TRACHEOSTOMY TUBE CHANGES:
Tracheostomy changes will become very routine, but for your first couple changes it is good to have a senior resident with you.
Before every trach tube change, there are a couple very important questions to answer to avoid a potential disaster:
- What was the indication for the tracheostomy to begin with? If the trach was placed for prolonged ventilation, this is much different than for acute upper airway obstruction or a slash tracheostomy in someone who could not be intubated. The answer to this question will guide what you will do in the case of either accidental decannulation or inability to cannulate the stoma during the trach change. Make sure to always set yourself up for success. Have all the equipment with you that you could possibly need, particularly for patients who are completely dependent on the tracheostomy for ventilation.
- How long has the trach been in place? The longer the tracheostomy tube has been in place, the more mature the stoma and usually the less difficult the tracheostomy change.
- Was the stoma surgically “matured” during surgery? Patients with Bjork flaps or stay sutures are easier to perform trach changes on and you are much less likely to false passage.
Bottom-line: take each trach change seriously and be prepared. Unfavorable conditions include new trach (<5-10 days out, no “surgical maturing” of the stoma, patients that are completely depending on trach for ventilation.
What tube to replace with?
Tracheostomy tubes can be broadly categorized into cuffed and non cuffed tubes. Any patient that requires ongoing or night time positive pressure ventilation will require a cuffed tube. Common cuffed tubes include Bivonas and Shileys. The Bivona brand typically should have saline in the cuff while Shiley’s usually require air. Typical size requirements for adults are 7-8 (male) and 6-7 for a female. One final consideration is whether to use a tube that has an inner canula. Having an inner canula is particulary helpful in patients with large amounts of thick secretions because they can easily cleaned without needing the whole tube removed. Trach tubes without the inner canula have a larger inner diameter therefore less resistance than those with.
Equipment you should have readily available during a trach change:
- An extra set of hands to help with suction, holding the trach in place while you secure it etc…
- Good lighting, preferably a powerful headlight
- Suction (flexible suction catheter and Yankauer)
- Nasal speculum (helpful to examine stoma tract and dilate opening if needed)
- Trach hook, particularly for the low riding trachea
- The correct obturator
- Some sort of scope (flexible nasopharyngoscope) to ensure that the trach is in the correct location and not abutting the tracheal wall
- Soft Velcro trach ties or cotton twill ties
- Normal saline or K-Y jelly for lubricant
How to replace the tracheostomy tube:
- Make sure you have everything that you might need out and readily accessible. Again, if the patient has absolute dependence on the tracheostomy tube for ventilation, make sure you bring any additional supplies to help in the event that you are having difficulty replacing it.
- Lay the patient flat and have a strong light source focused on the trach site.
- Examine the new trach to ensure it looks OK. If there is a cuff, test it for a leak.
- Place the obturator in the trach tube and lubricate the tip
- Suction out the existing tracheostomy tube and proximal trachea
- Have an assistant hold the existing tracheostomy tube with a suction ready while you remove the ties
- With a nasal speculum in hand, remove the existing tracheostomy tube and open the stoma with the nasal speculum to examine the stoma
- Replace with the new tracheostomy tube, remove obturator and have assistant hold new tube in place
- If the patient requires positive pressure ventilation, have the assistant reconnect the circuit while you inflate the cuff and secure the tube with trach ties
- Use your flexible scope to examine placement to ensure it is sitting centrically in the lumen of the trachea to avoid the long term complications of iatrogenic tracheoesophageal fistula or anterior tracheal wall erosion and the ever feared tracheoinnominate fistula.
Helpful hints in the case of patients with accidental decannulation or inability to replace tracheostomy tube during trach change:
- Remember, if the patient is not completely dependent on trach, replacement is much less urgent that those that are.
- Use a nasal speculum to dilate the opening of the stoma and a cric hook (if you can safely identify the cric cartilage) to expose the tract
- Place the tracheostomy tube over a flexible nasopharyngoscope and guide the scope into the tracheal lumen. This carries the advantage that you can directly see if you have entered the trachea and not a false passage. Once you have entered the trachea, you can “Seldinger” the trach tube into the trachea
- If this fails and the patient urgently needs an airway, you can try to mask, intubate or LMA the patient from above
- In an absolute emergency with respiratory distress, surgical cricothyrotomy or “slash” second tracheostomy can be performed
- If you encounter a patient and anticipate an abnormally difficult trach tube change, you can always change the trach over a flexible stylet or similar device
* Accounts of George Washington’s death suggest that he died from an episode of acute epiglottitis. One December morning in 1799, George Washington awoke with a severe sore throat. Throughout the day, his condition rapidly deteriorated as he developed difficulty in swallowing, a muffled voice, and persistent restlessness. Although a tracheotomy was suggested by one physician in attendance at his bedside, the procedure was not well-practiced at that time, and a series of bloodlettings were performed instead. He expired less than 24 hours from the onset of his symptoms.
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