Clinical Indications:
- 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.
Procedure:
- 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).
Tracheostomy Tube Suctioning Procedure:
Indications:
- Obstruction
- Excessive Secretions
Complications Suctioning May Induce:
- Hypoxemia
- Cardiac Arrhythmia
- Soft Tissue Trauma
- Infection
- Increasing ICP
Steps:
- Preoxygenate the patient for 1-2 min (if unable to ventilate due to secretions quickly move to step 2).
- Maintain universal precautions and a sterile technique.
- Lubricate a French ("Whistle tip") catheter
- Inject 3ml of saline through the stoma and into the trachea
- If the patient is responsive, instruct them to exhale and/or insert the catheter until resistance is felt (do not exceed 12cm).
- Apply suction only while removing the catheter and remove with a twisting motion.
- Suction for no longer than 10 seconds, cardiac monitoring should be observed during this procedure for dysrhythmia, rinse catheter in sterile water.
- Observe the patient's response to suctioning, and , if need be, repeat this procedure from Step 1.
EMERGENT SUCTIONING of Tracheostomy Tube may be performed by ALL Levels (when patient is unable to breathe adequately).
Certification Requirements:
- Maintain knowledge of the indications, contraindications technique, and possible complications of the procedure. Assessment of this knowledge may be accomplished via quality assurance mechanisms, classroom demonstrations, skills stations or other mechanisms as deemed appropriate by medical control.