return to: Tracheotomy - Tracheostomy

PURPOSE

1. To ensure the patency of the tube, promote hygiene, and minimize the potential for infection.

EQUIPMENT

1. Appropriate size sterile tracheostomy tube with ties/Velcro strap
2. Sterile tracheostomy dressing/drain sponge
3. Sterile gloves, drape, basin, and scissors
4. Sterile saline solution or water-soluble lubricant
5. Sterile 10 cc syringe

PROCEDURE (see: video demonstration of tracheotomy change)

1. Explain the procedure to the patient.
2. Wash hands thoroughly.
3. Unfold drape on dry surface.
4. Place the tracheostomy tube and a small amount of lubricant or basin of saline solution on sterile drape.
5. Position the patient supine with a pillow under shoulders to hyperextend the neck.
6. Glove.
7. Insert tracheostomy tie through slit in the flange of the outer cannula.
8. Ensure that the obturator and inner cannula properly fit the outer cannula. If a cuffed tracheostomy tube is used, assess the integrity of the cuff. Refer to package instructions for specific information.
9. Place the obturator in the outer cannula.
10. Lubricate the tip of the obturator and outer cannula with sterile saline solution or water-soluble lubricant.
11. Ensure that the tracheostomy cuff of the tube to be removed is deflated.
12. While holding the tracheostomy tube in place, cut the ties of the tube to be removed.
13. Remove the tracheostomy tube from the stoma and immediately insert the sterile tracheostomy tube. During insertion, the obturator should be held securely inside the outer cannula.
14. After insertion of the tube, withdraw the obturator immediately.
15. Secure the tie in a triple knot at the side of the neck. Tension of tie should allow for easy placement of an index finger underneath the tie. A Velcro tracheostomy tube strap is another option.
16. Insert the inner cannula and lock in place.
17. Inflate the tracheostomy cuff (if ordered).
18. Place the sterile tracheostomy dressing/drain sponge next to the skin surface under the neck plate.
19. Ensure that the obturator is readily available for reinsertion of the tube if displaced.
20. Discard disposable equipment.
21. Wash hands thoroughly.

PRECAUTIONS, CONSIDERATIONS, AND OBSERVATIONS

1. The patient's airway should be cleared by coughing or suctioning prior to changing the tracheostomy tube.
2. The obturator is to remain with the patient at all times.
3. A second complete sterile tracheostomy tube of the same size should be readily available.
4. The first tracheostomy tube change should be performed by the physician after 3 to 5 days when the tract is well formed. Thereafter, the tube may be changed by a registered nurse for the following indications:
   1. Physician order
   2. Weekly tracheostomy change for hygiene measures
   3. Faulty tracheostomy tube cuff
   4. Occluded outer cannula that cannot be cleared with suction
   5. An alternate style or size of tube is required
5. It is recommended that a second nursing staff member be present during the tracheostomy tube change.
6. In an emergency, the tracheal airway can be maintained with a nasal speculum, hemostat, trachea stoma spreader, endotracheal tube, or suction catheter. The adult patient should be positioned with the neck hyperextended until the tracheostomy tube can be reinserted.

REFERENCES

Tabaee A, Lando T, Rickert S, Stewart MG, Kuhel WI. Practice patterns, safety, and rationale for tracheostomy tube changes: a survey of otolaryngology training programs. Laryngoscope. 2007 Apr;117(4):573-6. doi: 10.1097/MLG.0b013e318030455a. PMID: 17415123.