Overview of Tracheostomy Tube Change

A tracheostomy is a medical procedure that involves creating a new passageway that connects the windpipe to the outside of your body. This bypasses the voice box and upper air passage. The term “tracheostomy” refers to both the procedure itself and the resulting passageway between the windpipe and the skin. The history of tracheostomies goes back to ancient Egypt and was studied in ancient Greece and Rome. The first known life-saving tracheostomy was done by a doctor named Brassavola in Italy in 1546 on a person with an abscess (a pocket full of pus) near their tonsils.

The procedure became popular in the early seventeenth century thanks to a doctor named Severino. He found it was especially useful during a diphtheria outbreak in 1610. Diphtheria is a serious throat infection that can block the airway. In the early twentieth century, a doctor called Chevalier Jackson worked on developing and refining the technique, addressing a lot of the problems and debates related to the procedure. However, during this century, doctors discovered that inserting a tube through the mouth or nose was often a safer and quicker alternative to a tracheostomy, with fewer complications. Therefore, nowadays careful thought is given to the pros and cons and the care needed after the procedure before deciding to do a tracheostomy.

In the United States, there was a significant increase in the number of tracheostomies being done between 1993 and 2012. In 1999 alone over 83,000 tracheostomies were performed. In England, around 15,000 tracheostomies are done each year in intensive care units, along with an extra 5000 surgeries carried out in operating rooms.

As more people are having tracheostomies, it is becoming increasingly important to make sure that their care is managed safely. This includes cleaning, suctioning (removing fluids), weaning (gradual withdrawal from dependency on a ventilator), decannulation (removal of the tracheostomy tube), and how to handle any emergencies related to the tracheostomy. Routine changes of the tracheostomy tube are an essential part of ongoing care, but without the help of trained staff, proper education, and a strong team specializing in tracheostomy care, complications can occur more often. This information should provide a basic understanding of the tracheostomy procedure, the relevant anatomy, and the principles behind tracheostomy care, focusing mainly on the safe exchange of the tracheostomy tube.

Anatomy and Physiology of Tracheostomy Tube Change

Tracheostomy is a medical procedure that can be done through open surgery or a technique known as percutaneous. This procedure involves making an opening in the neck to place a tube into a person’s windpipe. The tube allows air to enter the lungs. The doctor needs a thorough understanding of the structures in the neck to perform this procedure correctly.

The surgeon can choose to make either a vertical or transverse (horizontal) cut on the patients’ neck. Most prefer a horizontal cut because it can be hidden naturally in the creases of the skin on the neck, making it less noticeable. The operation involves several layers of tissue in the neck. These include the skin, fat under the skin, a muscle called the platysma, various protective layers in the neck, a structure called the thyroid gland isthmus, and finally, the windpipe.

Once the windpipe is reached, a horizontal cut is made between its second and third hard, ring-like structures. Different surgeons prefer different ways to do this. For example, some might make a cut that spans across the first three rings, while another technique involves securing a small flap of tissue to the skin where the tube will be inserted.

An alternative to the traditional tracheostomy is a technique called percutaneous tracheostomy, which can be done at the patient’s bedside or in an operating room, often guided by ultrasound or special cameras. This method became popular in the ’80s because it doesn’t require an operating room. It’s done by making a small hole and gradually widening it using dilators over a thin flexible wire. The choice between these methods depends on the equipment and expertise available.

For some patients – such as those who are very overweight, children, or those with a stiff or unstable neck spine – tracheostomy can pose unique challenges and require special considerations. For instance, in overweight patients, the layer of fat under the skin may require a longer tube. However, longer tubes may cause some issues when changing the tube. In children, the windpipe is shorter, so tubes need to be shorter as well, increasing the risk of accidentally puncturing the wall between the windpipe and the esophagus (the tube that carries food) if not handled with care.

A 2017 study found that most complications from tracheostomy occurred more than a week after the surgery, with a significant percentage of patients experiencing complications linked to the procedure. The leading cause of deaths related to tracheostomy is blockage of the tube, usually from sticky secretions or blood clots, followed by tube misplacement and unplanned removal. So, it’s very important to take measures that prevent these problems. Regularly checking vital signs is particularly crucial in children, who may not be able to express discomfort or difficulty breathing and may have less ability to tolerate these problems than adults.

