How do you properly assess and verify the placement of a tracheostomy (trach) tube?

How to Check Trach Tube Placement and Patency

After inserting or assessing a tracheostomy tube, verify patency by passing a suction catheter easily through the tube to the expected depth, observing for bilateral chest rise, listening for breath sounds, and using waveform capnography when available. 1

Clinical Assessment of Tube Patency

The primary method for verifying tracheostomy tube placement involves a systematic clinical assessment:

• Pass a suction catheter through the tube to the depth indicated on the bedhead sign—easy passage confirms the tube is in the trachea and not in a false passage 1
• Observe for bilateral chest movement and assess whether the chest rises symmetrically with each breath 1
• Listen for equal breath sounds over both lung fields, particularly over the axillae 1
• Check for spontaneous breathing through the tracheostomy tube or open stoma 1
• Apply waveform capnography when available to confirm proper positioning and adequate ventilation 1

Critical Warning Signs

Do not attempt ventilation if a suction catheter will not pass easily, as this indicates the tube may have entered a false passage anterior to the trachea, and ventilation attempts risk causing subcutaneous emphysema 1. If the suction catheter does not pass or meets resistance, remove the tube immediately and attempt reinsertion 1.

Assessment During Emergencies

When a patient with a tracheostomy deteriorates:

• Remove a blocked or displaced tube immediately—consider it a foreign body that must be removed, as a non-functioning tube offers no benefit and considerable potential for harm 1
• Assess the upper airway for spontaneous breathing through the nose/mouth in addition to checking the tracheostomy 1
• Apply oxygen to both sites (nose/mouth and stoma) if the patient is breathing spontaneously but in distress 1
• Check oxygen saturation with pulse oximetry to assess adequacy of oxygenation 1

Verification After Tube Changes

Following emergency tube replacement, the assessment sequence is:

1. Pass a suction catheter to the documented depth—this is the most reliable immediate confirmation 1
2. Assess for chest rise and breath sounds bilaterally 1
3. Use capnography if the patient has reduced or absent respiratory effort, as clinical assessment alone is more difficult in these situations 1
4. Only attempt gentle hand ventilation after confirming suction catheter passage in patients without spontaneous respiration 1

Equipment Requirements

Every bedside must have immediately available 1:

• Suction source and catheters appropriate for the tube size
• Two spare tracheostomy tubes: one the current size with ties in place, and one half-size smaller with ties in place
• Manual resuscitation bag of appropriate size
• 15-mm adapter for children with metal tracheostomy tubes
• Shoulder roll for positioning during tube changes

Common Pitfalls to Avoid

Never assume proper placement based on insertion alone—tubes can enter false passages in the tissues anterior to the trachea, particularly in new tracheostomies or when there is bleeding or swelling at the stoma site 1. The tube may appear to be inserted successfully but actually be malpositioned.

Do not rely on a single assessment method—combine clinical signs (chest rise, breath sounds) with objective measures (suction catheter passage, capnography) for the most reliable verification 1.

If patency cannot be confirmed after tube insertion, remove the tube immediately rather than persisting with a potentially malpositioned tube 1. Consider alternative airway management including mouth-to-stoma ventilation or bag-mask ventilation through the nose and mouth while occluding the tracheal stoma 1.