Tracheostomy Tube Change

Tracheostomy has been performed since 1500 BCE and is one of the oldest reported surgical procedures in the medical literature.[1, 2]  Before the 19th century, however, the procedure was fraught with difficulty, and only a limited number of successful tracheostomies were reported. During this early period, the indications for tracheostomy were few, but beginning in the early 20th century, with the work of Chevalier Q Jackson, the procedure was refined and standardized.[3]

As experience with the procedure grew within the surgical community, its morbidity and mortality decreased, and its indications were broadened. In 1999, more than 83,000 tracheostomies were placed in the United States, most commonly for purposes of mechanical ventilation in chronically ill patients.[3]  A 2015 study by Mehta et al found that tracheostomy use in mechanically ventilated patients in the United States rose substantially between 1993 and 2008 (to 9.8% of these patients) but decreased somewhat by 2012 (to 8.7%).[4]

Changing of the tracheostomy tube may warranted for any of several reasons (see Indications). This procedure is the focus of the present article. For discussion of the procedure by which the tube is initially inserted into the tracheal incision, see Tracheostomy.

The most common accepted indications for tracheostomy include the following:

• Need for prolonged ventilatory support
• Upper-airway obstruction
• Pulmonary toilet

The benefits commonly ascribed to tracheostomy as compared with prolonged endotracheal intubation include the following[5] :

• Improved patient comfort
• More effective clearance of airway secretions
• Improved ventilatory parameters through decreased airway resistance
• Enhanced patient mobility
• Increased opportunities for articulated speech
• Ability to eat orally
• Decreased complications of prolonged pressure of the endotracheal tube on the larynx and trachea
• More secure airway

Indications for tracheostomy tube change include the following:

• Minimizing the risk of postoperative infection and granulation tissue formation
• Verifying the formation of a stable tract for ancillary support staff
• Downsizing the tracheostomy tube if the patient is clinically improving
• Tube malfunction

Contraindications for a tracheostomy tube change are as follows:

• Changing a tracheostomy tube too soon (generally, < 5 days) after operation, before the tract has healed adequately; this increases the likelihood of entry into a false passage
• Inadequate lighting, exposure, and equipment
• Performer inexperience and unavailability of staff versed in airway management
• Extremely high ventilator settings; these increase the risk of decannulation
• Patient noncooperation without ancillary support

Anatomy

The trachea is nearly, but not quite, cylindrical and flattened posteriorly. In cross-section, it is D-shaped, with incomplete cartilaginous rings anteriorly and laterally and a straight membranous wall posteriorly. The trachea measures about 11 cm in length and is chondromembranous. This structure starts from the inferior part of the larynx (cricoid cartilage) in the neck, opposite C6, to the intervertebral disk between T4 and T5 in the thorax, where it divides at the carina into the right and left bronchi.

For more information about the relevant anatomy, see Trachea Anatomy.

Best practices

At present, there is no definitive set of published recommendations that establish a standard for adult tracheostomy tube changes, and most current protocols are the result of local practices.[6]  Because this is an aerosol-generating procedure, various recommendations have been made for reducing the risk to healthcare providers during the coronavirus disease 2019 (COVID-19) pandemic.[7, 8, 9]

Regarding pediatric best practice, the American Thoracic Society (ATS) published guidelines on the specifics of the procedure as they pertain to the care of children; however, this information may no longer be current.[10]  In 2021, the American Association for Respiratory Care (AARC) published guidelines for the management of tracheostomies in children in acute care settings.[11]

Future investigations designed in a prospective randomized manner and including larger numbers of patients are needed in order to enable clinicians to draw valid concrete conclusions as to the optimal methods of evaluating and caring for these patients.[12]

In general, a tracheostomy is routinely performed in a sterile setting in the operating room (OR). Postoperative dressing changes, suctioning, and first postoperative tracheostomy tube changes are performed with sterile equipment but under clean conditions.[13] Thereafter, care is usually performed under clean conditions.[14]

Although the process of changing a tracheostomy tube is generally straightforward in the majority of patients, best practice dictates that changes be performed only by someone who is skilled in the procedure. Furthermore, it is highly advisable to have two people present during any tracheostomy tube change and to ensure that the new tracheostomy tube is checked for integrity before the old one is removed.[10]

The designation of specific teams dedicated to performing tracheostomy tube changes also warrants serious consideration. For example, Johns Hopkins Hospital created a program wherein preidentified specialist teams composed of surgical staff, including credentialed otolaryngologists, trauma surgeons, interventional pulmonologists, specially trained anesthesiologists, a tracheostomy-trained nurse practitioner (NP), a tracheostomy coordinator, equipment specialists, intensive care unit (ICU) nurses, respiratory therapists, and experienced speech and language pathologists.

