Equipment
Equipment required for tracheostomy tube change includes the following:
-
Tracheostomy tubes (2), one the same size as the patient's existing tube and the other a size smaller (see the first, second, third, and fourth images below); if stomal obstruction is encountered, a smaller tube can be placed more easily
-
Empty syringe, for cuff deflation/inflation and for suction prior to the change to remove secretions being held up by the cuff (see the fifth image below)
-
Soft suction catheter; these catheters prevent mucosal trauma; use caution regarding latex allergy (see the fifth image below)
-
Gauze, hydrogen peroxide diluted 50% (see the fifth image below)
-
Water-based lubricant, to facilitate atraumatic placement of tube
-
Suction source
-
Mask, gloves, gown, eye protection (see the sixth image below)
-
Shoulder roll (see the seventh image below)
-
Ambu bag/tracheostomy collar with oxygen source, for preoxygenation
-
Suture removal kit
-
Velcro ties
-
Tracheostomy tray containing Trousseau dilators, which can aid in difficult placement; a nasal speculum could also be used for this purpose
-
Fiberoptic scope
Obturator, inner cannula, cuffed tracheostomy tube, and tracheostomy tube Velcro tie.
Top (left to right): gauze and hydrogen peroxide; middle (left to right): syringe, forceps, scissors, lubricant; bottom: soft suction catheter.
Selection of tube type
Size and style
Tracheostomy tubes are available in various sizes and styles, which are described in terms of their inner diameter, outer diameter, length, and curvature. [13] Tracheostomy tubes can be angled or curved to optimize fit into the trachea. They can be customized with additional length at the proximal end (to accommodate patients with large or deep necks) or the distal end (to accommodate patients with tracheal anomalies such as stenosis).
Tracheostomy tubes are available with and without a cuff. Cuffed tubes are used to create a seal in the setting of positive end-expiratory pressure (PEEP) or to prevent downward flow of secretions. Specific cuff types on tracheostomy tubes include low-pressure, high-volume cuffs; tight-to-shaft cuffs; and foam cuffs. [13] Fenestrated tracheostomy tubes have an opening in the posterior portion of the tube above the cuff, which allows the patient to breathe through the upper airway when the inner cannula is removed, thus facilitating phonation.
Knowledge of the specific type of tracheostomy tube being used and awareness of the factors relevant to the particular situation that determined its selection are both critical, especially before a tube change.
Material
The material of a tube is likewise an important consideration, in that the appropriateness of a given tube for a specific situation may vary according to the patient's specific needs and the type of procedure involved.
The majority of tracheostomy tubes are made of plastic and have a variable range of flexibility. They can be made from polyvinyl chloride, a material that becomes softer when in contact with body temperatures, or from silicone, which is by nature soft and is unaffected by body temperature. [26] In rare cases, patients may prefer metal tubes or those reinforced with wire, and these can likewise be used to secure airway patency. [13] Plastic tubes can be cuffed or cuffless, but metal ones are uniformly cuffless. [26]
Patient Preparation
Anesthesia
Anesthesia, sedation, and analgesia are not required for tracheostomy tube change.
Positioning
Patient positioning is critical to the safety of the procedure. The bed should be adjusted to a comfortable height, and the rails should be released to allow the practitioner to get close to the patient.
The patient should be placed supine with the neck in mild hyperextension over a shoulder roll, provided that the patient’s general condition can tolerate such positioning. This position brings the tracheal orifice closer to the surface.
If the practitioner changing the tube is right-handed, the practitioner should stand on the patient’s right and the assistant on the patient’s left. If the person changing the tube is left-handed, these positions should be reversed.
-
Obturator.
-
Inner cannula.
-
Cuffed tracheostomy tube.
-
Obturator, inner cannula, cuffed tracheostomy tube, and tracheostomy tube Velcro tie.
-
Shoulder roll.
-
Gloves, gown, and mask.
-
Top (left to right): gauze and hydrogen peroxide; middle (left to right): syringe, forceps, scissors, lubricant; bottom: soft suction catheter.
-
Tracheostomy tube change. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
