How often should tracheal (endotracheal) tubes be changed?

Tracheostomy Tube Change Frequency

Tracheostomy tubes should not be routinely changed in the ICU setting; instead, changes should be guided by specific clinical indications such as suspected infection, bleeding, tube malfunction, or the need to downsize for speech facilitation. 1

Primary Recommendation for ICU Patients

The French Intensive Care Society and French Society of Anaesthesia and Intensive Care Medicine explicitly recommend against routine tracheostomy tube changes in intensive care settings. 1 This represents the most current expert consensus, prioritizing patient safety over arbitrary scheduling, as early tube changes in the ICU carry significant risks including tube displacement and respiratory arrest. 1

Timing of First Tube Change

The initial tracheostomy tube change should not occur before 4 days after surgical tracheotomy or 7-10 days after percutaneous tracheotomy. 1 This critical waiting period allows tract maturation and reduces the risk of catastrophic complications during the first change. 2

• The first change carries the highest risk and should be performed by skilled operators in a controlled environment 2
• Earlier changes (before day 7) may facilitate faster speech valve use and oral intake resumption, but this benefit must be weighed against safety concerns in the acute ICU setting 3

When Tube Changes ARE Indicated

Tube changes should be performed for specific clinical reasons: 1

• Suspected local infection at the stoma site
• Bleeding from the tracheostomy site
• Tube malfunction (cuff failure, obstruction, structural damage)
• Downsizing to facilitate speech and swallowing
• Tube displacement or malposition causing patient distress 2

Tube Type-Specific Considerations

The British Intensive Care Society provides differentiated guidance based on tube design: 1

• Tubes without inner cannula: Change every 7-14 days if routine changes are performed
• Tubes with inner cannula: Change every 30 days if routine changes are performed
• The inner cannula itself should be cleaned regularly without requiring full tube changes 1

Long-Term Management

For patients requiring prolonged tracheostomy beyond the ICU: 1

• Weekly changes are most commonly practiced, though no objective data support this specific frequency 1
• Individual tube inspection before each use is mandatory 1
• Flexible PVC tubes may be used for 3-4 months before stiffening, with individual tubes lasting 6 months to 1 year in rotation 1
• Silicone tubes do not stiffen and can be reused indefinitely if undamaged 1

Critical Safety Considerations

Common pitfalls to avoid:

• Performing routine changes in unstable ICU patients without clinical indication 1
• Changing tubes before tract maturation (before day 4 surgical, day 7-10 percutaneous) 1
• Using damaged or stiffened tubes without inspection 1
• Attempting changes without appropriate backup equipment and skilled personnel 2

Practice Variation Context

There is substantial international practice variation: 60% of Dutch ICUs never routinely change tubes, while 80% of US ICUs perform routine changes with considerable variability. 1 The Belgian Society of Pneumology recommends changes only for specific indications, aligning with the French guidelines. 1 This variation reflects the lack of high-quality evidence linking change frequency to clinical outcomes such as pneumonia or mortality. 1

The safest approach prioritizes clinical assessment over arbitrary schedules, with changes performed only when clinically necessary after the initial high-risk period has passed.