Why do People Need Tracheostomy Tube Change

Tracheostomies, or surgeries that create an opening in the neck to reach the windpipe, have been performed for a long while, and for different reasons. These reasons vary widely, but include: taking care of obstructions in the upper airway, also known as the nose and throat area; securing the airway when it is compromised, like during injuries to the face, head or neck; helping to keep the airway clean and help remove secretions; keeping the airway safe, especially in those with neuromuscular disorders; and for people who require a machine to help breathe for more than 10 days, as a way to avoid complications from having a breathing tube for a long time. For kids, tracheostomies are done for other reasons, including problems with the airways from birth or acquired later, long-term ventilation needs due to neurological conditions, problems with the vocal cords, and infections that affect the airway.

In some situations, the tracheostomy tube might need to be changed for various reasons. These can include: checking the maturity of the new pathway made in the surgery, especially during the first change; maintaining a clean area around the opening and managing its hygiene, which is typically done every 30 days; changing the tube type, for example, from a type of tube that has a cuff to one without when someone doesn’t need machine-supported breathing anymore, or from a tube without holes to one with holes when someone starts speech therapy; making the tube size smaller; and finally, taking steps towards removing the tube.

When a Person Should Avoid Tracheostomy Tube Change

The only situation in which a tracheostomy tube absolutely should not be changed is if the stoma, which is the hole made in the neck for the tube, has not fully matured, or is not yet healed and stable.

There might in addition be reasons that make changing the tracheostomy tube not suitable or potentially risky, including:

  • The patient is in an unstable condition and is not strong enough for the procedure.
  • A patient requires a high level of oxygen and additional help from a ventilator (a machine that helps you breathe) to maintain their breathing
  • There’s a high chance that changing the tube might cause more damage to the tissues around the stoma or cause bleeding.

Equipment used for Tracheostomy Tube Change

There have been various scientific studies conducted to compare the risks of complications associated with two different ways of creating a tracheostomy – a surgical procedure that involves creating an opening in the neck to allow air to enter the lungs. One method is performed surgically (known as the open method) and the other using a needle and dilating devices, known as percutaneous tracheostomy.

In a study in 2007 by Oliver and colleagues, it was found that the percutaneous method was quicker than the surgical one, but it had a higher risk of early complications. However, other comprehensive analyses (known as meta-analyses) showed a preference for the percutaneous method despite these risks. That’s because this method generally takes less time and has a lower likelihood of causing an infection.

Both types of tracheostomy can have complications. These can be minor or major. Minor complications include limited bleeding, infection, short-term drop in oxygen levels, blockage of the tube, creation of a false passage, formation of an abnormal connection between the trachea and the skin (tracheocutaneous fistula), and an unsightly scar.

Major complications include severe bleeding that requires a blood transfusion due to an abnormal connection between the trachea and the innominate artery (tracheoinnominate fistula), formation of an abnormal connection between the trachea and the esophagus (tracheoesophageal fistula), narrowing of the area above the vocal cords (subglottic stenosis), narrowing of the trachea (tracheal stenosis), a condition that makes the trachea weak and collapsible (tracheomalacia), and death.

Complications can happen at different times. Some occur soon after the operation (early postoperative complications) such as severe bleeding, tube dislodgement or blockages, air trapped underneath the skin (subcutaneous emphysema), soft tissue infection, and air in the chest cavity (pneumothorax or pneumomediastinum). Others occur more than three weeks after the operation (late complications) and include tracheal narrowing or weakness, equipment failure, abnormal connection between the trachea and the innominate artery or esophagus, infections like aspiration pneumonia, etc.

A tracheoinnominate fistula, although rare, is a concerning complication. This forms an abnormal connection between the trachea and an artery in the neck. Sometimes, minor bleeding from the tracheostomy may suggest the development of a fistula. Typically, this artery runs beneath the usual place for the tracheostomy, but factors like creating the tracheostomy too low down, over inflating the tube, or previous radiation treatment to the neck can increase the risk of fistula formation.

If severe bleeding happens, the tube is inflated to the maximum and pulled towards the breastbone to put pressure on the artery. As needed, suction is used to keep the airway open. Immediately, a senior heart and lung surgeon should be called while preparations for blood transfusion are made.

