Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [198], C).
2. 2.Show
   This is a clean procedure.
   To ensure patient safety (NTSP [206], C).
3. 3.Show
   Cleanse hands with soap and water or an alcohol‐based handrub.
   To minimize the risk of infection (NHS England and NHSI [179], C).
4. 4.Show
   Ensure the following are readily available in case required:

   • emergency oxygen and equipment (masks, tubing)
   • suction and equipment (suction catheters and Yankauer suction tips)
   • resuscitation trolley
   • emergency airway trolley
   • bedside tracheostomy box
   • additional staff.
   To ensure patient safety if unable to secure the airway with the new tube (NTSP [206], C).
5. 5.Show
   Help the patient to sit in a semi‐recumbent position with the neck slightly extended.
   To ensure patient comfort and allow easy access to the neck area (Dawson [58], C).
6. 6.Show
   Pre‐oxygenate the patient if they are known to desaturate off oxygen.
   To minimize the risk of hypoxia (Greenwood and Winters [95], C).
7. 7.Show
   Prepare a dressing tray or trolley for the procedure. Open the sterile procedure pack and empty the tracheostomy inner tube onto the sterile sheet. If a reusable inner tube is being used, pour normal saline 0.9% into a gallipot and open a tracheostomy tube brush cleaner.
   To ensure all equipment required is prepared prior to starting the procedure. E

Procedure

1. 8.Show
   Cleanse hands with an alcohol‐based handrub and put on disposable plastic apron, gloves and eye protection.
   To minimize the risk of cross‐infection (NICE [193], C).
2. 9.Show
   Remove the inner cannula and dispose of it in the clinical waste. If non‐disposable inner tube is used, remove it and place it on the sterile sheet.
   To minimize the risk of cross‐infection (NICE [193], C).
3. 10.Show
   Immediately place the new inner tube in position and ensure it is secured in the ‘locked’ position.
   To re‐establish the airway and ensure the inner cannula is secure. E
4. 11.Show
   Check that the patient is comfortable and they are at ease with their breathing.
   To ensure patient comfort. E
5. 12.Show
   If a reusable inner tube is used, clean the old tube with normal saline 0.9% and the brush cleaner. Do not leave the inner tube to soak. The tube should be dried thoroughly then placed in a clean container for future use.
   Soaking tubes in stagnant cleaning solutions may cause bacterial colonization and subsequent cross‐infection (Cosgrove and Carrie [52], C).
6. 13.Show
   Remove apron, gloves and eye protection and dispose of them in the clinical waste, along with the old procedure pack. Cleanse hands with an alcohol‐based handrub.
   To minimize the risk of infection (NICE [193], C).

Post‐procedure

1. 14.Show
   Monitor the patient's respiratory status and observations/NEWS. Escalate any concerns or deterioration in condition/NEWS immediately.
   To identify any concerns or clinical deterioration early, and ensure timely escalation to senior staff if required (RCP [230], C).

   Changing an inner tube is potentially hazardous and may cause respiratory problems. E
2. 15.Show
   Document the inner cannula change time, in addition to the tenacity and volume of the secretions.
   To ensure all staff are aware of the tracheostomy care that has been performed and how often the inner tube requires checking or changing. E