Patient Education & Consent
Elements of Informed Consent
Informed consent may not always be possible to obtain immediately prior to tube reinsertion or repositioning, as the patient may be in distress, requiring quick action. However, the possibility of tube dislodgement and possible loss of airway both during and after the surgical insertion of the tube should be explained to the patient or their legal representative prior to performing the tracheotomy.
Pre-Procedure Planning
Equipment
A dislodged tracheostomy tube often requires emergent replacement. Therefore, it is important to have all of the necessary equipment readily available (see Table 1).
Table 1. Devices to Have Available During Replacement of a Dislodged Tracheostomy Tube (Open Table in a new window)
Device |
Use |
Ambu-bag with face mask |
Allows ventilation via nose/mouth if stoma covered until tube can be replaced |
Obturator |
Replace current tube with graduated, smooth tip instead of blunt end; decreased risk of false passage creation |
Tracheostomy tube (current size and one size smaller) |
Replace a plugged tube; replace a tube with broken cuff; replace tube into narrowed stoma |
Suction catheter |
Suction through tube to confirm placement and can help identify tract; can be used as guide for replacement of tube |
Water-based lubricant |
Allows gentle reinsertion of tube or other devices to manipulate stoma |
Endotracheal tube (cuffed) |
Variety of sizes available to place through narrowed tract; can also provide increased length to bypass stenosis, granulation tissue, tumor; can be used if orotracheal intubation is necessary |
Flexible fiberoptic endoscope |
Can be used to identify tract versus false passage; can be used to confirm proper positioning of tube after replacement; can be used to identify presence of granulation tissue or tumor in trachea; tube can be replaced over endoscope via Seldinger technique |
Cook catheter |
Can be used as guide for replacement of tube; lumen of catheter allows jet ventilation |
Cricoid hook |
Elevates trachea toward skin in new tracheotomies |
Army-Navy retractors |
Can pull soft tissue away from tracheostoma, improving visualization |
Trousseau dilator or nasal speculum |
Use to dilate tracheostoma |
Tracheostoma dilators |
Graduated dilators can be passed to increase size of stoma; a lumen allows jet ventilation |
Mayo scissors |
Cut ties, sutures, or obstructing soft tissue |
Scalpel |
May be necessary for re-entry into a closed stoma |
Headlamp |
Improves visualization of stoma |
Patient Preparation
Anesthesia
No anesthesia is required for replacement of a dislodged tracheostomy tube. If a large amount of manipulation of the tracheostoma is necessary, such as with dilators, 4% topical lidocaine may be sprayed at the site to decrease irritation. Injection of local anesthesia around the stoma should be avoided, as it may cause a temporary narrowing of the opening as it infiltrates surrounding tissue, although a judicious amount may alleviate discomfort from dilation, if needed.
Positioning
The patient should be placed in the supine position with the neck gently extended by placement of a shoulder roll.
Monitoring & Follow-up
After the dislodged tracheostomy tube has been replaced, a suction catheter should pass easily past the distal end of the tracheostomy tube and airway secretions suctioned for confirmation. Tube positioning can be confirmed by passing a fiberoptic endoscope through the tube to visualize tracheal rings and carina or by obtaining a chest radiograph.
A stethoscope should immediately be used to auscultate bilateral breath sounds. A tube that was difficult to reinsert should be tightly secured with consideration to placing string ties and/or stitches. The tube should be treated as a freshly placed tracheostomy tube, and 5-7 days should pass prior to its next change. If the tube was very difficult to insert, the next tube change should be performed in a monitored setting. Changing it in the operating room should be considered, as a variety of airway equipment is available.
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Tracheostomy tube change over fiberoptic scope
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Tracheostomy tube placement over red rubber catheter
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Repositioning dislodged tracheostomy tube. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
Tables
Device |
Use |
Ambu-bag with face mask |
Allows ventilation via nose/mouth if stoma covered until tube can be replaced |
Obturator |
Replace current tube with graduated, smooth tip instead of blunt end; decreased risk of false passage creation |
Tracheostomy tube (current size and one size smaller) |
Replace a plugged tube; replace a tube with broken cuff; replace tube into narrowed stoma |
Suction catheter |
Suction through tube to confirm placement and can help identify tract; can be used as guide for replacement of tube |
Water-based lubricant |
Allows gentle reinsertion of tube or other devices to manipulate stoma |
Endotracheal tube (cuffed) |
Variety of sizes available to place through narrowed tract; can also provide increased length to bypass stenosis, granulation tissue, tumor; can be used if orotracheal intubation is necessary |
Flexible fiberoptic endoscope |
Can be used to identify tract versus false passage; can be used to confirm proper positioning of tube after replacement; can be used to identify presence of granulation tissue or tumor in trachea; tube can be replaced over endoscope via Seldinger technique |
Cook catheter |
Can be used as guide for replacement of tube; lumen of catheter allows jet ventilation |
Cricoid hook |
Elevates trachea toward skin in new tracheotomies |
Army-Navy retractors |
Can pull soft tissue away from tracheostoma, improving visualization |
Trousseau dilator or nasal speculum |
Use to dilate tracheostoma |
Tracheostoma dilators |
Graduated dilators can be passed to increase size of stoma; a lumen allows jet ventilation |
Mayo scissors |
Cut ties, sutures, or obstructing soft tissue |
Scalpel |
May be necessary for re-entry into a closed stoma |
Headlamp |
Improves visualization of stoma |
