Tracheostomy Care: Changing a Tracheostomy Tube

Changing a Tracheostomy Tube

The tracheostomy tube is typically changed every 1-4 weeks to prevent mucus build-up and for cleanliness. This may very depending on the particular child. Check with the doctor for frequency of trach change. Always change the trach tube with two people present (unless this is not possible in an emergency). Change the trach tube before a feeding or at least 2 hours after a feeding.

Supplies

• Same size trach tube with obturator
• Size smaller trach tube with obturator
• Trach ties
• Small blanket or towel roll
• Blanket for mummy restraint (if needed)
• Sterile water soluble lubricant
• Blunt ended scissors
• Tweezers or hemostats
• Suction machine
• O2 blow-by (if ordered)
• Good light source
• The kitchen or dining room table covered with a pad or blanket may be a good place for a trach change.
  

Procedure

• Explain the procedure in a way appropriate for a child's age and understanding. Use a calm gentle approach. If you are anxious, the child may sense this.
• Wash hands.
• Cut trach ties to the appropriate length, cut the ends of the tape at an angle to make it easier to thread through the hole in the trach wing (flange) and to prevent fraying. Or wrap a piece of tape around the end of the tie similar to the end of a shoe lace to make it easier to thread.
• Inspect all tubes for cracks, tears, or decreased flexibility before use, especially if tubes are reused. For cuff tubes, inflate cuff to check function and check for leaks (deflate completely before inserting).
  Bring trach tie through one end of new trach tube. Avoid touching the part of the tube that is inserted into the trachea. Try to keep it sterile.
• Insert obturator into new tube; be sure it slides in and out easily. The obturator helps to guide the tube, and the rounded tip adds protection to the stoma during insertion.
• Place a small amount of sterile water soluble lubricant (surgilube or KY Jelly) on the end of the new trach tube and place the tube in sterile tray or clean surface until ready to insert. Note: Never use Vaseline or petroleum as a lubricant.  Some doctors do not recommend using lubricant, because of the danger of aspiration. If you do use a lubricant, use it sparingly and wipe off excess.
• Have a suction machine and O2 handy if needed.
• Place the child on his/her back with a small blanket or towel roll under his/her shoulders to help with hyperextension. It might be helpful to wrap the child in a blanket mummy-style, if he/she is not cooperative. The child may also sit up for the trach change.
• Administer oxygen if ordered.
• Cut the old trach ties while holding onto trach tube. Always hold the tube when ties are not secure; a cough can dislodge the tube.
• Gently remove the old trach tube (follow angle of the tube, an upward and outward arc).
• Insert the new tube in a smooth curving motion directing the tip of the tube toward the back of the neck in a downward and inward arc (like inserting a suction catheter).
• Do not force the tube!
• Remove the obturator immediately while holding the tube securely with the other hand. Remember that the child cannot breath with the obturator in place.
• Changing the trach tube will cause the child to cough; do not let go of the tube.
• Thread the trach tie through other end of tube and tie, allowing one finger between the neck and the ties. Tweezers or hemostats may be needed to thread ties through the hole of the wing of tracheostomy tube. Once the ties are properly adjusted, secure with a double or triple square knot and cut off the excess tape (Never tie in a bow).
• Inspect old tube for color, mucus plugs or odor, then discard. Most plastic pediatric trach tubes are disposable and are not washed and reused. Metal tracheostomy tubes are washed, then boiled to sterilize and reused.
• When changing trach tube, observe for skin irritation, breakdown, and signs of infection.
• Remember to praise the child. A trach change can be emotionally difficult for some children.

Tracheostomy Ties

Tracheostomy ties will need to be changed more often than the tube if they become soiled, wet, loose or cause pressure on the child's skin. Some specialists recommend changing ties daily, although this is usually not necessary in home care. However, infants with short fat necks, overweight children, and children on high humidification will probably need daily tie changes. Trach tie changes should also be done with two people. Twill tape comes with the tracheostomy tube or by the roll. If possible, secure new ties before removing old ties to decrease chances of the trach tube dislodging. There are several different techniques for securing the tracheostomy ties. The important things to remember are to use a knot, not a bow, and to be sure the ties are snug, but not too tight. You should be able to slip one finger under the ties. Change the position of the knot slightly with each change to avoid skin breakdown from the knot. If skin irritation does occur, place a gauze pad under the ties or use soft Velcro ties instead.
Check tension of trach ties several times a day, because ties may loosen.

