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Changing a Tracheostomy Tube

It is usual for all tracheostomy tubes to be changed. A change may be required because of a tube fault, a change in the patients clinical needs or the length of time the tube has been in place for.

Every planned tube change should be carried out with at least two suitably trained staff or carers, this will allow one person to hold the tube securely whilst the tapes and dressings are being removed and changed. Where the patient is likely to struggle or become agitated, a third person may be needed to offer further assistance.

Preparation
Communication between the team, including the patient, is paramount for a safe and successful procedure.

A tube change can be a worrying time for a patient and their carers. An adequate explanation and preparation for the patient are essential in helping to alleviate these concerns.

If the patient is at risk from vomiting and/or aspirating any gastric contents, then the patient should have been kept nil by mouth (NBM) for at least 3-4 hours and/or aspirate the nasogastric tube if present (St. Georges Healthcare NHS Trust, 2000).

Patient positioning
The ideal position to change a tube is with the patient in the supine position with the neck in hyperextension. A sandbag or rolled towel underneath the patient’s shoulders will allow neck hyperextension as shown in figure 1. However, some patients may be more comfortable to sit upright for the procedure to help clear secretions (Mirza and Cameron, 2001).
Fig 1: Adult positioned for a tube change

Equipment List (photograph of equipment )

  • Same size tube (checked an intact)
  • Smaller size tube
  • Stitch cutters
  • 10ml syringe
  • Cuff pressure manometer
  • Blunt ended scissors
  • Sandbag or rolled up towel
  • Tracheostomy ties/tapes
  • Suction equipment
  • Water soluble lubricating gel
  • Normal saline
  • Pre cut tracheostomy dressing and barrier solution

Additional equipment

  • Guidewire or bougie
  • Tracheal dilators
  • Re-breath bag
  • Stethoscope
  • Intubation equipment
  • Gloves, apron and eyeshield

The tube change procedure

Action

Rationale

Put on gloves, apron and eye protection

To adhere to infection
control guidelines

Remove clothing that obstructs
the neck or equipment

To allow good visualisation and access to the tracheostome

Prepare tube with introducer in place
on a prepared sterile surface

To allow ready access to a prepared tube and dressing pack

Apply a small amount of water soluble lubricating gel along the length of the
shaft, deflated cuff and introducer tip Optional: attach tapes/straps

To minimise trauma to tracheal mucosa during insertion of the tube, excessive amounts will cause aspiration and coughing

Lie the patient flat with neck extended and pillow underneath the shoulders (unless contra-indicated)

To ensure correct positioning
for insertion of the tube

Cut/untie the tapes/straps and remove the soiled tube whilst asking the patient
to breathe out

Conscious expiration relaxes the patient and reduces the risk of coughing (Addenbrooke’s NHS Trust, 1996)

Observe stoma site

To identify signs of infection, wound breakdown and/or granulation tissue

Insert new tube in an ‘up and over’ action

 

Introducing the tube in this way is less traumatic as this directs the tube along the contour of the tracheostomy tract

Remove the introducer

The patient can not breathe
with the introducer insitu.

Assess for correct positioning,

  • Chest rising?
  • Expired breath observed/heard/felt
  • Equal and bilateral air entry

To assess patency of new
tube and correct placement

If correct position confirmed then proceed to next steps

Re-inflate cuff to within 15-25cmH 2O, check with pressure manometer

To assist with positive pressure ventilation and protect from aspiration

Place the inner tube in position

The inner tube maintains patency of the tube

Suction mouth and tracheostomy as required

To clear secretions following tube change and cuff deflation

Re attach required ventilation equipment

To recommence ventilation support

Clean around the stoma and gently dry

To prevent wound infection and promote comfort and skin integrity

Replace dressing if appropriate

To protect the patients skin from secretions and improve comfort

Secure the tube with tracheostomy tape or velcro ties

To prevent dislodgement of the tube

Frequency of tube changes
The timing of subsequent tube changes will depend on the patient’s condition, clinical needs and the suitability of the current tube to accommodate these needs.

The majority of adult patients with a tracheostomy, especially on general wards are recommended to have a tube with an inner cannula (Heafield, Rogers & Karnik, 1999). This system helps maintain a patent airway due to the ability to remove and clean/replace the inner cannula. It is recommended that these tubes be changed every 28-30 days, depending on the manufacturer’s guidelines, (EEC Directive, 1993).

Tubes without an inner cannula should be changed more frequently to help maintain a patent airway. It is recognised best practice that single lumen tubes are changed every 7 to 10 days (St. Georges Healthcare NHS Trust, 2000).

Troubleshooting - Strategies to help with a difficult tube change
Changing a new tracheostomy tube is not without risk or anxiety for the patient. It is therefore only advocated when clinical indicated.

  • Re-positioning the patient (fully extending the neck and/or lying flat)
  • Tracheal dilators can be used to hold open the stoma whilst attempts to re-insert the tube continue.
  • Using your fingers, gently spread the skin either side of the stoma
  • Attempt tube insertion as the patient inhales
  • If partly inserted, remove the tubes introducer, to allow the patient to breath whilst attempts continue, and then fully insert the whole tube, (Adamo-Tumminelli, 1993).
  • Following three or more unsuccessful attempts with the same sized tube, attempt inserting the smaller sized tracheostomy tube already prepared at the bedside
  • If a tube can be inserted but air entry cannot be confirmed on several attempts, then the tube should be removed to prevent obstruction of the airway by the tube in the pre-tracheal space and re-inserted into the correct position, a longer length tube may be required.
  • If no suitable tube is at the patient’s bedside then whilst awaiting the required tube of further assistance the use of a suction catheter, a small uncuffed endotracheal tube or a yankeur sucker may be used to prevent complete lose of the stoma opening and enable O2 delivery.
  • If no tube can be inserted then insert a suction catheter, trim and secure and administer O2 as required (Seay, Gay & Strauss, 2002).
  • If oxygen therapy and or resuscitation are required whilst awaiting tracheostomy re-insertion, cover the stoma and provide bag valve mask ventilation or mouth to mouth ventilation, (Tippett, 2000).
  • If your patient has no patent upper airway due to vocal cord palsy, upper airway oedema or tumour, then deliver required O2 via stoma supported by tracheal dilators.
  • If an alternative airway is needed then urgently seek the assistance of your on-call anaesthetist or ENT Surgeon to re-establish an airway.

References:
Adamo-Tumminelli P. A guide to pediatric tracheotomy care (2nd Ed) Charles C Thomas Springfield Illinois 1993
Addenbrooke’s NHS Trust Tracheostomy Care: Information Pack and Nursing Protocols Addenbrooke’s Cambridge University Teaching Hospital Trust 1996
EEC Directive- Class IIA, Rule 7. Council directive concerning medical devices, 93/42 EEC
Heafield S, Rogers M, Karnik A. Tracheostomy management in ordinary wards Hospital Medicine 1999 60 (4) 261-262
Mirza S, Cameron DS. The tracheostomy tube change: a review of techniques Hospital Medicine 2001 62(3) 158-163
Seay SJ, Gay SL, Strauss M. Tracheostomy Emergencies: correcting accidental decannulation or displaced tracheostomy tube. Am J Nurs 2002 102(3) 59-63
St. Georges Healthcare NHS Trust. Guidelines for the Care of patients with tracheostomy tubes St.Georges Healthcare NHS Trust. 2000 p.47-51
Tippett DC (Ed) Tracheostomy and ventilator dependency: management of breathing, speaking and swallowing Thieme New York 2000