Tracheostomy Tube Changes

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Although tracheostomy tube changes are relatively simple and easy procedures, it should only be changed by someone who is trained and competent to do so.

Tracheostomy Tube Changes

The healthcare provider as well as the careprovider for an individual in a home care setting must have knowledge of performing a routine tracheostomy tube change.  As always, emergency equipment should be at the bedside or near the patient, with a range of sizes of tracheostomy tubes and equipment to perform oral intubation if required. 

Clinicians should be particularly cautious with the first tracheostomy tube change.  A newly formed stoma will close more quickly than a stoma with an established tracheostomy tract and thus in a newly formed tract there is a higher risk for loss of airway.  The Clinical Consensus Guideline recommends that the first time a tracheostomy tube is changed, this should be done by a physician with the assistance of nursing, respiratory therapy, medical assistant or another physician (Mitchell, 2012).  The careprovider changing the tube should be competent in tracheostomy management to manage the stoma and upper airways in case there is difficulty changing the tube.  

Caregivers and parents are often experienced at changing tubes in the home environment.  However, if the patient requires a clinical environment, it is often due to tracheostomy-related problems and it is safer if tube changes are supervised by experienced clinicians until the patient is discharged (Mitchell, 2012). 

Tracheostomy tubes should only be changed by staff who are competent to do so.  The choice of tracheostomy tube is important.  Please see Tracheostomy Tubes for the different types of tracheostomy tubes available.  The ideal tube size for a patient is one that maximizes the functional internal diameter while limiting the outer diameter to approximately three quarters of the internal diameter of the trachea. This reduces airway resistance and the work of breathing while facilitating airflow around the tube.  Ideally, the end of the tracheostomy tube should be 2-3 cm from the carina to avoid the potential for the tube to enter the mainstem bronchus with neck flexion.  Additionally, in very obese patients, the length of the tube needs to be factored into the depth of insertion, because in a few patients, the tube may just barely enter the trachea

 

Indications for Tracheostomy Tube Change

 There are a variety of reasons for a tracheostomy tube change including:

  • the need for a different tube size or type
  • tube malfunction
  • routine changes as part of ongoing airway management
  • emergent tracheostomy tube changes due to tracheostomy blockage, dislodgement, or accidental decannulation (See Emergency Tracheostomy Algorithm for more information from the National Tracheostomy Safety Project.)
 

The need for a different tube size or type

downsizing the tracheostomy tube

The tube size may need changing to a smaller size to facilitate weaning of spontaneous breathing trials, improve speech production, or improve patient comfort.  Decreasing the outer diameter of the tracheostomy tube facilitates use of speaking valves and caps because it allows more room for expiratory airflow around the tracheostomy tube and through the upper airway.

  • Downsizing the tracheostomy tube or changing to a cuffless tube reduces airway resistance and increases tolerance and comfort for a speaking valve or cap (Johnson, D. et al, 2009).
  • Downsizing within 7 days of the tracheotomy procedure is associated with earlier use of a speaking valve, earlier oral intake, and reduced length of stay (Fisher, et. al, 2013).
  • Downsizing and cuff deflation improve weaning for patients on spontaneous breathing trials.  In a randomized controlled study of critically ill patients, increasing effective airway diameter by deflating the tracheal cuff and downsizing the tracheal cannula shortened weaning time, reduced respiratory infections, and improved swallowing (Hernandez, G. et al, 2013).

Increasing the tracheostomy tube size

 When on mechanical ventilation, the cuff limits airflow around the tracheostomy tube and may improve positive pressure ventilation.  If the tracheostomy tube is small in comparison to the circumference of the trachea, more air may be necessary to fill the space, resulting in high cuff pressures.  Increasing the outer diameter may be necessary if the tracheostomy cuff pressures are too high in order to create a minimal leak. 

