Tracheostomy Tube Change
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Tracheotomy has been performed since 1500 BCE and is one of the oldest reported surgical procedures in the medical literature. [1] Before the 19th century, however, the procedure was fraught with difficulty, and only a limited number of successful tracheotomies were reported. During this early period, the indications for tracheotomy were few, but beginning in the early 20th century, with the work of Chevalier Q Jackson, the procedure was refined and standardized. [2]
As experience with the procedure grew within the surgical community, its morbidity and mortality decreased, and its indications were broadened. In 1999, more than 83,000 tracheostomies were placed in the United States, most commonly for purposes of mechanical ventilation in chronically ill patients. [2] A 2015 study by Mehta et al found that tracheostomy use in mechanically ventilated patients in the United States rose substantially between 1993 and 2008 (to 9.8% of these patients) but decreased somewhat by 2012 (to 8.7%). [3]
The trachea is nearly, but not quite, cylindrical and flattened posteriorly. In cross-section, it is D-shaped, with incomplete cartilaginous rings anteriorly and laterally and a straight membranous wall posteriorly. The trachea measures about 11 cm in length and is chondromembranous. This structure starts from the inferior part of the larynx (cricoid cartilage) in the neck, opposite C6, to the intervertebral disk between T4 and T5 in the thorax, where it divides at the carina into the right and left bronchi.
For more information about the relevant anatomy, see Trachea Anatomy.
For discussion of the procedure by which the tube is initially inserted into the tracheal incision, see Tracheostomy.
The most common accepted indications for tracheostomy include the following:
The benefits commonly ascribed to tracheostomy as compared with prolonged endotracheal intubation include the following [4] :
Indications for tracheostomy change include the following:
Contraindications for a tracheostomy tube change are as follows:
At present, there is no definitive set of published recommendations that establish a standard for adult tracheostomy tube changes, and most current protocols are the result of local practices. [5] Regarding pediatric best practice, the American Thoracic Society (ATS) published guidelines on the specifics of the procedure as they pertain to the care of children; however, this information was released more than a decade ago and may no longer be current. [6]
Accordingly, future investigations designed in a prospective, randomized manner and with a sufficient number of patients are needed in order to enable clinicians to draw valid, concrete conclusions as to the optimal methods of evaluating and caring for these patients. [7]
In general, a tracheotomy is routinely performed in a sterile setting in the operating room (OR). Postoperative dressing changes, suctioning, and first postoperative tracheostomy tube changes are performed with sterile equipment but under clean conditions. [8] Thereafter, care is usually performed under clean conditions. [9]
Although the process of changing a tracheostomy tube is generally straightforward in the majority of patients, best practice dictates that changes be performed only by someone who is skilled in the procedure. Furthermore, it is highly advisable to have two people present during any tracheostomy tube change and to ensure that the new tracheostomy tube is checked for integrity before the old one is removed. [6]
The designation of specific teams dedicated to performing tracheostomy tube changes also warrants serious consideration. For example, Johns Hopkins Hospital created a program wherein preidentified specialist teams composed of surgical staff, including credentialed otolaryngologists, trauma surgeons, interventional pulmonologists, specially trained anesthesiologists, a tracheostomy-trained nurse practitioner (NP), a tracheostomy coordinator, equipment specialists, intensive care unit (ICU) nurses, respiratory therapists, and experienced speech and language pathologists.
An institutional review was performed by Johns Hopkins after implementing this program; it compared outcomes in patients who had received tracheostomies in 2004, the year before the program’s implementation, and those who received tracheostomies in 2008. [10] The review found that comparative outcomes, including the efficiency of procedure; the subsequent length of patient stay in an ICU; complication rates for bleeding, hypoxia, loss of airway; and a financial cost-benefit analysis, were greatly improved as a result of the program.
Other programs that included a specialist service for the care of patients with tracheostomy tubes have likewise been found to have significantly reduced numbers of patients transferred from the ICU to the wards with tracheostomies in situ. [11] Thus, it seems evident that the combination of fewer tracheostomy patients per ward, the existence of a daily outreach service, and better nurse education are all likely to reduce the occurrence of tracheostomy-related complications.
Critical factors to take into account in preparation for changing a tracheostomy tube include the following:
Timing
The interval between the tracheostomy tube placement and the first tube change allows a tract between the skin and the trachea to develop. Confirming stomal maturity at the time of the first tube change likewise minimizes the risk of establishing a false tract, which carries the attendant morbidities of subcutaneous emphysema, loss of the airway, mediastinitis, and even death. Confirming a safe healed tract allows nurses or other trained personnel (eg, respiratory therapist) to safely perform subsequent tracheostomy tube changes.
