Correspondence (letter to the editor): Pathogenesis Was Only Touched on

Klemm and Nowak in their article (1) mention hemorrhage as well as fatal complications of a tracheotomy, but they hardly discuss the pathogenesis. The most severe complications include arterial or aortic hemorrhages, which develop as a result of a mostly inflammatory fistula formation with erosion of the vascular wall. In one of our own postmortem examinations, a 42 year old deceased man had developed an aorto-tracheal fistula starting from the lower edge of the tracheal cannula after 2 months, with acute hemorrhage into the upper airway and fatal aspiration of blood. Such a complication has been mentioned in the literature (2), and there are other reports of further iatrogenic fistula formations with fatal hemorrhage after tracheotomy (3). A rupture of the vascular wall with acute hemorrhage should be regarded as a severe to unmanageable complication that will be fatal in most cases, even though the number of such deaths can only be estimated. A postmortem examination in every case would help to determine the cause. But in Germany—by contrast to the former German Democratic Republic—no catalog exists of indications for postmortem examination that includes deaths associated with medical interventions. Such a regulation was, for example, included into the Romanian code of criminal procedure in 2014 (4). It should be checked whether options exist to avoid fistulous inflammation with rupture of the aortic wall—for example, by redesigning the lower edge of the tracheal cannula (assuming that mechanical stimulation triggers the development of an inflammatory fistula).