Can a patient with a tracheostomy (tracheal tube insertion) be placed in a prone position?

Prone Positioning in Patients with Tracheostomy

Patients with tracheostomy can be placed in prone position, but this requires special precautions for airway security and should only be performed when the patient has recovered sufficiently that prone positioning is unlikely to be needed repeatedly. 1

Safety Considerations for Prone Positioning with Tracheostomy

Airway Security

• Tracheostomy tubes must be properly secured before prone positioning to prevent accidental dislodgement or displacement 1
• When sutures are used to secure the tracheostomy tube, they should be left in place during prone ventilation rather than being removed within the usual 7-10 days 1
• Foam straps are preferred over twill ties for securing the tracheostomy tube as they place minimal stress on the skin and decrease risk of skin breakdown 1

Ventilation Management

• Ensure the tracheostomy cuff is properly inflated with pressure at least 5 cmH2O above peak inspiratory pressure to prevent leaks during position changes 1
• Monitor and record tracheostomy tube depth before and after position changes to minimize risk of displacement 1
• Use closed tracheal suction systems to manage secretions during prone positioning 1

Specific Precautions

• Prone positioning should be performed by a trained team with experience in managing patients with tracheostomy 1
• The head should be positioned in a centered position during prone positioning to avoid lateral rotation that could stress the tracheostomy site 1
• Complete (180°) prone positioning is recommended rather than incomplete positioning as it has a stronger effect on oxygenation 1

Timing Considerations

• Tracheostomy should only be considered in patients who have recovered sufficiently that prone positioning is unlikely to be needed repeatedly 1
• If a patient still requires frequent prone positioning for oxygenation, it may be prudent to delay tracheostomy until this need has decreased 1, 2
• According to the American Thoracic Society, patients who require continued prone positioning should not undergo tracheostomy 2

Risk Management

Preventing Complications

• Carefully examine areas at risk for pressure ulcers during prone positioning, particularly around the tracheostomy site 1
• Ensure proper stabilization of the patient's head to prevent unintended movement of the tracheostomy tube 1
• Have emergency equipment readily available, including spare tracheostomy tubes of the same size and one size smaller 3

Managing Secretions

• Secretion management is critical during prone positioning as secretions may pool differently 1
• Use a closed-circuit suctioning system with an inline suction catheter to decrease aerosolization risk 1
• Avoid instillation of saline before suctioning as it increases risk of coughing and provides little benefit 1

Special Considerations

COVID-19 Patients

• In COVID-19 patients, additional infection control measures are needed during positioning changes due to the risk of aerosol generation 1
• Use heat moisture exchange (HME) filters with viral filtration efficiency >99.9% during any disconnection from the ventilator circuit 1
• Pause the ventilator before any circuit disconnection and clamp the tracheostomy tube to minimize aerosol generation 1

Common Pitfalls to Avoid

• Failing to secure the tracheostomy tube adequately before position changes 1
• Neglecting to check tube position and cuff pressure after repositioning 1
• Inadequate team coordination during the positioning maneuver, which can lead to tube displacement 1
• Overzealous inflation of tracheostomy cuffs, which can lead to tracheal ischemia and stenosis 1

By following these guidelines, prone positioning can be safely performed in patients with tracheostomy when clinically indicated, though it requires careful planning and execution by a trained team to minimize risks.