleeding, it is essential to recognize the rare but life-threatening complication of TIF. Although uncommon, it carries extremely high mortality and requires immediate recognition. TIF results from erosion of the tracheal wall into the innominate artery, most often due to prolonged mechanical irritation or pressure from the tracheostomy tube (6,7). Risk factors described in the literature include low tracheostomy position, excessive cuff pressure, infection, radiation, and anatomic or mechanical factors (6,7,22). A small sentinel bleed may precede catastrophic hemorrhage; therefore, delayed or unexplained bleeding should not automatically be treated as routine stomal oozing (6,7,21). When TIF is suspected, airway and hemorrhage control take priority, with immediate escalation for definitive surgical or endovascular management (7,21). Temporizing maneuvers may include cuff hyperinflation and digital compression while definitive treatment is mobilized (21).

High-risk populations

Patients receiving ECMO warrant particular attention because systemic anticoagulation, thrombocytopenia, platelet dysfunction, and critical illness can increase the frequency and persistence of stomal bleeding; the existing ECMO literature in this review reports bleeding rates substantially higher than those in general tracheostomy populations (5). Post-transplant patients represent a population of particular interest because immunosuppression and other transplant-related factors may affect infection and wound-healing risk; however, tracheostomy-specific evidence remains limited (23). A study of solid-organ allograft recipients found that percutaneous tracheostomy was generally well tolerated, with clinically significant bleeding uncommon and no infectious complications in that cohort (23). This limited and mixed evidence should be presented cautiously rather than assuming transplant status independently increases tracheostomy bleeding.

Management of minor and persistent stomal bleeding

Management should first be guided by bleeding severity and suspected source. Minor superficial oozing may be managed with direct pressure, correction of reversible coagulopathy, local packing, and topical hemostatic measures (2,8,24). Granulation tissue can be treated with silver nitrate or cautery when appropriate (8,13,24). Additional local hemostatic approaches described in practice include topical or gauze-applied tranexamic acid (TXA) and local epinephrine; however, direct comparative evidence specific to tracheostomy stomal bleeding remains limited (24,25). Persistent or recurrent bleeding despite local measures should prompt reassessment for granulation tissue, infection, tube trauma or malposition, systemic coagulopathy or anticoagulation, and a vascular source such as TIF (24).

Proposed workup and treatment approach

Given the limited comparative evidence, a practical severity-based approach may improve clinical consistency. Any pulsatile, high-volume, recurrent, or otherwise concerning delayed bleed should trigger urgent evaluation for a vascular source and escalation for airway and hemorrhage control (6,7,21,26). In a stable patient with clearly superficial minor oozing, the stoma can be inspected for a focal source, granulation tissue, infection, tube trauma, or malposition while reversible coagulopathy is assessed. Initial local measures can include direct pressure and packing, followed by an appropriate topical or cautery-based intervention when a superficial source is identified (2,8,24). Failure of local control, recurrent bleeding, airway bleeding, hemodynamic change, or uncertainty about the source should prompt specialist evaluation and consideration of bronchoscopy, imaging, or operative exploration according to the clinical scenario (21,26). This proposed algorithm reflects synthesis of available literature and clinical practice principles and has not been prospectively validated.

Discussion

Tracheostomy-related bleeding and stomal complications are common and clinically significant. Presentations range from minor, persistent oozing to rare but life-threatening hemorrhage. These results emphasize that these presentations should not be treated as a single entity. Superficial stomal bleeding, anticoagulation-associated bleeding, granulation tissue, infection, and TIF differ in etiology, urgency, and management. Early decannulation, subcutaneous emphysema, and focal airway stenosis also further demonstrate the need to evaluate tracheostomy complications according to timing and mechanism rather than within one bleeding framework. This broad clinical spectrum highlights the importance of effective and consistent management strategies. Current management remains largely reactive, relying on pressure, packing, cautery, and surgical intervention when necessary.

While these approaches can be effective, they are often inconsistent, labor-intensive, and provide only temporary control. Much of current management is adapted from general wound care principles, such as pressure, packing, and cautery, rather than approaches specifically designed for the tracheostomy site. As a result, clinicians often rely on tools that were not intended for this unique anatomical setting. Controlled compression remains a potential concept for persistent minor superficial bleeding, but its benefits around a tracheostomy stoma have not been demonstrated in clinical studies. In many areas of medicine, controlled compression is a well-established method for promoting hemostasis and supporting wound healing (27). Any proposed device would require preclinical testing followed by prospective feasibility and safety evaluation before clinical claims could be made. Potential harms of sustained circumferential pressure include pressure injury, skin or soft-tissue necrosis, tube displacement, airway compromise, impaired access to the stoma, and delayed recognition of significant or sentinel bleeding. Accordingly, compression should be framed as an investigational future direction rather than an established preventive or therapeutic strategy.

Furthermore, most current approaches to granulation tissue are reactive, focusing on removal or treatment after formation. While interventions such as cautery or debridement can be effective, they often require repetition and may contribute to further irritation. Some evidence suggests that prevention is possible. Routine tube changes, for example, have been associated with reduced granulation tissue formation (13), highlighting the importance of minimizing chronic irritation.

Several limitations of this review should be acknowledged. Although the search was structured, this remains a narrative review rather than a formal systematic review or meta-analysis. Included evidence is heterogeneous in study design, population, tracheostomy technique, definitions of minor and major bleeding, and reported outcomes. Much of the management literature is observational or based on expert practice, and comparative trials of individual local hemostatic strategies are limited. Evidence is also sparse for some high-risk groups, including transplant recipients, and there are no clinical studies establishing the safety or efficacy of prophylactic circumferential compression around the tracheostomy stoma. Publication and selection bias may therefore influence the synthesis.

Future research should focus on establishing clearer definitions of bleeding severity, improving risk stratification, comparing existing management techniques, and developing standardized approaches to bleeding and complications. Additional studies are needed to compare commonly used local hemostatic interventions, including pressure, packing, topical agents, cautery, and other bedside measures, as direct comparative evidence remains limited. Further investigation is also needed in high-risk populations, including patients receiving ECMO, anticoagulated patients, and transplant or immunosuppressed populations, in whom bleeding and wound-related risks may differ from the general tracheostomy population. Compression-based interventions may also warrant investigation as a potential strategy for persistent minor superficial stomal bleeding; however, their clinical benefit needs to be evaluated for safety, including pressure-related tissue injury, tube stability, and airway compromise, before assessing efficacy in prospective clinical studies. There is also a need for better methods to detect TIF earlier, whether through biomarkers, imaging, or clinical algorithms. Collectively, these efforts could contribute to more proactive, standardized, and effective management of tracheostomy-related bleeding.

Conclusions

Tracheostomy-related bleeding and stomal complications remain important challenges in critically ill patients, ranging from minor superficial oozing to rare but life-threatening hemorrhage. Management should be guided by the timing, severity, and suspected etiology of bleeding, with careful distinction between superficial stomal bleeding and concerning presentations such as sentinel bleeding from TIF. Although local pressure, packing, topical hemostatic agents, and procedural interventions remain the mainstay of treatment, comparative evidence supporting individual strategies is limited. Further research is needed to establish standardized management approaches, better define outcomes in high-risk populations, and evaluate the safety and efficacy of emerging strategies for persistent stomal bleeding.

Supplementary

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Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.