From the Guidelines
Replacing a tracheostomy tube requires careful preparation and technique to ensure patient safety, and the procedure should be performed by trained healthcare professionals, ideally with two people present, following the most recent guidelines from 2018 1. The procedure involves gathering all necessary equipment, including the replacement tube of the same size (or smaller if encountering difficulty), suction equipment, oxygen source, lubricant, tracheostomy ties, and sterile gloves.
- Key steps include:
- Pre-oxygenating the patient for 3-5 minutes before tube removal
- Suctioning the existing tube to clear secretions, then deflating the cuff if present
- Removing the old tube during exhalation using a curved downward and outward motion
- Quickly inserting the new lubricated tube following the natural curve of the airway, aiming downward and backward
- Securing the tube with tracheostomy ties, confirming proper placement by checking for symmetrical chest movement and breath sounds, and reconnecting to oxygen if needed
- If the first attempt at replacement is unsuccessful, a second emergency tube change should be performed with a tube one half-size smaller, again followed by assessing for airway patency 1.
- If the second attempt at replacement is unsuccessful, a third attempt using a soft suction catheter to guide placement, much like a Seldinger technique, may be necessary 1.
- It is essential to have emergency equipment nearby, including bag-valve-mask, suction, and smaller tubes, and to be aware of potential complications such as hypoxia, tube misplacement, bleeding, or inability to reinsert the tube 1.
- The procedure requires skill because the stoma can begin to close quickly after tube removal, and the airway must be secured promptly to prevent respiratory distress 1.
From the Research
Procedure for Replacing a Tracheostomy Tube
The procedure for replacing a tracheostomy tube involves several steps and considerations to ensure patient safety.
- The first tracheostomy tube change, typically performed 1-2 weeks after placement, carries some risk and should be done by a skilled operator in a safe environment 2.
- The use of an airway exchange catheter can facilitate the safe replacement of a tracheostomy tube with a tracheal tube, especially in patients with a fresh tracheostomy 3.
- When converting from an endotracheal tube to a tracheostomy tube, one approach is to advance the endotracheal tube just proximal to the carina and reinflate the cuff before surgically securing the airway 4.
- Airway management plans should take into account the indication for the tracheostomy, the maturity status of the stoma, the type and size of the tracheostomy tube, and the patient's concurrent health conditions 5.
- Techniques such as the 'railroad' technique can be used to optimize the safeguarding of the airway during a tracheostomy tube change, and management of accidental decannulations should also be considered 6.
Key Considerations
- The risk associated with changing the tracheostomy tube diminishes over time as the tracheo-cutaneous tract matures 2.
- A malpositioned tube can cause patient distress and patient-ventilator asynchrony, and should be recognized and corrected 2.
- Airway endoscopy can be helpful in ensuring optimal positioning of a replacement tracheostomy tube 2.
- Multidisciplinary care involving anesthesiologists, surgical specialists, and perioperative nurses is important for managing patients with a tracheostomy 5.