Frequent tube exchange comes with its own risks and requires a good understanding of the procedure and readiness for potential problems. In fact, many healthcare centers have guidelines to ensure safe and smooth exchange. Continuous training helps improve proficiency and minimize complications, especially those associated with tube blockages. The most common cause of tube blockage is inadequate cleaning and maintenance of the inner tube. The inner tube helps to collect secretions and in case of emergencies, it can be pulled out quickly to help maintain an open airway while it is cleaned or replaced.

The primary issue during a tracheostomy tube change is the tube dislocating or creating a false passage. This false passage, signaled by air trapped under the skin and breathing difficulty, is more likely when the tracheostomy and its tract are not completely healed, usually during the first tube replacement. This first replacement should ideally be done not before 5 to 7 days after the procedure and under direct visualization. Thankfully, the rate of accidental decannulation has substantially dropped over the years due to improved care of tracheostomies. If suspected, the tracheostomy tube should be immediately and carefully replaced. An airway exchange catheter may be used during changes to reduce the risk of dislocation.

Obstruction and accidental dislodgement of the tube seem to be more common in people who are overweight or obese. Dislodgement specifically is associated with higher morbidity and mortality. In the rare event of this complication, following basic or advanced life support protocols is vital and emergency support should be called bringing experienced staff like anesthesiologists, surgeons, or ear, nose, and throat specialists to assist in re-establishing an open airway. Attempting oral intubation may be considered to establish a definite airway, especially in cases of respiratory arrest. However, using a bag and mask for ventilation might be a quicker way to provide oxygen to the patient.

Who is needed to perform Tracheostomy Tube Change?

If you’ve had a tracheostomy (a hole made in your neck for breathing), it’s safe for medical staff to replace the tube on a regular hospital floor, as long as they are properly trained and have the right equipment and support. However, the first time they replace the tube, they might need more help from other medical staff. This can be risky, and it’s more common for problems to happen on a general hospital ward than in intensive care or other specialized units. There’s a lot of advice about how and who should replace the tube. Usually, an experienced resident doctor handles or oversees the first replacement and they avoid doing this at night or on weekends to make sure there’s an experienced team around in case of emergencies. Other healthcare professionals can do this too – such as ear, nose and throat specialists, general surgeons, lung doctors, anesthesiologists, trained nurses, speech therapists, respiratory therapists, and specialist nurses. For children, or serious cases, an ear, nose and throat specialist or general surgeon should ideally do the first tube change.

The treatment for tracheostomy patients can, and should, involve a team of different medical professionals. This can improve the overall care you receive. Studies have shown that teamwork can reduce the time patients have the tube, the length of their hospital stay, and the number of bad outcomes or problems. Better results have also been seen when everyone involved in the patient’s care, including the patient, doctors, nurses, speech therapists, work together. This approach has been used by The Johns Hopkins Hospital in Baltimore since 2012, leading to better results, fewer complications, and cost savings.

In the United Kingdom, a project called the National Tracheostomy Safety Project works across the whole country to improve care for tracheostomy patients. Their teams involve the same types of medical professionals as those in North America and they’ve shown that working together can increase the safety and quality of care for patients and their families.

Preparing for Tracheostomy Tube Change

Before a doctor begins to change a tracheostomy tube, it is very important that all the needed tools are easily reachable. Usually, patients don’t need to be asleep or sedated for this procedure. If possible, devices to monitor the patient’s heart rate, the oxygen in their blood, and their breathing should be used to make sure the new tube is placed properly.

It’s critical to know the model and size of the tracheostomy tube that will be used for the change. It’s also good to have the tube’s guide tool and removable inner tube ready. If the tube has an air-filled cuff, it should be inflated to make sure it works properly and doesn’t leak. After confirming it’s good, the air should be let out before the tube is inserted. The guide tool should be put into the tube and the inner tube should be placed aside, in a way that it can be easily moved in and out of. To make inserting the tube easier, the replacement tube should be covered with a type of lubricant that dissolves in water.

Positioning the patient correctly for this procedure is extremely important. The bed should be raised or lowered to a height that’s comfortable for the doctor or nurse who is performing the procedure. Any railings or bedside tables should be moved aside. The patient should be lying down with their neck extended over a rolled-up towel or pillow. This way, the doctor can reach the windpipe easier. The doctor or nurse should stand on the side of the patient that matches their dominant hand. Likewise, an assistant, who will help with suctioning and stabilizing the tube, should stand on the other side. No one should be standing at the foot of the bed because the patient might cough strongly while the tube is being adjusted, which could spray mucus in that direction.

