A tracheostomy tube is a specialized breathing tube inserted through a surgically created opening, called a stoma, in the front of the neck and into the trachea, or windpipe. This procedure creates a patent airway to assist with breathing, manage secretions, or deliver oxygen directly to the lungs, often bypassing an obstruction in the upper airway. The tube itself must be changed routinely for several important reasons to maintain airway hygiene, prevent the buildup of secretions and biofilm, and minimize the risk of infection at the stoma site. Consistent replacement also allows for the assessment of the stoma, replacement of a worn or malfunctioning tube, or a change in tube type to accommodate a patient’s progress, such as transitioning to a smaller size or a cuffless model. This article will provide a detailed, step-by-step guide on the preparation and procedure for safely changing a tracheostomy tube.
Essential Supplies and Preparation Steps
The foundation of a safe tracheostomy tube change is having all the necessary equipment prepared before the procedure begins. A clean, flat surface should be used to lay out the supplies, ensuring a sterile or clean field to work from. A second person should ideally be present to assist with the process and manage any immediate needs. Key items include the new tracheostomy tube of the correct size, its obturator, and a spare tube that is one full size smaller for emergency use. This smaller size can often be inserted more easily if the stoma tightens.
Hand hygiene is the first and most fundamental step, requiring thorough washing with soap and water for at least 20 seconds, followed by the donning of sterile gloves to maintain asepsis. The new tube must be inspected for any damage. If it is a cuffed tube, a syringe should be used to inflate and deflate the balloon to test its integrity and ensure it holds air without leakage.
Once the new tube is verified, the obturator—the solid, rounded guide—is inserted into the outer cannula. A water-soluble lubricant is applied generously to the tip of the obturator and the lower part of the tube to facilitate smooth insertion.
Patient positioning is also a critical preparatory step, typically involving placing a rolled towel or small blanket beneath the patient’s shoulders to slightly hyperextend the neck. This positioning helps to align the trachea and makes the stoma opening more visible and accessible. All other supplies, including the new tracheostomy ties, split gauze dressing, and suction equipment, should be placed within immediate reach. Confirm the suction unit is functional and appropriate catheters are available.
Detailed Procedure for Tracheostomy Tube Replacement
The initial step of the replacement procedure involves clearing the existing airway to minimize the risk of introducing secretions into the lungs during the tube exchange. The patient should be suctioned through the existing tube to remove any pooled mucus. If the tube is cuffed, the balloon must be completely deflated using the syringe. This deflation should ideally be timed with the patient exhaling or coughing forcefully to help expel any remaining secretions from the upper trachea.
With the old tube firmly held in place, the old tracheostomy ties are carefully cut and removed from around the patient’s neck. The patient should then be instructed to take a deep breath to dilate the airway. As they begin to exhale, the old tube is withdrawn smoothly in a downward and outward motion. The goal is to perform the removal and subsequent insertion as rapidly as possible to limit the amount of time the airway is unsecured.
Immediately after the old tube is removed, the new, lubricated tube, with the obturator securely locked inside, is inserted into the stoma with a gentle, smooth, and slightly downward arc. The obturator provides a blunt, rounded tip that guides the tube safely along the path of the stoma and into the trachea, preventing the tube from catching on the tissue and creating a false passage. If resistance is felt at any point, the insertion should cease immediately, and the tube should be withdrawn slightly and repositioned before attempting to advance again.
The obturator must be removed instantly once the tracheostomy tube is fully seated, as it completely blocks the flow of air. The caregiver must hold the outer cannula securely in place while withdrawing the obturator to ensure the new tube does not become dislodged. If the tube has an inner cannula, it is then inserted and locked into place. If the tube is cuffed, the balloon is reinflated using the syringe to the appropriate pressure, creating a seal within the trachea.
The final procedural step is to secure the new tracheostomy ties around the neck. Ensure they are snug enough to prevent movement but not so tight as to cause skin irritation or impede blood flow. One to two fingers should fit comfortably between the tie and the patient’s neck. A sterile, pre-cut split gauze dressing is then placed beneath the flange of the new tube to absorb secretions and protect the skin.
Post-Change Care and Emergency Protocols
Following the successful insertion of the new tracheostomy tube, a series of immediate checks must be performed to confirm proper placement and patient stability. The caregiver should listen closely for air movement through the tube and check for bilateral breath sounds with a stethoscope to confirm that both lungs are being ventilated equally. Observing the patient’s skin color and level of comfort provides quick reassurance that the airway exchange was successful and the patient is receiving adequate oxygenation.
Routine Stoma Care
Routine stoma care forms the basis of long-term infection prevention and skin integrity maintenance. It should be performed at least once daily or whenever the dressing becomes soiled. The skin around the stoma should be gently cleaned using cotton-tipped applicators or gauze moistened with sterile saline or a prescribed cleaning solution. Wipe away from the stoma opening to prevent contamination. A fresh split-gauze dressing should be applied after cleaning, keeping the area dry and free from excessive pressure from the tracheostomy tube flange.
Emergency Decannulation Protocols
Despite careful technique, emergencies can occur, with the most pressing being accidental decannulation, where the tube is completely dislodged. If this happens, immediate action is required. The caregiver must call for emergency medical assistance or 911 while simultaneously attempting to re-establish the airway.
The primary goal is to reinsert a tracheostomy tube quickly. First, try the replacement tube of the same size. If that meets resistance, immediately attempt to insert the smaller-sized rescue tube that should always be kept at the bedside.
If the tube cannot be immediately reinserted, oxygenation must be maintained by covering the stoma with a resuscitation bag (Ambu bag) and mask and ventilating, or by attempting to ventilate the patient through their mouth and nose. The obturator from the dislodged tube must be kept available to assist with reinsertion efforts, as it is the smoothest guide for the tube. Significant coughing, bleeding, or the inability to pass a suction catheter through the new tube are all signs of a potential complication that requires urgent medical evaluation.