Tracheostomy tube malfunction

A tracheostomy tube change is warranted if there is a malfunction.  Some examples of tube malfunction include:

  • Cuff failure- noted by the pilot balloon deflating after cuff inflation or the presence of a significant leak around the cuff during mechanical ventilation, even after performing normal cuff inflation.  
  • A blocked tracheostomy tube- noted by difficulty passing a suction catheter, failure to wean, or intermittent high peak airway pressures during mechanical ventilation (Morris, 2013).  NOTE: This must be managed immediately!  If the suction catheter is unable to be passed, the tracheostomy tube is considered blocked and must be managed immediately. First remove the inner cannula, if present.  See Emergency Tracheostomy Algorithm for more information about managing a blocked tracheostomy tube from the National Tracheostomy Safety Project.
 
 It is difficult to discern between a blocked tracheostomy tube and a malpositioned tracheostomy tube as inability to pass the suction can occur in both cases.  

Routine tracheostomy tube change

Initial Tracheostomy Tube Change:

Care providers should use caution during the initial tracheostomy tube change to prevent airway loss.  The first tracheostomy tube change is performed once the tracheotomy tract has matured.  Intensive Care Society Guidelines (2008) indicate that the tracheostomy tube change should not be performed within 72 hours following a surgical tracheostomy and not before 3 – 5 (and ideally 7 – 10) days after a percutaneous tracheostomy to allow the stoma to become established.  Changes within the first 72 hours should be avoided unless absolutely essential and should only be performed in an environment in which trans-laryngeal intubation can immediately be established.

The indications for a first tracheostomy tube change include downsizing the tube to improve patient comfort, to reduce pressure on the tracheal mucosa by reducing the tube external diameter, and to facilitate speech.  In some patients the original tracheostomy tube may have been the wrong size or length for the patient.  

Second and subsequent routine tracheostomy changes:

There is variability between institutions on when to change a long term tracheostomy tube.  Recommendations are generally inconsistent and unsupported by evidence.  Manufacturers typically recommend 30 days as the maximum amount of time for a double lumen tracheostomy tube to be left in place.  Single cannula tracheostomy tubes are recommended to be changed every 7-10 days.  The tracheostomy tube should be routinely changed based on the manufacturer’s recommendations, because tube materials perish and can result in device failure or infection.   

The most frequently reported rationale for performing routine tracheotomy changes was examination of the stoma for maturity (46%), prevention of stomal infection (46%), and confirmation of stability for transport to a less monitored setting (41%) (Tabee, A et al, 2007).  Another reason to support tracheostomy tube change is the prevention of granulation tissue formation.  An observational study has shown that regular tracheostomy tube changes every 2 weeks can often result in a statistically significant decrease in the number of patients who require surgical intervention for removal of granulation tissue (Yaremchuk, 2003).  

 

Tracheostomy Tube Change Procedure

It is recommended to have two people present during the procedure.  

Inspect the new tracheostomy tube for any signs of damage and test the cuff by inflating it to make sure that it is functioning adequately and to check for leaks.  The cuff can then be deflated and the obturator inserted.  Water-soluble lubricant may be placed on the tube for smoother access.  Monitor the patient’s vital signs.   Pre-oxygenate the patient prior to the tracheostomy change.  Oxygen should be applied to the upper airway.  Positioning the patient with the neck extended brings the trachea anteriorly and should be done for all patients unless contraindicated (ie cervical spine injury).  Suction is performed while the patient’s cuff is slowly deflated.  Untie tracheostomy tapes and remove dressings while the tube is held in place. The tracheostomy is then removed with an out and downward movement as the patient exhales.  The new chosen tracheostomy tube is inserted into the stoma with the obturator in place.  Remove the obturator after placement as the patient will be unable to breathe through the tracheostomy tube when the obturator is in place.  Check for correct positioning of the tube by listening to determine if the patient is able to exhale out the tracheostomy tube.  Suction to confirm that the tracheostomy tube is appropriately placed within the trachea.  