To make sure that everything goes smoothly, all members of the healthcare team might find it helpful to talk about or practice the steps involved in changing the tracheostomy tube before actually doing it. This is especially helpful if some members of the team aren’t familiar with how to change a tracheostomy tube.

How is Tracheostomy Tube Change performed

Changing a tracheostomy tube needs to happen quite quickly. This procedure needs to be swift because it reduces patient discomfort and lowers the risk of the stoma closing over. Quick changes also minimize the time the patient may be without oxygen. This process is best carried out between 5 to 7 days after the initial tracheostomy procedure, or 7 to 10 days later if a different method called a ‘percutaneous approach’ was used initially.

Some medical professionals recommend changing the tube every 7 to 14 days after the initial change to avoid a build-up of secretions. Other professionals may propose only changing the tube as necessary to make it smaller. The type of tracheostomy tube a patient needs depends on their particular circumstances. Several factors might influence this, including how long the patient is expected to need the tracheostomy, why they needed a tracheostomy in the first place, and the type of secretions they have.

Changing a tracheostomy tube is usually done by two people. One person holds the tube and supports the patient, while the other person does the change. If the patient is at risk of food or drink entering their lungs (aspiration), it’s best to stop tube feeding for 3 to 4 hours before the change. The feeding tube should also be emptied right before the operation.

There are two main ways to change a tracheostomy tube, depending on the situation: using a Tube Exchange Device for a Guided Exchange; or a Blind Exchange using an Obturator. The choice depends on how high the risk of losing the airway is and how early its being changed.

Guided tube exchange is usually done on patients who are at high risk of losing their airway or when early tube changes are necessary. The new tube is inserted using a guide called an Exchange Device.

In the alternative method, called Blind Exchange using an Obturator, the trachea is not visible. This approach is suitable for patients with well-formed stomas and a smaller risk of airway loss. The new tube is inserted without direct vision, using an Obturator to shape the tube.

In some scenarios where the tube can’t be placed back successfully, or the patient’s condition becomes compromised, additional procedures should be followed. These may include maintaining the oxygenation or considering the usage of a smaller size tube. In emergencies, medical professionals should be contacted to provide assistance.

Possible Complications of Tracheostomy Tube Change

Research has been conducted comparing the rate of complications between two procedures performed to create an opening in the windpipe or trachea: surgical tracheostomy and percutaneous tracheostomy. Studies found the percutaneous procedure to be quicker. However, it was linked to more complications happening soon after the procedure. Despite this, further analysis of several studies suggests that percutaneous tracheostomy may still be preferred due to its short duration and less likelihood of infection.

Here are some minor complications that can happen with a tracheostomy:

* Limited bleeding
* Infection
* Temporary decrease in oxygen levels
* Blockage of the tube
* Accidental creation of a new airway
* The formation of a tunnel between the skin and trachea
* A noticeable scar

Some major complications can also occur:

* Heavy bleeding requiring blood transfusion due to a tunnel forming between the trachea and a major artery
* The formation of a tunnel between the trachea and esophagus
* Narrowing of the airway above the vocal cords
* Narrowing of the trachea
* Softening of the trachea
* Death

Types and times of post-procedure complications vary. Early complications that can happen in the first few weeks include:

* Heavy bleeding
* The tube moving or being blocked post-procedure
* Air getting trapped under the skin
* Soft tissue infection
* Air entering the space around the lungs
* Air entering the area between the lungs

Late complications can happen more than 3 weeks after the procedure. They include:

* Narrowing or softening of the trachea
* Tube getting dislodged or blocked
* Equipment failing
* The formation of a tunnel between the trachea and a major artery
* The formation of a tunnel between the trachea and esophagus
* Infections, like pneumonia from inhaling food, liquid, or vomit into the lungs

A very rare but serious complication is when a tunnel forms between the trachea and a major artery. This tunnel can cause dangerous bleeding. It usually shows up first as minor coughing up of blood, which happens 24 to 48 hours before heavy, life-threatening bleeding can occur. In an emergency, the medical team will work rapidly to apply pressure on the artery, clean the trachea of blood, and arrange for the patient to receive more blood if needed while urgently reaching out to a heart and chest (cardiothoracic) surgeon.

