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? Was the tracheostomy planned or an emergent procedure? Can the patient be masked or intubated from above if necessary?
- Do you have the right tools? Make sure to always set yourself up for success by having 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? A recent (<1 week) stoma carries the risk of creating a false passage with a new tube. Also, beware the trach change on a patient who’s had a longstanding trach who may have developed extensive granulation tissue or stenosis around the stoma – it can be difficult to bypass with a new tube.
- 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?
- Cuffed or uncuffed: Any patient that requires positive pressure ventilation requires a cuffed tube. Uncuffed tubes are more comfortable for patients and better to use with a Passy-Muir valve.
- Size: Typical requirements for adults are inner diameter 7-8 for men and 6-7 for women.
- Brand names: The two most commonly used brands are Bivona and Shiley. Note that the sizes between brands are not equivalent (see chart). Shiley tubes have an inner cannula, which can be helpful in patients with large amounts of thick secretions because they can be cleaned without removing the entire tube. Bivona tubes do not have an inner cannula, which allows for a smaller outer diameter.
- Shiley sizing
|Size||O.D. (mm)||I.D. (mm)||Length (mm)|
- Bivona sizing
|Size||O.D. (mm)||I.D. (mm)||Length (mm)|
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 or curved clamp (helpful to examine stoma tract and dilate opening if needed)
- Trach hook, particularly for the low riding trachea
- Trach tube with correct obturator, and an extra trach tube one size smaller
- 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 lubrication
- 10cc syringe if changing a cuffed tube
- Consider bringing a percutaneous tracheotomy kit if you are worried about stomal granulation or stenosis; the dilator in the kit can come in very handy
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. Place a shoulder roll if the patient can tolerate it.
- 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
- Deflate the cuff of the existing tracheostomy tube
- With a nasal speculum or curved clamp in hand, remove the existing tracheostomy tube and open the stoma with the nasal speculum (or clamp) 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.
If you are unable to replace tracheostomy tube during trach change:
- Assess the patient’s respiratory status. Are they moving any air without the trach tube in place? If they are breathing comfortably, there is much less urgency to getting the new tube in.
- Use a nasal speculum or curved clamp to gently 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
- For a mature stoma that is too tight to pass the new trach tube, try using the next size smaller, or try dilating the tract with the trach dilator from a percutaneous tracheotomy kit.
- If you are still unsuccessful and the patient is in distress, you should call a code to get the airway cart. If the patient has a patent upper airway, try to mask ventilate, intubate or place an LMA. You can also try passing a very small endotracheal tube (size 5 or smaller) through the stoma.
- In an absolute emergency with respiratory distress, surgical cricothyrotomy or “slash” second tracheostomy can be performed