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Tracheostomy Exchange
Overview
The majority of tracheostomy changes are uneventful; however, appropriate preparation and planning is important in avoiding and addressing emergent situations that can occur during tracheostomy changes. Each tracheostomy change should be approached with a well thought out plan and the necessary equipment to regain control of the airway in the event of complications. The first tracheostomy change is commonly performed by the service that originally placed the tracheostomy on post-operative day 5-14, depending on the institutional protocol and patient-specific situation. An American Academy of Otolaryngology and Head and Neck Surgery consensus statement recommends that an experienced physician make the first change on days 10-14 for trachs placed percutaneously, but allow for surgical tracheostomies with favorable anatomy to be changed as early as 3-7 days to facilitate discharging a patient. It is recommended to have a more senior resident walk you through your first several tracheostomy changes. Calling ahead to inform nursing staff, ICU teams, and respiratory therapy also makes tracheostomy changes more safe and efficient.
Key supplies for tracheostomy exchange
Nurse and/or respiratory therapist to help you
Appropriate PPE including masks, eye protection, gloves, gown
Headlight
Appropriate tracheostomy tubes***
Lubricant
Suture removal kit
10 ml syringe
Suction (Yankauer tip and flexible inline suction)
Nasal speculum or tracheostomy spreader
Retractors: Cric hook, army-navy’s x 2, bands
Trach ties (velcro or Dale collar)
Flexible fiberoptic endoscope
***Consideration should be given to the patient’s ventilator needs. It is important to compare various tracheostomy tubes based on their outer diameter (size of tract) and their inner diameter (correlation of effective airway size with other tubes). A patient requiring ventilator support with a significant secretion burden will benefit from a cuffed Shiley tracheostomy tube, to allow for inner cannula exchanges. Patients trending towards vent weaning or requiring intermittent ventilation will benefit from a Bivona, due to its “tight to shaft” cuff allowing for breathing and talking around the tube more easily. Patients with no ventilator needs can be exchanged to a cuffless Shiley. Ultimately a joint decision should be made that allows for the best care of the patient.
Steps of Tracheostomy Tube Exchange
Place an ABD pad on the patient’s chest and lay out the following items: tracheostomy tube (test the balloon if using cuffed tube, lubricated) with the obturator inside, empty 10ml syringe (or syringe with sterile water if applicable), nasal speculum, new inner cannula if applicable. If using a water-cuff tube, ensure that the cuff inflates circumferentially when testing it (cuff often sticks to shaft and inflates partially on first test). Remove all air from the cuff, pilot balloon, and tube (most tubes ship with a small amount of air that will affect your measurement of cuff inflation volume). Prepare the flexible scope (use anti-fog) and place it at the foot of the patient’s bed for easy access. Have nasal speculum and other retractors immediately available at bedside. Know where endotracheal tubes are kept on the floor
Increase FiO2 to 100% If otherwise clinically safe to do so
Using a flexible suction to clear the airway before the tracheostomy tube change may be helpful
Patient positioning: lay the patient flat (flatten the bed), and remove any pillows. Extend the patient’s neck if possible; a shoulder bump may be helpful for obese patients
While a colleague holds the tracheostomy in place, cut the sutures securing the tracheostomy tube to the skin
Have both a flexible suction and Yankauer suction set up. Remove the tracheostomy tie or collar and have an assistant hold the trach until it is time to remove. Verbally prepare the patient (We are going to remove the tube now, you will probably cough, etc)
Deflate the balloon completely. This may cause patients to cough significantly as any secretions sitting above the cuff will fall into the airway
Use the help of RT to disconnect from the vent when the time comes. You may have to move more quickly if the patient is requiring ventilation support
Remove the tracheostomy tube. With the help of your headlight and the nasal speculum, get a good view of the tracheostomy tract. Use Yankauer suction to clear the path of secretions. Place the new tracheostomy tube, remove the obturator, place the inner cannula, if applicable, inflate the new balloon. Connect the ventilator if needed. If the anatomy is difficult, or if you’re having a hard time visualizing, use the retractors to visualize the tracheostomy tract. Visualization of the tract is important to avoid a false passage. If helpful, the fiberoptic scope or a suction catheter can be used in a Seldinger fashion to identify the airway and then slide the tracheostomy tube into the airway
