What are the indications and recommended timing for changing a tracheostomy tube?

Criteria for Tracheostomy Tube Change

Emergency Indications (Immediate Change Required)

When a child with a tracheostomy presents with severe respiratory distress, change the tracheostomy tube immediately—when in doubt, change it out. 1 A blocked or displaced tracheostomy tube should be considered a foreign body in the trachea that must be removed, as it offers no benefit and carries considerable potential for harm. 1

Absolute Emergency Indications:

• Suspected tube obstruction with respiratory distress 1
• Tube displacement (partial or complete) 1
• Inability to pass suction catheter through the tube 1
• Severe respiratory distress of unclear etiology in a tracheostomy patient 1

Emergency Tube Change Technique:

1. First attempt: Use same-size tube with obturator (do NOT use exchange guide/bougie if tube is blocked or displaced) 1
2. Second attempt (if first fails): Use tube one half-size smaller with neck extension 1
3. Third attempt (if second fails): Use soft suction catheter as Seldinger guide with half-size smaller tube 1
4. Stop after three attempts if unsuccessful and pursue alternative airway management 1

Non-Emergency Clinical Indications

In ICU patients, routine tracheostomy tube changes should be avoided; changes should only be performed for specific clinical indications. 2, 3 The French Intensive Care Society and French Society of Anaesthesia and Intensive Care Medicine explicitly recommend against routine changes, prioritizing patient safety over arbitrary scheduling. 2, 3

Specific Clinical Indications for Tube Change:

• Tube malfunction: cuff failure, obstruction, structural damage 2, 3
• Local infection at the stoma site 2, 3
• Bleeding from the tracheostomy site 2, 3
• Downsizing to facilitate speech and swallowing 2, 3
• Decannulation preparation when original indication is resolving 3
• Damaged or stiffening tubes identified on inspection 1, 2

Timing Considerations

First Tube Change After Placement:

The initial tracheostomy tube change must not occur before 4 days after surgical tracheotomy or 7-10 days after percutaneous tracheotomy. 2, 4 Early changes carry significant risks including tube displacement and respiratory arrest due to immature tract formation. 2, 3, 4

The first change should be performed by a skilled operator in a safe environment, as it carries inherent risk before tract maturation. 5

Routine Change Frequency (If Performed):

For chronic tracheostomy patients outside the ICU, weekly changes are most commonly practiced, though no objective data support this specific frequency. 1, 2 Practice varies substantially:

• Tubes without inner cannula: every 7-14 days if routine changes performed 2
• Tubes with inner cannula: every 30 days if routine changes performed (inner cannula cleaned regularly without full tube change) 2
• International variation: 60% of Dutch ICUs never routinely change tubes, while 80% of US ICUs perform routine changes 2

One observational study found that changing tubes every 2 weeks reduced granulation tissue requiring surgical intervention, though this represents lower-quality evidence. 6

Tube Inspection and Replacement Criteria

All tracheostomy tubes must be inspected before each use, and damaged or stiffening tubes must be discarded. 1, 2

Material-Specific Lifespan:

• Flexible PVC tubes: may be used 3-4 months before stiffening; individual tubes last 6 months to 1 year in rotation 1, 2
• Silicone tubes: do not stiffen and can be reused indefinitely if undamaged 1, 2
• Metal tubes: may be reused indefinitely but inspect for cracking at soldered joints 1

Critical Safety Considerations and Pitfalls

Avoid These Common Errors:

• Do NOT perform routine changes in unstable ICU patients without clinical indication 2, 3
• Do NOT change tubes before tract maturation (before day 4 surgical, day 7-10 percutaneous) 2, 3, 4
• Do NOT use damaged or stiffened tubes without inspection 2
• Do NOT attempt ventilation through a newly placed tube if suction catheter will not pass easily—risk of subcutaneous emphysema from false passage 1
• Do NOT be reluctant to remove a tube in a deteriorating patient, even with known difficult upper airway—a non-functioning tube is harmful 1

Emergency Preparedness Requirements:

Every tracheostomy patient must have an emergency kit immediately available containing: manual resuscitation bag, suction equipment, one tube of current size with ties in place, one tube one size smaller with ties in place, shoulder roll, and emergency phone numbers. 1

Special Populations

Pediatric Considerations:

In children, routine tracheostomy tube changes can be safely performed by properly trained family members (33.7% of changes in one study), with complications occurring in only 10.7% of routine changes. 7 The most common complications were peristomal bleeding (47.37%) and first failed attempt (34.21%). 7