A tracheostomy tube is a curved, hollow device inserted into the trachea through a surgically created opening in the neck known as a stoma. This tube provides an alternative airway, bypassing the nose, mouth, and throat to facilitate breathing, especially for individuals requiring long-term mechanical ventilation. Changing the tracheostomy tube is performed regularly, often every one to eight weeks, to ensure airway hygiene and integrity. Routine replacement is necessary because mucus and secretions can build up inside the tube, potentially leading to blockage, or because a change in tube size or type is needed.
Gathering Necessary Supplies and Preparing the Patient
Preparation is necessary for a safe tracheostomy tube change, ensuring all necessary items are immediately accessible before the old tube is removed. The care provider must have two new tracheostomy tubes ready: one of the patient’s current size and one a size smaller, in case of difficulty with re-insertion. Essential equipment includes the new tube with its obturator inserted, a syringe for cuff inflation/deflation (if cuffed), water-based lubricant, and suctioning apparatus. Additional items, such as sterile gloves, saline solution, a light source, and new tracheostomy ties, must be organized on a clean field.
Proper patient positioning is required to align the trachea for easier tube insertion. The patient should be placed supine with the neck slightly extended, often achieved by placing a small rolled towel beneath the shoulders, unless a neck injury prevents this. This maneuver brings the trachea anteriorly, making the stoma easier to visualize and access. The procedure should be explained clearly to the patient to ensure cooperation.
The old tracheostomy ties and dressings should be removed while a second person stabilizes the tube to prevent accidental dislodgement. If the patient is dependent on high levels of oxygen or ventilation, pre-oxygenation is implemented using an Ambu bag or specialized collar. This maximizes the oxygen reserve before the airway is temporarily interrupted during the brief tube exchange.
Step-by-Step Procedure for Tube Replacement
The initial step involves clearing the airway of secretions by suctioning through the existing tracheostomy tube. If the old tube is cuffed, secretions pooled above the cuff must be removed prior to deflation to prevent aspiration into the lower airway. Once cleared, the cuff is completely deflated using the syringe to ensure the tube can be removed smoothly without causing trauma to the tracheal wall.
The old tube is removed with a swift, controlled, downward and outward movement, often timed with the patient’s cough or exhale. Speed is necessary during the exchange, as the patient’s airway is unprotected until the new tube is fully seated. Immediately after removal, the new tracheostomy tube, with the obturator securely inserted, is guided into the stoma.
The new tube should be inserted gently, following the natural curvature of the stoma and trachea. The obturator must be removed immediately upon successful placement, as the patient cannot breathe while it is in the lumen. If a cuffed tube is used, the cuff is then reinflated to the prescribed pressure, creating a seal against the tracheal wall.
If the stoma is new or insertion meets resistance, the tracheostomy tract may be temporarily dilated. A tracheal dilator or a hook may be used to gently widen the opening. If the new tube is difficult to insert, attempting a tube one size smaller is the standard approach to minimize trauma and secure the airway. The insertion should never be forced, as this risks creating a false passage in the tissue.
After successful placement, the care provider must hold the neck plate firmly until the new ties or holders are secured. In complex situations, an airway exchange catheter can be inserted through the old tube before removal, acting as a guide wire to maintain the path to the trachea.
Immediate Post-Change Care and Assessment
Once the new tracheostomy tube is secured, immediate assessment confirms proper placement and adequate ventilation. The provider must listen to the patient’s chest with a stethoscope to confirm bilateral breath sounds, ensuring air moves equally into both lungs. Observing the patient’s comfort level, skin color, and chest wall movement helps verify the airway is functional.
The new ties or specialized holders must be secured firmly, yet comfortably, around the neck. Only one finger should fit snugly between the neck strap and the patient’s neck, preventing dislodgement while avoiding excessive pressure. If the tube is cuffed, the cuff pressure must be checked with a manometer to ensure it is within the safe range (typically 20 to 30 cm H2O) to prevent tracheal injury.
The stoma site requires meticulous care to prevent infection and skin breakdown. The area around the tube’s flange should be gently cleaned with sterile saline to remove secretions. A fresh, pre-cut dressing is then placed under the neck plate, ensuring the dressing is not frayed, as loose fibers could enter the stoma.
The patient’s vital signs, including oxygen saturation and respiratory rate, should be monitored closely for several minutes following the procedure. Any signs of respiratory distress, persistent coughing, or excessive bleeding warrant immediate attention. Documenting the date, time, and size of the new tracheostomy tube is the final step in post-change care.
Identifying and Managing Potential Issues
The most serious complication during a tube change is complete dislodgement, or decannulation, especially if the stoma tract is not fully mature. If the old tube is accidentally removed and the new tube cannot be inserted easily, the primary focus is maintaining a patent airway. The care provider should attempt re-insertion with the smaller tube size kept at the bedside for this purpose.
If immediate re-insertion fails, the stoma may begin to close rapidly, leading to respiratory compromise. The stoma should be kept open using a tracheal dilator or by inserting a rigid suction catheter to act as a guide. Oxygen should be administered over the mouth, nose, and stoma simultaneously, and emergency medical services must be called immediately.
Difficulty inserting the new tube can signal a false passage, meaning the tube is entering the tissue next to the trachea. If resistance is encountered, the tube must be withdrawn immediately and the insertion angle adjusted; never force the tube. Persistent bleeding or signs of respiratory distress, such as cyanosis or rapid heart rate, indicate a serious issue requiring urgent medical intervention.
For high-risk patients or those experiencing a difficult exchange, an airway exchange catheter can be employed to secure the airway. This device is passed through the old tube into the trachea and remains in place as a guide for the new tube, ensuring a continuous route to the airway.