Chapter 17. Tracheostomy Tube Placement

• • Routine replacement (usually once a week).

  • Emergent replacement (occlusion with secretions, mucous plug, foreign body, or accidental dislodgment).

Absolute

• • Insufficient training in procedure. (Children with tracheostomies should never be left in the care of someone who is not trained in replacement of a tracheostomy.)

• • Suction catheters.

  • Sterile gloves.

  • Suction machine.

  • Saline bullets.

  • 5-mL syringe to deflate balloon, if applicable.

  • Tracheostomy ties.

  • Scissors.

  • New tracheostomy tube of appropriate size (1 of same size and 1 size smaller).

  • Lubrication (water soluble).

  • Oxygen with tubing.

  • Resuscitation bag.

• • Inability to establish a new airway.

  • Perforation of airway.

  • Bleeding.

  • Infection.

• • If replacement is emergent and no new tracheostomy tubes of appropriate size are available, an endotracheal tube of the same size can be used as a temporary airway.

  • Once the endotracheal tube is inserted, the old tracheostomy tube can be cleaned and replaced.

  • Size of tracheostomy tube is embossed on wings of tracheostomy tube.

  • Suctioning of the tracheostomy is only to clear the tube itself.

  • The suction catheter should not extend beyond the end of the tracheostomy tube. (Aggressive deep suctioning can lead to granulation tissue in the airway.)

  • If unable to insert same size tracheostomy tube, use 1 size smaller.

• • Explain the procedure in a developmentally appropriate manner before and during the procedure to help the patient remain calm; many patients are familiar and comfortable with the routine replacement of their tracheostomy tubes.

• • A shoulder roll helps extend the neck for improved visualization.

• • If nonemergent replacement, prepare all equipment prior to beginning procedure.

  • • Place tracheostomy ties on new tracheostomy.

    • Lubricate new tracheostomy.

    • Prepare suctioning equipment.

    • Prepare resuscitation bag.

  • Suction tracheostomy tube.

  • • Give several positive pressure breaths with resuscitation bag (use 100% oxygen, if available).

    • With sterile gloves on, insert appropriate suction catheter (without suction applied) into tracheostomy tube. (Do not insert past end of tracheostomy tube.)

    • Once at desired depth, occlude suction port to begin suction.

    • Remove suction catheter while applying suction and twist catheter in fingers to allow sweep of sides of tracheostomy tube.

    • Give several positive pressure breaths with resuscitation bag (use 100% oxygen, if available).

    • Repeat as needed to clear tracheostomy tube.

    • A few drops of saline may need to be instilled before positive pressure breaths to loosen secretions and facilitate removal.

  • If tracheostomy tube has balloon, attach syringe to bulb and withdraw air.

  • Remove tracheostomy ties while holding current tracheostomy tube in place.

  • Remove tracheostomy tube.

  • Immediately replace new tracheostomy tube into existing tract.

  • Insert straight and then curve gently posteriorly and distally (Figure 17–1). Do not force.

• • Hold tracheostomy tube in place with fingers.

  • Remove stylet.

  • Provide ...