An institutional review was performed by Johns Hopkins after implementing this program; it compared outcomes in patients who had received tracheostomies in 2004, the year before the program’s implementation, and those who received tracheostomies in 2008.[15] The review found that comparative outcomes, including the efficiency of procedure; the subsequent length of patient stay in an ICU; complication rates for bleeding, hypoxia, loss of airway; and a financial cost-benefit analysis, were greatly improved as a result of the program.

Other programs that included a specialist service for the care of patients with tracheostomy tubes have likewise been found to have significantly reduced numbers of patients transferred from the ICU to the wards with tracheostomies in situ.[16]  Thus, it seems evident that the combination of fewer tracheostomy patients per ward, the existence of a daily outreach service, and better nurse education are all likely to reduce the occurrence of tracheostomy-related complications.

Procedural planning

Critical factors to take into account in preparation for changing a tracheostomy tube include the following:

• Timing
• Available lighting
• Type of tube being used
• Setting
• Time of day
• Frequency of previous tube changes
• Individual patient characteristics such as size, age, weight, and general health factors

Timing

The interval between the tracheostomy tube placement and the first tube change allows a tract between the skin and the trachea to develop. Confirming stomal maturity at the time of the first tube change likewise minimizes the risk of establishing a false tract, which carries the attendant morbidities of subcutaneous emphysema, loss of the airway, mediastinitis, and even death. Confirming a safe healed tract allows nurses or other trained personnel (eg, respiratory therapist) to safely perform subsequent tracheostomy tube changes.

The exact timing prior to the first postoperative change can vary. At the authors’ institution, the first tracheostomy tube change is performed after 5 days but may occasionally be delayed in patients with impaired wound healing (eg, patients taking steroids, patients with poorly controlled diabetes, patients with nutritional deficits).

This timing fits with various survey studies of current practice. For example, the mean time interval between surgery and the first tube change was reported as 5.3 days (range, 3-7 days) in a survey of 46 training programs.[17, 18, 19]  It is also worth noting, however, that one study recommended waiting longer to change the tube, suggesting a window of 7-14 days following placement, so as to allow time for a stable endotracheal-cutaneous tract to form.[20]  

In a retrospective case series involving pediatric patients, the first tracheostomy tube change was safely performed at 3-4 days after routine tracheotomy procedures in 20 of 21 patients.[21]  In another case series, the initial tracheostomy tube change was safely made on postoperative day 3 in 65 of 151 children (43.0%) without any complications.[22]  A retrospective review of 83 pediatric patients who underwent tracheostomy found that a first tube change on postoperative day 2 was safe and was associated with earlier discharge from intensive care, a shorter duration of sedation, and an earlier start to parent/carer training.[23]

Type of tube

The various types of tracheostomy tubes have subtle differences that are often underappreciated yet possess specific indications based on the needs of the individual patient. A discussion of the various nuances of respective tube designs is beyond the scope of this article, but these differences can depend on the indication for the tracheostomy, anatomic considerations, patient age, and availability, among other conditions. Some principles to keep in mind in the selection of a tube are discussed elsewhere in this article (see Equipment).

Setting

The setting of the first tracheostomy tube change should be considered. At the authors’ institution, patients who underwent a technically challenging tube placement (eg, because of challenging body habitus, morbid obesity, cervical instability/presence of a halo, a high degree of respiratory support, or critical condition) have their tracheostomy tubes changed in a more acute-care setting (eg, the OR). However, for stable patients in routine cases, tube changes may be performed in various locations in the hospital (eg, the general inpatient ward, a stepdown unit, or the ICU).

