Chapter 12: Respiratory care, CPR and blood transfusion
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Tracheostomy: changing a tube
Evidence‐based approaches
Rationale
Changing a tracheostomy tube involves the removal of the old tracheostomy tube and its replacement with a new device.
Indications
Changing a tracheostomy tube is indicated as follows (Greenwood and Winters [95], Hess and Altobelli [108], NTSP [206]):
- when the tracheostomy tube has been in place for 30 days, or as per the manufacturer's recommendations (Hess and Altobelli [108])
- changing from a non‐fenestrated to a fenestrated tracheostomy tube to facilitate weaning and improve communication
- downsizing the tracheostomy tube if the patient is clinically improving
- changing from an uncuffed tube to a cuffed tube if the patient requires mechanical ventilation
- to replace a faulty, ill‐fitting or displaced tube.
Contraindications
The decision to change a tracheostomy tube will be made after weighing up the risks and benefits and after discussion and agreement with the multidisciplinary team. Contraindications may include (NTSP [206]):
- time since formation: changing a tracheostomy tube too soon after formation is contraindicated as the tract may not have healed adequately and can create a false passage
- poor visualization of the tracheostomy tract and inadequate lighting or exposure
- lack of emergency equipment
- practitioner inexperience or lack of availability of staff competent in airway management
- patient is on high ventilator settings or has high oxygen requirements
- patient is receiving radiotherapy to the neck or has done in the past 2 weeks
- patient is nearing the end of their life
- patient refuses or is not co‐operative.
Principles of care
The first tracheostomy tube change must be performed by a practitioner who is not only competent in tracheostomy tube placement but also has advanced airway management and intubation skills (ICS [116]). Except in emergencies, the first change should not be performed for 72 hours following a surgical tracheostomy or for 7–10 days following a percutaneous tracheostomy (Mitchell et al. [161]). This is to allow the tract between the skin and the trachea to develop. Removal of the tracheostomy tube before this time may result in complete loss of the patient's airway if there is difficulty recannulating the tracheostomy. This procedure requires the presence of a second practitioner who is trained in tracheostomy care and who is able to summon more expert help if required. Subsequent changes should be performed by practitioners trained in tube changes, and always with a second practitioner present who is competent in tracheostomy care (ICS [116]).
Unless it is an emergency situation, the procedure should be well planned in advance. All equipment, including emergency equipment and intubation drugs, should be immediately accessible. Appropriate medical support should also be readily available if the tube change does not go to plan.
The tube change may be performed using a ‘blind insertion’ technique for well‐established stomas, or it may be guided using a bougie, an exchange catheter or a guidewire. A guided technique allows the tube to be exchanged over the guide, reducing the risk of creating a false passage (ICS [116]). It is particularly useful for newly created stomas and for patients with a large neck (NTSP [206]). A fibreoptic scope may also be used to assist with the insertion and confirm the correct placement of the new tube (NTSP [206]). The tube change should be documented in the patient's records along with any adverse events and when the next tube change is due.
Anticipated patient outcomes
The procedure will be well planned with all the necessary equipment immediately available and suitably trained personnel present to ensure patient safety. The tracheostomy tube will be changed confidently and efficiently, causing the patient minimal distress and anxiety.
Pre‐procedural considerations
Prior to tube change, the following questions should be asked:
- Is this the best time to be doing this procedure?
- Am I the best person to do it?
- Have I got all the essential equipment required?
- Is there appropriate support available if required?
If the answer to all of the questions above is ‘yes’, then it is safe to proceed with the procedure. The practitioner should talk through the details of the procedure with all staff involved and ensure all members are familiar with what to do if the exchange does not go to plan. The procedure should always be explained to the patient and verbal consent gained (if the patient is conscious). The patient should be repositioned to allow easy access to the tracheostomy stoma. This can be achieved by lying the patient supine or at 45°, with a towel or pillow under their shoulders and the neck extended (NTSP [206]).
Procedure guideline 12.11
Tracheostomy: changing a tube
Complications
Changing a tracheostomy tube is a high‐risk procedure and may result in the loss of an airway. All staff involved should stay calm and reassure the patient as necessary. There should be no delay in seeking expert or additional help if required, or in following the emergency algorithm for an altered airway if necessary (see Figure 12.35) (ICS [116], NTSP [206]). The patient should be oxygenated in between attempts and the stoma kept open using dilators or by putting traction on the stay sutures (Lee et al. [131]). If there is difficulty recannulating the stoma then insertion of a tube half a size smaller should be attempted (Mitchell et al. [161]). The tube should never be forced, and blind insertion of a guide into the stoma after the tube has been removed should only be considered in an emergency. The NTSP ([206]) recommends the use of a fibreoptic scope and airway exchange catheter as a second line if recannulation using a tube one size smaller is unsuccessful.