Patients react differently to tracheostomy tube changes. Some handle it very well, others are coughing, choking, gasping. Continue to communicate with them and help them remain calm. If they are coughing up mucus, you can suction with Yankauer or flexible suction
After the new tracheostomy tube is in place, confirm appropriate placement within the trachea with the flexible endoscope. The tracheostomy tube should sit easily in a neutral position without abutting the tracheal wall
Secure the trach in place with new trach collar. The collar should be relatively tight, but you should be able to fit 2 fingers under the collar. Place any needed stomal dressings while your assistant holds the tube
that the patient is comfortable and moving air well. If the new tracheostomy tube is a different size or type, it may initially be irritating to the trachea and cause coughing for several minutes to hours. If the patient is moving air, oxygen saturation is normal, and placement has been confirmed with a scope, reassure the patient that the adjustment period is normal and will improve
Pro Tips:
In all cases, a second set of hands is helpful; some institutional protocols require more than one person to be available during a tracheostomy tube change
When documenting a note regarding the tracheostomy change, describe the new trach type and how it sits in the trachea. Tracheostomy change before the stoma is fully healed is a billable code (CPT 31502)
See the Tracheostomy Bleed section or below for more detail on Shiley and Bivona tracheostomy tubes
Some patients will have metal tracheostomy tubes or tracheostomy tubes with which you may not be familiar. Compare the outer diameters for fit and the inner diameters for airway sizing needs. Sizes of uncommon tubes can generally be found quickly on the internet
Example Procedure Note
A routine tracheostomy tube change was performed at the bedside. Verbal consent was obtained from the patient and/or family prior to proceeding. Universal protocol was followed throughout. The patient was placed in the supine position with the neck extended. The original tracheostomy tube was examined, and the stoma appeared to be healing well with no signs of infection, bleeding, irritation, or wound breakdown. A fiberoptic exam was performed through the lumen of the existing tube, which demonstrated that the current tracheostomy tube was in position in the center of the airway. There were no signs of granulation tissue or airway irritation.
A suction catheter was used to clear the tracheostomy tube and trachea or secretions. The sutures securing the tracheostomy tube to the skin were cut, and the trach ties were undone. The balloon on the existing trach was deflated. The existing trach was gently removed, and a ___ was used as a retractor to maintain patency of the stomal opening. The tract was examined, and appeared to be healing appropriately. A new ___ -sized tracheostomy tube was placed through the stoma. The fiberoptic scope was placed through the lumen of the new tube to confirm positioning. The tube appeared to be in good position, without abutting the walls of the trachea. The balloon on the trach was inflated. The tube was secured with Velcro ties. The patient tolerated the procedure well with no desaturations or complications. Please do not hesitate to page the Otolaryngology Consult service at ___ with any additional questions or concerns.
Tracheostomy Tubes
Shiley:
Inner Cannula
Safety measure for patients with increased secretions; this is a great answer to RT when they want to switch to a Bivona
Rigid shaft, more right-angled
Cuffless option for long-term trachs
Proximal and Distal XLT for obese necks
Floppy cuff if deflated, can take up space in trachea and make it more difficult to breath around
Bivona:
Cuff is tight to shaft when deflated
Smaller flange, less peristomal skin irritation
Flexible shaft
Come in flexible adjustable length for difficult to fit necks
Cuff filled with sterile water
With time NaCl in saline can precipitate, and cause air leak or obstruct the small tubing that allows for inflation/deflation of cuff
Airway Size Guide
* Fenestrated and cuffless Shileys have same dimensions as above x = size number (i.e. 4DCT is a 5.0 mm ID)
Model xDCT: cuffed with inner cannula
Model xDFEN: cuffed, fenestrated, with inner cannula Model xDCFS: cuffless with inner cannula
Model xDCFN: cuffless, fenestrated, with inner cannula
References
Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. 2013;148(1):6-20. doi:10.1177/0194599812460376
Kraft SM, Schindler JS. Tracheotomy. In P.W. Flint, et al (Eds.), Cummings Otolaryngology Head and Neck Surgery 7e (pp. 95-103). Philadelphia, PA: Elsevier.
Durbin CG Jr. Tracheostomy: why, when, and how?. Respir Care. 2010;55(8):1056-1068.