Some Ways to Secure Trach Ties

• Use one long piece of twill tape and thread half the length through one side of trach tube. Then bring one end around the back of the neck and through the other side of the trach tube and tie the two ends in a triple knot in the back of the neck.
• Mallinckrodt (maker of Shiley Tracheostomy Tubes) recommends cutting two lengths of twill tape, each long enough to fold in half and still reach around the child's neck. Thread the folded end of one of the ties through one of the holes on the trach tube, going from skin side out. Pull the tie through until it forms a loop. Draw the ends through the loop until the tie is secured to the tube. Repeat on the other side of the trach tube. Bring the loose ends of both ties around to the back of the neck and tie them together using a square knot.

 

• Cut two pieces of twill tape long enough to fit around the neck and tie. Cut the tie at an angle to prevent fraying. Cut a 1/4 inch slit in each tape about 1 inch from the end. Insert the cut end of the tape through the neck plate hole from back to front. Pull the other end of the tape through the hole in the tape using tweezers or hemostats. Pull tightly while holding the tube. Repeat this on other the other side. Bring both ties together and tie in a triple square knot.

 

• Velcro straps, such as the Dale tracheostomy tube holder.  Note: Velcro holders are comfortable and easy to adjust; however, keep in mind that toddlers and children with developmental disabilities may be able to release Velcro. If you clean and reuse Velcro ties, be sure the Velcro still holds securely after washing.

Dale Medical Products, Inc.

• Cotton shoe laces can be fun, as they come in many different colors and designs and are easy to thread.
• Umbilical cord tape or hemming tape from a sewing store can also make good trach ties.
• Metal trach holders are good because they do not trap moisture and they are reusable. However, they are also hard to find. Some parents have had these custom made by jewelers. Note: Keep wire cutters handy incase of an emergency when using metal trach holders.

Metal Tracheostomy Tube Holder
More on Chain Tracheostomy Holders

Dog-tag chains (army ID tag chains) can also be adapted for a chain trach holder.  Check your local Army Surplus store.  For ties other than metal, keep a sample size tie handy for easy measuring and cutting of new ties.

• Gold Chain Tracheostomy Holder
• New Vent-Tie(R), combination trach tie and ventilator anti-disconnect device.
• Stronghold Anti-Disconnect

You may find it easier to place your child in a sitting position to adjust and tie the trach ties.

Risk Factor Associated with Difficult Tracheostomy Tube Changes

• When the stoma is scarred, calcified, distorted or obscured by granulation tissue
• When the trachea is deviated or rotated
• When the trachea is narrowed or smaller than normal
• When the patient is a child
• When the patient is obese
• If the tube must be placed quickly in an emergency
• If it is a new or recent tracheostomy
• If the person performing the change is not well-trained
  

Techniques for a Difficult Trach Change

• The obturator helps make insertion easy and trauma-free. Always keep an obturator on hand should the tube need an emergency change.
• Reposition the child if needed
• If the tube cannot be completely inserted, hold the tube in place, remove the obturator to let the child breathe, then continue to insert to tube.
• If still unable to insert tube, remove the tube, re-lubricate and try again.
• If this is unsuccessful, try to insert the one size smaller tube.
• Try spreading the skin around stoma and try to insert tube as the child is breathing in.
• If needed, insert a suction catheter through the smaller tube and guide the suction catheter into the trach stoma. Then slide the trach tube over the suction catheter and into the stoma. Remove the suction catheter. Click on thumbnail 

 

Illustration Source:
The Center for Pediatric Emergency Medicine (CPEM), Teaching Resource for Instructors in Prehospital Pediatrics.  Illustrations by Susan Gilbert. http://www.cpem.org/html/giflist.html

• If all else fails, cut a section of suction catheter to place it into the stoma in order to keep the stoma open and maintain an airway. Be sure to cut the catheter long enough so that it cannot be aspirated! Hold on to the catheter and call emergency services.
• Give supplemental oxygen if needed and available
  

Do not force tube! If you absolutely cannot get any tube or catheter into the stoma, and the child is breathing fairly comfortably (through the stoma or through the mouth and nose), go immediately to the emergency room. Sometimes, the airway can be made worse by a trach tube inserted in the wrong place.