Tracheostomy Tube Change Technique

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]