Pre‐procedure

ActionRationale

1. 1.Show
   The first tracheostomy change should be carried out by a practitioner trained in advanced airway and intubation skills. Subsequent changes should be carried out by practitioners competent in tube change. In both cases, a second appropriately trained person should assist.
   To ensure that the most appropriately trained member of staff performs the procedure, ensuring patient safety (ICS [116], C).
2. 2.Show
   The patient should be nil by mouth for 6 hours (solids) and for 2 hours (fluids) prior to the tube change. If the patient has a nasogastric tube, this should be aspirated prior to the procedure.
   Any manipulation of the airway may cause the patient to vomit, increasing the risk of aspiration. Keeping the patient nil by mouth will reduce this risk (NTSP [206], C).
3. 3.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).
4. 4.Show
   Cleanse hands with an alcohol‐based handrub.
   To minimize the risk of infection (NHS England and NHSI [179], C).
5. 5.Show
   Ensure all emergency equipment is immediately available.
   In case it is not possible to secure the airway with the new tube (ICS [116], C).
6. 6.Show
   Help the patient to sit in a semi‐recumbent position with the neck extended. It may be necessary to place a rolled towel under the patient's shoulders to further extend the neck.
   To allow easy access to the neck area. E

   To bring the trachea closer to the skin and stretch the stoma opening to aid tube reinsertion (NTSP [206], C).
7. 7.Show
   Pre‐oxygenate the patient if they are known to desaturate off oxygen.
   To reduce the risk of hypoxia (NTSP [206], C).
8. 8.Show
   Prepare a dressing tray or trolley for the procedure. Open the sterile procedure pack and open the new tracheostomy tube and its contents onto the sterile sheet.
   To ensure all equipment required is prepared prior to starting the procedure. E
9. 9.Show
   If the new tracheostomy is cuffed, fully inflate the cuff using a 10 mL syringe. Once satisfied the cuff is functioning correctly, deflate the cuff prior to insertion.
   To ensure there is no air leak and the cuff does not spontaneously deflate. E
10. 10.Show
    Insert the obturator into the new tube, checking that it can be easily removed.
    To become familiar with removing the obturator prior to insertion. E
11. 11.Show
    Lubricate the new tube sparingly with a lubricating jelly and place it onto the sterile sheet.
    To facilitate insertion and maintain sterility (Hess and Altobelli [108], C).

Procedure

1. 12.Show
   Cleanse hands using an alcohol‐based handrub and apply disposable plastic apron, gloves and eye protection.
   To minimize the risk of infection (NHS England and NHSI [179], C).
2. 13.Show
   Encourage the patient to cough and suction any secretions as required from the oral cavity (see Figure 12.50). Aspirate the subglottic port if present.
   To reduce the risk of pooled secretions sitting above the cuff entering the lungs when the cuff is deflated (NTSP [206], C).
3. 14.Show
   Remove the inner cannula.
   To assist with the outer tube removal. E
4. 15.Show
   While one practitioner holds the tube, the other practitioner should unfasten the tube tapes and remove the sutures (if applicable).
   To secure the tube and ensure it is not accidentally removed before the right time (NTSP [206], C).
5. 16.Show
   If the tracheostomy tube is cuffed, gently deflate the cuff, providing additional suctioning if required.
   To prevent secretions from entering the lungs when the cuff is deflated (NTSP [206], C).
6. 17.Show
   Check both practitioners and the patient are happy to proceed prior to removing the tube. Provide reassurance to the patient as required.
   To ensure patient safety at all times. E

   To reassure the patient and ease any anxiety. E
7. 18.Show
   Administer conscious sedation as required and as prescribed.
   Conscious sedation relaxes the patient and reduces the risk of coughing (NTSP [206], C).

   Coughing can result in unwanted closure of the tracheostomy stoma. E
8. 19.Show
   If a guided technique is being used, insert the guide into the tracheostomy tube.
   To maintain the patency of the stoma (NTSP [206], C).
9. 20.Show
   Gently remove the old tube from the patient's neck while asking the patient to exhale. Remove it using a brisk, ‘out and downwards’ movement. Place it directly into the clinical waste bag.
   To reduce the risk of cross‐infection (NICE [193], C).
10. 21.Show
    Put traction on the stay sutures if present, or use tracheal dilators if required.
    To maintain the patency of the trachea and prevent soft tissues from obstructing the stoma (Lee et al. [131], C).
11. 22.Show
    Quickly clean around the stoma with 0.9% sodium chloride and dry it gently with gauze. Apply barrier cream if required.
    To clean the skin, reducing the risk of infection and tissue damage (ICS [116], C).
12. 23.Show
    If using a blind technique: insert the clean tube with the obturator in place using an ‘up and over’ action. Remove the obturator immediately.
    Introduction of the tube is less traumatic if directed along the contour of the trachea (Greenwood and Winters [95], C).

    The patient cannot breathe while the obturator is in place as it completely occludes the tracheostomy tube (NTSP [206], C).
13. 24.Show
    If using a guided technique: railroad (thread) the new tracheostomy tube over the guide and into the stoma. Once satisfied, remove the guide as quickly as possible.
    To guide insertion of the new tube into the stoma and prevent the creation of a false passage (NTSP [206], C).

    The patient cannot breathe properly while the guide is in place. E
14. 25.Show
    Whether using a blind technique or a guided technique: insert the inner tube and ensure it is in a ‘locked’ position.
    The presence of an inner tube increases safety as it can be quickly removed and replaced if it becomes obstructed with tenacious secretions or a sputum plug (NTSP [206], C).
15. 26.Show
    If the tube is cuffed, gently inflate the cuff and check the pressure using a cuff manometer. The cuff pressure should be 15–25 cmH₂O (10–18 mmHg).
    Too low a pressure will cause a cuff leak, resulting in ineffective ventilation and protection from aspiration. Too high a pressure may cause tracheal stenosis, tracheomalacia, tracheo‐oesophageal fistula or an arterial fistula (ICS [116], C; NTSP [206], C).
16. 27.Show
    Insert the tracheostomy dressing around the tube if required.
    A foam dressing will protect the skin and prevent tissue damage (Everitt [75], C).
17. 28.Show
    Secure the tracheostomy tube with the tapes/ties. Ensure one or two fingers can be comfortably inserted between the tapes and the patient's skin.
    To secure the tube without causing the patient discomfort (Dawson [58], C).
18. 29.Show
    Check that the patient is comfortable and they are at ease with their breathing.
    To ensure patient comfort and to assess for any signs of incorrect tube placement. E
19. 30.Show
    Remove apron, gloves and eye protection and dispose of them in the clinical waste bag, along with the procedure pack and all other disposable equipment used. Cleanse hands with an alcohol‐based handrub.
    To minimize the risk of infection (NHS England and NHSI [179], C).

Post‐procedure

1. 31.Show
   Assess the airway by checking the following:

   • no evidence of breathing problems
   • bilateral chest movement
   • exhaled air felt through the end of the tracheostomy
   • air entry heard on auscultation
   • suction catheter able to pass though tube
   • for difficult procedures, capnography or a fibreoptic scope can be used to confirm placement.
   To ensure the new tracheostomy is sitting in the trachea and the patient is being ventilated or oxygenated (NTSP [206], C).
2. 32.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).
3. 33.Show
   Document the tracheostomy tube change, including the new tube make and size. Document any problems observed during the procedure.
   To ensure all staff are aware of the new tube size and type (NMC [198], C).