My friend and kick@$$ flight clinician, Brian King (@BKing1453), recently finished the Speaker's Atlas Course. For his Capstone project, he recorded an amazing video and blog on managing the tracheoinomiate fistula. Watch his use of animations, engaging graphics, and vocal modulation!

Ladies & Gentlemen, I present ... Brian King.

A Bleeding Hole In The Neck w/ Brian King

If you are like me, you are thankful that a bleeding trach is a rare encounter. After all you are staring into a black hole with blood coming from a unknown source. But there is one cause of tracheostomy bleeding that should give you nightmares and that’s bleeding from a tracheoinnominate artery fistula. 

The innominate artery arises off of the aortic arch and crosses the trachea at approximately the 9th trachea ring and goes on to bifurcate into the right subclavian artery and the right common carotid artery.

Tracheoinomiate Artery Fistula

Tracheoinomiate Artery Fistula is a thankfully a exceedingly rare complication of tracheostomy placement occurring in 0.7% of patients. Even with it being a rare complication it carries a 100% mortality rate without operative intervention. It occurs from erosion of the innominate artery by either the tracheostomy tube or the balloon itself. Bleeding develops between weeks 3 and 4 post tracheostomy. Over 50% of bleeding from a tracheoinomiate artery fistula will present with a “sentinel bleed”. So even in the setting of minor tracheostomy bleeding, tracheoinomiate artery fistula should remain on your differential until excluded. A pulsating tracheostomy tube is also a sign of a possible tracheoinomiate artery fistula. 

Patient Assessment & Management: 

Any patient with a tracheostomy, bleeding or not there are a number of questions that need to be answered. 

  • What was placed? 
    • Cuffed or Uncuffed Tracheostomy Tube 
    • What Size Tracheostomy Tube
    • Simple Tracheostomy or Laryngectomy 
  • When was it placed? 
    • This question is most important for patients who have decannulated their trach as stomas take 7-10 days to mature. 
  • Why was it placed? 
    • This question is important, as it will give you a better idea of the patient’s history. 

In the setting a of SEVERE bleeding with a cuffed tracheostomy tube. You will want to hyperinflate the balloon with 50cc of air. By overinflating of the cuff, the hope is that the balloon will tamponade the innominate artery until definitive operative management can be undertaken. This technique is successful in 85% of cases. 

If this technique is unsuccessful, there is one remaining option. You will deflate the cuff, orally intubate the patient and then remove the tracheotomy tube. After the tube has been removed compression of the innominate artery by finger compression through the stoma site, which is referred to as the Utley maneuver and is successful in 90% of cases. 


Grillo, H. C. (2004). Surgery of the trachea and bronchi. Hamilton: BC Decker.

Jafri, S., Dinh, K., & Akkanti, B. (2019). A Rare Case Of Tracheoinominate Fistula. Chest156(4). doi: 10.1016/j.chest.2019.08.1576

Lee, E. (2018, June 7). Tricks of the Trach: Approach to Tracheostomy Patients in the Emergency Department. Retrieved from

Leyn, P. D., Bedert, L., Delcroix, M., Depuydt, P., Lauwers, G., Sokolov, Y., … Schil, P. V. (2007). Tracheotomy: clinical review and guidelines. European Journal of Cardio-Thoracic Surgery32(3), 412–421. doi: 10.1016/j.ejcts.2007.05.018

Nickson, C. (2019, February 10). Bleeding Tracheostomy • LITFL • CCC Airway, ENT. Retrieved from


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