Tabaee et al demonstrated that the initial tube change on the floor has been associated with higher risk of airway loss.[17]  They concluded that the level of nursing and ancillary support on the floor may result in an inadequate level of care for safe airway management. They found that changes on general wards are safe in most patients, as long as adequate training, equipment, and support are available. Indeed, the respiratory therapy service at the authors’ hospital performs routine changes in stable patients weekly.

Patient issues

Pulse oximetry and supplemental oxygen may be warranted in patients who have comorbidities associated with poor pulmonary reserve. In addition, patients with above-average neck circumference, an elevated body mass index (BMI), or otherwise unfavorable airway anatomy can be at greater risk for placement of a tube into a false passage in the anterior mediastinum.[24]

In pediatric patients, tracheostomy-related mortality has been reported to be as high as 3.4%, in part as a result of pneumothorax and the creation of false passageways.[25]  In view of this danger, and because pediatric patients are sometimes unable to verbalize their discomfort, careful monitoring of vital signs should be undertaken during the first tracheostomy tube change performed on a child. Additionally, tracheostomy tube change should be deferred in patients who are hemodynamically unstable. For more information, see Pediatric Tracheostomy.

Frequency

Studies have shown that regular tracheostomy tube changes can often result in a statistically significant decrease in the number of patients who require surgical intervention for removal of granulation tissue—information that is highly germane to the determination of best practices for the timing of tracheostomy tube changes.[14]

Granulation tissue is a common consequence of tracheotomy, occurring in 10-80% of cases, and it typically appears as pink and fleshy protuberant tissue.[14] Histologically, it is composed of friable, immature blood vessels, which are prone to bleeding and can complicate a tracheostomy tube change by obstructing the stoma or with bleeding, resulting in loss of airway.

Topical applications of corticosteroid creams, antibiotic preparations, and silver nitrate have been proposed for addressing granulation tissue.[14] However, it remains to be determined whether changing the tracheostomy tube more frequently than once every 2 weeks might eliminate the problem entirely or whether a certain subset of patients would require less frequent changes.[14]

Another important issue concerns the design and material of the specific tracheostomy tube used on a given patient on the basis of currently available information. For an inpatient, a polyvinyl chloride tube may be changed every 8 weeks, whereas a silicone tube should be changed every 4 weeks. Meanwhile, for an outpatient, a tracheostomy tube is best changed every 8-12 weeks.[6] The authors recommend tube changes weekly or biweekly to reduce the possibility of bacterial colonization or superinfection.

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

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]

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.

The video below illustrates the process of changing a tracheostomy tube.

The procedure is as follows.[27]

Ensure that the lighting in the room, specifically over the patient’s bed and neck, is adequate for visualizing the stoma. In some cases, the use of a headlight is helpful. Ensure that the necessary equipment is available, including an assistant who is competent in tracheostomy care, if possible. Check the equipment for functionality. For example, if the existing tracheostomy tube is being replaced with a new cuffed tube, the balloon should be checked for leaks.

Position the patient as previously described (see Patient Preparation).

If the indwelling tracheostomy tube is cuffed, deflate the balloon and suction the patient gently with a soft suction catheter to remove secretions being held above the cuff and in the lower airway. Once this is done, the cuff can be reinflated, if necessary, while remaining preparations are made. Additionally, the opportunity can be taken to preoxygenate the patient for several minutes to maximize his or her oxygen reserve.

Remove any sutures and ties to free the tracheostomy tube. The assistant must stabilize the flange in place at all times to prevent premature decannulation. Deflate the cuff and remove the tracheostomy tube.

Inspect the stoma for wound breakdown, granulation tissue, and adequacy of a tract into the trachea. Clean the area with gauze moistened with hydrogen peroxide, sweeping debris away from the trachea to prevent foreign bodies from falling into the lower airway. Next, clean the area with dry gauze in a similar fashion.

If stay sutures were placed at the time of the tracheotomy, apply traction gently, raising them up and out to provide better exposure, exteriorizing the trachea against the skin.

Apply the new lubricated tracheostomy tube, with the obturator within its lumen initially rotated 90º from its correct position, to engage the tracheostoma. Then turn the obturator back 90º to its correct position to be inserted into the trachea. This reduces the risk of creating a false anterior passage in the pretracheal space. If any resistance is encountered, do not advance further. Instead, remove the tube, inspect the tract again, and reinsert the tube.

