What is the procedure for changing a cuffed tracheostomy tube?

Procedure for Changing a Cuffed Tracheostomy Tube

When changing a cuffed tracheostomy tube, follow a systematic step-by-step approach to ensure patient safety and minimize complications, as this is a potentially life-threatening procedure if performed incorrectly. 1

Preparation

• Gather all necessary supplies before beginning the procedure: new tracheostomy tube of current size with ties in place, one tracheostomy tube one size smaller with ties in place, obturator, suction equipment, shoulder roll, scissors, and resuscitation equipment 1
• Check the integrity and flexibility of the new tube and verify cuff integrity before proceeding 1
• Position the patient with neck in slight extension using a small roll under the shoulders to optimize access to the stoma 1
• Place the obturator in the new tube (if used) 1

Procedure Steps

1. Suction the current tracheostomy tube to clear secretions before removal 1
2. Deflate the cuff of the current tube 1
3. Cut strings/detach ties securing the current tube 1
4. Remove the old tube in an upward and outward arc 1
5. Insert the new tube in a downward, inward arc following the natural curve of the airway 1
6. Immediately remove the obturator (if used) 1
7. Reposition the patient to neutral position by removing the shoulder roll 1
8. Secure the ties to prevent accidental dislodgement 1
9. Inflate the cuff if needed for ventilation or to prevent aspiration 1
10. Lock inner cannula in place if present 1

Special Considerations for Cuffed Tubes

• When using a cuffed tracheostomy tube, understand the difference between high-volume/low-pressure cuffs and low-volume/high-pressure cuffs 1
• For low-pressure/high-volume cuffs, maintain cuff pressures below 20 cm H₂O to prevent decreased perfusion of airway epithelium 1
• For patients on mechanical ventilation, use minimal leak technique or minimal occlusion technique while still monitoring cuff pressure 1
• For low-volume/high-pressure cuffs, ensure the maximum diameter of the tracheostomy tube with cuff inflated remains smaller than the minimum tracheal diameter 1
• Follow manufacturer recommendations for whether air or liquid should be used for cuff inflation 1

Safety Measures

• Ideally, two trained adults should be present for tube changes, especially in home settings 1
• Have emergency equipment readily available, including suction equipment and a manual resuscitation bag 1
• Keep a tracheostomy tube one size smaller available in case the current size cannot be reinserted 1
• If difficulty is encountered during insertion, a suction catheter can be used to guide the new tube through the stoma into the tract 1
• Never attempt vigorous ventilation through a potentially displaced tube as this can cause surgical emphysema 1

Troubleshooting Difficult Changes

• If resistance is met during insertion, do not force the tube as this may create a false passage 1
• If unable to pass the tube, use a suction catheter to confirm proper placement in the trachea before attempting ventilation 1
• If the tube cannot be reinserted, attempt insertion with a smaller size tube 1
• In case of complete obstruction or displacement where a suction catheter cannot pass, the tracheostomy tube should be removed and oxygen applied to both the stoma and face while awaiting expert assistance 1

Post-Change Assessment

• Confirm proper placement by observing chest rise, breath sounds, and patient comfort 1
• Ensure the cuff is properly inflated if needed for ventilation or aspiration prevention 1
• Secure the tube with ties to prevent accidental dislodgement 1
• Maintain proper skin care around the stoma to prevent infection and pressure necrosis 1

Remember that tracheostomy tube changes, especially in the early post-operative period, carry significant risks and should be approached with caution. When in doubt about respiratory distress in a patient with a tracheostomy, changing the tube should be considered an emergency intervention 1.