- Presence of tracheostomy site.
- Urgent or emergent indication to change the tube, such as obstruction that will not clear with suction, dislodgement, or inability to oxygenate or ventilate the patient without other obvious explanation.
- Have all airway equipment prepared for standard airway management, including equipment for oral tracheal intubation and failed airway.
- Have airway device (endotracheal tube or tracheostomy tube) of the same size as the tracheostomy tube currently in place as well as 0.5 size smaller available (i.e., if the patient has a 6.0 Shiley, then have a 6.0 and a 5.5 tube).
- Lubricate the replacement tube(s) and check the cuff.
- Remove the tracheostomy tube from mechanical ventilation devices and use a bag-valve apparatus to pre- oxygenate the patient as much as possible.
- Once all equipment is in place, remove devices securing the tracheostomy tube, including sutures and/or supporting bandages.
- If applicable, deflate the cuff on the tube. If unable to aspirate air with a syringe, cut the balloon off to allow the cuff to lose pressure.
- Remove the tracheostomy tube.
- Insert the replacement tube. Confirm placement via standard measures except for esophageal detection (which is ineffective for surgical airways).
- If there is any difficultly placing the tube, re-attempt procedure with the smaller tube.
- If difficulty is still encountered, use standard airway procedures such as oral bag-valve mask or endotracheal intubation (as per protocol). More difficulty with tube changing can be anticipated for tracheostomy sites that are immature – e.g., less than two weeks old. Great caution should be exercised in attempts to change immature tracheotomy sites.
- Document procedure, confirmation, patient response, and any complications in the patient care report (PCR).