As soon as the tube is in place, remove the obturator, as it occludes the lumen of the tube. Replace the obturator with the inner cannula, which should be reconnected to the ventilator tubing if the patient is still mechanically ventilated. Inflate the cuff.

Pass the soft suction catheter to confirm placement. Breath sounds should be elicited bilaterally; they should be auscultated easily and confirmed to be unchanged from the preoperative condition. Placement can also be confirmed with a flexible fiberoptic endoscope, if necessary.

When placement is confirmed, secure the tracheostomy tube in place with the Velcro ties and remove the shoulder roll. Finally, remove any stay sutures or Bjork flap sutures at this time.

Pearls

If recannulation appears potentially difficult, the railroad technique can be used. This technique, described by Levy in 1982, is based on the Seldinger technique and can be used in difficult cases with continued maintenance of the airway.[28] Pearls include the following:

• Prepare the patient and equipment as described above; if an inner cannula is present, it is replaced with a hollow tube that is at least three times the length of the tracheostomy tube ^[28] ; the tube chosen may depend on resources available and could include a soft, flexible suction catheter or an orogastric tube
• Hold the upper end of the tube by the thumb and index finger
• Remove the tracheostomy tube over this tubing
• The indwelling guide tubing functions as an airway through which the patient can breathe, if necessary
• Using a Seldinger technique, slip the new tracheostomy tube in over the tubing
• Once the new tube is in place, remove the guide tubing; the patient may resume ventilation after replacement of the inner cannula
• Confirmation and reassessment are performed as above

In the case of unanticipated difficulty with a tracheostomy tube change and a poorly visualized stomal tract, the illuminated blade of a standard laryngoscope can be used as a retractor to enhance visualization, thereby allowing the insertion of the tracheostomy tube under direct vision.[28] Critically ill patients with respiratory failure can undergo stabilization by means of emergency endotracheal intubation in the absence of upper-airway obstruction. The tracheostomy tube can then be reinserted electively under more controlled conditions.

The postoperative care of patients undergoing tracheostomy is often underemphasized. Although many aspects of the care of tracheostomy tubes are critical (eg, suctioning, hygiene, humidity, and emergency preparedness), the tube change is perhaps the single most critical event after tracheostomy.

The safety of current practice patterns in tracheostomy management is not well defined. Relatively little attention has been devoted to the morbidity and mortality associated with postoperative tracheostomy tube changes as a part of routine care, despite multiple reports describing the incidence of perioperative complications associated with the procedure.[17]

Cases of airway loss and even death have been reported, typically (though not always) in the perioperative period. In a survey administered to 46 otolaryngology training programs, 42% of respondents reported awareness of a loss of airway, and 15% reported awareness of a death as a result of the first tube change at their institution during their residency.[17]

Although tracheostomies themselves represent one of the most frequently undertaken hospital procedures, there is at present relatively little evidence with which to direct practice in the postoperative care period.[17] These occurrences warrant an examination of the rationale and safety of this procedure, as well as specific guidelines for technical aspects of the change in both perioperative and routine settings.

Although tracheostomy tube change is routinely performed, the procedure is not without complications.[28]  A proper understanding of the procedure, in conjunction with anticipation of potential problems, can facilitate an uneventful tracheostomy tube change.

Tracheostomy tube displacement is a rare event that may occur at any time during the patient's course, though it is most common during the perioperative period, before the tract has matured. Occasionally, displacement occurs at the time of the first tube change, resulting from creation of a false tract in the pretracheal or peristomal region. This may present insidiously with respiratory failure and subcutaneous emphysema.

The consequences of tracheostomy tube displacement can be dire and can include loss of adequate airway and death. Prevention is critical to avoid this grave complication. Measures that reduce the risk include confirmation of placement following the procedure with passage of a flexible suction catheter. Resistance met with this maneuver may reflect improper placement.

Any medical procedure involves inherent risks. It is of vital importance to be prepared in advance to be able to control any life-threatening situations that may arise in patients with tracheostomy tubes. In some cases, having basic emergency equipment (eg, a manual ventilator bag) on hand at the bedside, as well as least two extra tracheostomy tubes (one the same size as the patient’s current device and the other one size smaller) and an obturator and suctioning devices and catheters, can represent the difference between life and death for a given patient.[29]