Changes to the tracheostomy tube are a regular part of care, but it comes with risks. As such, understanding the whole procedure and being prepared for potential complications is crucial. Ongoing education and efforts are needed to increase competence and decrease complications, especially those related to the tube being blocked. The cause of the blockage is often not cleaning and maintaining the inner tube part, which collects secretions and is vital in emergencies.

The most common complication when changing the tracheostomy tube is the tube moving or creating a new passage. This complication can cause air to get trapped under the skin and difficulty breathing, especially during the first tube change when the tube’s path hasn’t fully formed yet. Therefore, it’s advised that the first change should be visually guided and not done earlier than 5-7 days after the tracheostomy. Thankfully, accidental removal of the tube has decreased since 1985 thanks to better tracheostomy care. If a new passage is suspected, the tube should be removed and replaced carefully. An airway exchange catheter (a long, flexible tube) can be used to decrease the risk of the tube moving.

If the tube is blocked or accidentally removed, especially in overweight patients, this can lead to serious health risks. In these rare situations, it’s imperative to follow emergency procedures and get help from experienced health professionals. Oral intubation (putting a tube into the windpipe through the mouth) could be considered to establish a secure airway, especially for those who’ve stopped breathing. However, using a bag-valve mask might be more efficient for giving the patient oxygen.

What Else Should I Know About Tracheostomy Tube Change?

Changing the tracheostomy tube, which is a tube inserted into the windpipe to assist with breathing, regularly is important for patient care. By doing this, it can help lower the chance of complications like unusual tissue growth, bleeding, or infection. It’s also critical that the health care professional who does the routine tube change is skilled and experienced. This ensures the process can be done smoothly, causing the least amount of discomfort to the patient and keeping the risk of any complications low.

Frequently asked questions

1. How often should my tracheostomy tube be changed? 2. What are the potential risks and complications associated with tracheostomy tube changes? 3. What steps will be taken to ensure that the tube is placed properly during the change? 4. Are there any specific precautions or considerations I should be aware of before and after the tube change? 5. Who will be performing the tube change and what is their level of experience and expertise in tracheostomy care?

The Tracheostomy Tube Change procedure involves replacing the tube that is inserted into a person's windpipe. This procedure is typically done to prevent complications such as blockage of the tube, misplacement, or unplanned removal. It is important to regularly check vital signs, especially in children, to ensure that any discomfort or difficulty breathing is addressed promptly.

You may need a tracheostomy tube change for several reasons, including if the stoma (the hole in your neck for the tube) has fully matured and healed. However, there are situations where changing the tube may not be suitable or potentially risky, such as if you are in an unstable condition, require a high level of oxygen and assistance from a ventilator, or if there is a high chance that changing the tube could cause damage or bleeding around the stoma. It is important to consult with your healthcare provider to determine if a tracheostomy tube change is necessary and appropriate for your specific situation.

You should not get a tracheostomy tube change if the stoma has not fully matured or healed, if you are in an unstable condition and not strong enough for the procedure, if you require a high level of oxygen and additional help from a ventilator, or if there is a high chance that changing the tube might cause more damage or bleeding.

To prepare for a tracheostomy tube change, it is important to have all the necessary tools easily accessible, including the new tube, guide tool, and removable inner tube. The patient should be positioned correctly, with their neck extended over a rolled-up towel or pillow, and the bed should be adjusted to a comfortable height for the healthcare professional performing the procedure. It may also be helpful for the healthcare team to discuss and practice the steps involved in changing the tube before actually doing it.

The complications of Tracheostomy Tube Change include limited bleeding, infection, temporary decrease in oxygen levels, blockage of the tube, accidental creation of a new airway, formation of a tunnel between the skin and trachea, noticeable scar, heavy bleeding requiring blood transfusion, formation of a tunnel between the trachea and esophagus, narrowing of the airway above the vocal cords, narrowing of the trachea, softening of the trachea, death, tube moving or being blocked post-procedure, air getting trapped under the skin, soft tissue infection, air entering the space around the lungs, air entering the area between the lungs, narrowing or softening of the trachea, tube getting dislodged or blocked, equipment failing, formation of a tunnel between the trachea and a major artery, formation of a tunnel between the trachea and esophagus, infections such as pneumonia, and accidental removal of the tube.

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