The exact timing prior to the first postoperative change can vary. At the authors’ institution, the first tracheostomy tube change is performed after 5 days but may occasionally be delayed in patients with impaired wound healing (eg, patients taking steroids, patients with poorly controlled diabetes, patients with nutritional deficits). This timing fits with survey studies of current practice. For example, the mean time interval between surgery and the first tube change was reported as 5.3 days (range, 3-7 days) in a survey of 46 training programs. [12, 13, 14]
It is also worth noting, however, that one study recommended waiting longer to change the tube, suggesting a window of 7-14 days following placement, so as to allow time for a stable endotracheal-cutaneous tract to form. [15] In a retrospective case series, the first tracheostomy tube change was safely performed at 3-4 days after routine tracheotomy procedures in 20 of 21 pediatric patients. [16] In another case series, the initial tracheostomy tube change was safely made on postoperative day 3 in 65 of 151 children (43.0%) without any complications. [17]
Type of tube
The various types of tracheostomy tubes have subtle differences that are often underappreciated yet possess specific indications based on the needs of the individual patient. A discussion of the various nuances of respective tube designs is beyond the scope of this article, but these differences can depend on the indication for the tracheostomy, anatomic considerations, patient age, and availability, among other conditions. Some principles to keep in mind in the selection of a tube are discussed elsewhere in this article (see Equipment).
Setting
The setting of the first tracheostomy tube change should be considered. At the authors’ institution, patients who underwent a technically challenging tube placement (eg, because of challenging body habitus, morbid obesity, cervical instability/presence of a halo, a high degree of respiratory support, or critical condition) have their tracheostomy tubes changed in a more acute-care setting (eg, the OR). However, for stable patients in routine cases, tube changes may be performed in various locations in the hospital (eg, the general inpatient ward, a stepdown unit, or the ICU).
Tabaee et al demonstrated that the initial tube change on the floor has been associated with higher risk of airway loss. [12] They concluded that the level of nursing and ancillary support on the floor may result in an inadequate level of care for safe airway management. They found that changes on general wards are safe in most patients, as long as adequate training, equipment, and support are available. Indeed, the respiratory therapy service at the authors’ hospital performs routine changes in stable patients weekly.
Patient issues
Pulse oximetry and supplemental oxygen may be warranted in patients who have comorbidities associated with poor pulmonary reserve. In addition, patients with above-average neck circumference, an elevated body mass index (BMI), or otherwise unfavorable airway anatomy can be at greater risk for placement of a tube into a false passage in the anterior mediastinum. [18]
In pediatric patients, reported tracheostomy-related mortality is as high as 3.4%, in part as a result of pneumothorax and the creation of false passageways. [19] In view of this danger, and because pediatric patients are sometimes unable to verbalize their discomfort, careful monitoring of vital signs should be undertaken during the first tracheostomy tube change performed on a child. Additionally, tracheostomy tube change should be deferred in patients who are hemodynamically unstable. For more information, see Pediatric Tracheostomy.
Frequency
Studies have shown that regular tracheostomy tube changes can often result in a statistically significant decrease in the number of patients who require surgical intervention for removal of granulation tissue—information that is highly germane to the determination of best practices for the timing of tracheostomy tube changes. [9]
Granulation tissue is a common consequence of tracheotomy, occurring in 10-80% of cases, and it typically appears as pink and fleshy protuberant tissue. [9] Histologically, it is composed of friable, immature blood vessels, which are prone to bleeding and can complicate a tracheostomy tube change by obstructing the stoma or with bleeding, resulting in loss of airway.
Topical applications of corticosteroid creams, antibiotic preparations, and silver nitrate have been proposed for addressing granulation tissue. [9] However, it remains to be determined whether changing the tracheostomy tube more frequently than once every 2 weeks might eliminate the problem entirely or whether a certain subset of patients would require less frequent changes. [9]
Another important issue concerns the design and material of the specific tracheostomy tube used on a given patient on the basis of currently available information. For an inpatient, a polyvinyl chloride tube may be changed every 8 weeks, whereas a silicone tube should be changed every 4 weeks. Meanwhile, for an outpatient, a tracheostomy tube is best changed every 8-12 weeks. [5] The authors recommend tube changes weekly or biweekly to reduce the possibility of bacterial colonization or superinfection.
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William A Johnson, MD Staff Physician, Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, Flower Hospital, Toledo Children’s Hospital
William A Johnson, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.
Jayant M Pinto, MD Assistant Professor, Section of Otolaryngology-Head and Neck Surgery, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine
Jayant M Pinto, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Geriatrics Society, American Rhinologic Society, American Society of Human Genetics, Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.
Marianella Paz, MD Marianella Paz, MD, Researcher University of Chicago
Disclosure: Nothing to disclose.
Fuad M Baroody, MD Director of Pediatric Otolaryngology, Professor of Surgery, Section of Otolaryngology-Head and Neck Surgery, The University of Chicago
Fuad M Baroody, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Society of Pediatric Otolaryngology
Disclosure: Received honoraria from GaxoSmithKline for speaking and teaching; Received honoraria from Merck for speaking and teaching.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Laurie Scudder, DNP, NP Nurse Planner, Medscape; Senior Clinical Professor of Nursing, George Washington University
Disclosure: Nothing to disclose.
Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women’s Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine
Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society
Disclosure: Nothing to disclose.
Prajoy P Kadkade, MD Assistant Professor of Otolaryngology, Albert Einstein College of Medicine; Attending Physician, Department of Otolaryngology and Communicative Disorders, Director of Otolaryngology, North Shore University Hospital, North Shore-Long Island Jewish Hospital System
Prajoy P Kadkade, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, Medical Society of the State of New York
Disclosure: Nothing to disclose.
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