Why are tracheostomy (trach) sutures removed?

Why Tracheostomy Sutures Must Be Removed

Tracheostomy sutures are removed after 7-10 days (for surgical tracheostomy) or when the stoma has matured sufficiently to allow safe tube changes, because keeping them in place longer increases infection risk while removing them too early risks tube displacement and loss of airway during the critical early postoperative period. 1

Critical Timing Based on Tracheostomy Type

Surgical (Open) Tracheostomy

• Sutures should remain in place for at least 4 days post-procedure to allow initial tract formation and reduce risk of catastrophic tube displacement 1
• Optimal removal timing is 7-10 days, which balances tract maturation against infection risk 1, 2
• The French Intensive Care Society specifically recommends waiting a minimum of 4 days after surgical tracheostomy before the first tube change, which typically coincides with suture removal 1

Percutaneous Dilatational Tracheostomy (PDT)

• Sutures must remain longer—7-10 days minimum—because percutaneously formed stomas lack the surgical dissection plane and tissues can recoil if sutures are removed prematurely 1, 2
• The British Intensive Care Society advocates waiting 7-10 days before the first tube change in PDT patients 1

The Dual Function of Tracheostomy Sutures

1. Securing the Tube (Days 0-4)

• During the immediate post-tracheostomy period, sutures provide critical tube stabilization alongside ties or Velcro straps 1
• Early accidental dislodgement (before tract maturation) is a life-threatening emergency because the stoma can close rapidly, making reintubation extremely difficult or impossible 1
• Equipment for reintubation and emergency tracheostomy must be kept at bedside specifically because of this risk during days 0-4 1

2. Stay Sutures for Emergency Access

• Stay sutures (tracheal wall sutures) serve a distinct emergency function: if the tube becomes displaced before tract maturation, traction on these sutures lifts the trachea anteriorly and opens the stoma, permitting rapid reintubation 1, 3
• The 2018 multidisciplinary pediatric guidelines explicitly state: "If stay sutures are present then they should both be elevated by hand, lifting them 'up and out'" during emergency tube changes 1
• This is the rationale for attempting emergency tracheostomy tube change before upper airway management in patients with stay sutures 1

Why Sutures Must Eventually Be Removed

Infection Risk with Prolonged Retention

• Leaving sutures in place beyond 7-10 days significantly increases local infection risk at the stoma site 2
• The American Academy of Otolaryngology-Head and Neck Surgery specifically identifies prolonged suture retention as an infection risk factor 2
• Daily examination of the scar for signs of local infection is mandated during the suture retention period 1

Tract Maturation Eliminates Need

• By 7-10 days, the tracheostomy tract has matured sufficiently that the tube can be safely changed without stay sutures 1
• Once maturation occurs, sutures become foreign bodies that serve no protective function and only increase complication risk 1

Common Pitfalls to Avoid

Removing Sutures Too Early (Before Day 4-7)

• Risk: Catastrophic tube displacement with inability to reintubate through an immature tract 1
• Risk: Wound dehiscence with loss of the surgical tract 2
• This is particularly dangerous in percutaneous tracheostomies where tissue recoil can completely close the stoma 2

Keeping Sutures Too Long (Beyond Day 10)

• Risk: Stoma site infection requiring antibiotics and potentially complicating decannulation 2
• Risk: Tissue reaction and granulation tissue formation around the suture material 1
• No benefit to prolonged retention once tract has matured 2

Failing to Distinguish Skin Sutures from Stay Sutures

• Skin sutures secure the tube and are typically removed at 7-10 days 1, 2
• Stay sutures (tracheal wall sutures) are emergency access tools that may be removed at the first elective tube change, often coinciding with transfer from ICU to ward-level care 1, 2
• Both types should be removed once their protective function is no longer needed 1, 2

Post-Removal Care Requirements

After suture removal, the following care continues:

• Daily fixation changes if there is any oozing 1
• Daily scar examination and cleansing with isotonic saline 1
• Dressing changes with physiological saline three times per 24 hours to prevent secretion accumulation 1
• Monitoring for hemorrhagic signs at the scar site 1