Following successful insertion: 

  • reattach to any oxygen or ventilator equipment as needed. 
  • reinflate the cuff (if indicated) and check cuff pressures.  
  • apply tracheostomy tube tapes and dressings

If re-insertion is difficult, a smaller tracheostomy tube may pass easier.  

After the tracheostomy tube change is completed, it is important to document that the date and time that the change took place, the size of the tracheostomy tube, and any complications.  A spare tracheostomy tube the same size and a size smaller should always be at bedside as well as emergency equipment.  

Complications of Tracheostomy Tube Change

The tracheostomy tube change is typically a safe and easy procedure, but complications can arise.  Although rare, tracheostomy tube displacement can occur during the tracheostomy tube change, resulting in the creation of a false tract.  Tracheostomy tube displacement is most common in the first few days following the tracheotomy procedure, before the tract has fully matured.  Patients with increased neck circumference, unusual airway anatomy, or with an elevated body mass index are at increased risk of having the tube placed into a false passage in the anterior mediastinum, especially if the caudal turn during insertion is made prematurely. The patient with a displaced tube may present with respiratory failure or subcutaneous emphysema.  Prevention of a displaced tracheostomy tube is critical and includes passing the suction catheter through the tracheostomy tube in order to confirm airway patency.  If there is resistance while passing the suction catheter, this may represent an improperly placed tube.  A fiberoptic tracheoscope can be very helpful to ensure correct placement of a tracheostomy tube and in addition allows for visual inspection of the airway anatomy, including the subglottic space.

There is risk of dislodgement during tie placement, and therefore it is important for one person to hold the tracheostomy tube in place to maintain the airway while the other person secures the tracheostomy tube in place.  The time for a stoma to close varies and loss of airway can occur if a dislodged tracheostomy tube is not managed quickly.

A dislodged or displaced tracheostomy tube requires immediate management.  See Emergency Tracheostomy Management from the National Tracheostomy Safety Project for more information.  

Summary

Changing an established tracheostomy tube is typically a safe and simple procedure.  The initial tracheostomy tube change requires caution as there is increased risk of airway loss when the tract is not fully mature.  Patients who are morbidly obese or have anatomical airway anomalies are also at high risk for complications.  Airway endoscopy can help confirm the appropriately sized tracheostomy tube is in the correct position and help minimize complications.

Resources

Fisher, DF, Kondili, D, Williams, J, Hess, D, Bittner, E, Schmidt, U.  Tracheostomy Tube Change Before Day 7 Is Associated With Earlier Use of Speaking Valve and Earlier Oral Intake.  
Hernandez, G. et al. (2013). The effects of increasing effective airway diameter on weaning from mechanical ventilation tracheostomized patients: a randomized controlled trial. Intensive Care Medicine. Jun;39(6):1063-70
 
Johnson DC, Campbell SL and Rabkin JD. Tracheostomy tube manometry: evaluation of speaking valves, capping and need for downsizing. The Clinical Respiratory Journal 2009; 3: 8–14.
 
Standards for the care of adult patients with a temporary tracheostomy, Intensive Care Society (2008)
 
Morris, LL, Whitmer, A, McIntosh, E. Tracheostomy Care and Complications in the Intensive Care Unit. Crit Care Nurse October 2013 33:1830doi:10.4037/ccn2013518
Mitchell, R. B., Hussey, H. M., Setzen, G., Jacobs, I. N., Nussenbaum, B., Dawson, C., … Merati, A. (2013). Clinical Consensus Statement: Tracheostomy Care. Otolaryngology–Head and Neck Surgery148(1), 6–20. https://doi.org/10.1177/0194599812460376
 

Tabaee A, Lando T, Rickert S, Stewart MG, Kuhel WI, Tabaee A, etal. Practice patterns, safety, and rationale for tracheostomy tube changes: a survey of otolaryngology training programs. Laryngoscope 2007;

Yaremchuk, K. (2003), Regular Tracheostomy Tube Changes to Prevent Formation of Granulation Tissue. The Laryngoscope, 113: 1-10. doi:10.1097/00005537-200301000-0000