Tracheostomy is a procedure where an artificial airway is established surgically or percutaneously in the cervical trachea. The term “tracheostomy” has evolved to refer to both the procedure as well as the clinical condition of having a tracheostomy tube. The first documented tracheostomy (or tracheotomy) was performed in the 15th century.
In 1976, Dr. Frost wrote an interesting historical account on the development of tracheostomy through the ages, covering five main stages filled with drama and fear that eventually culminated in a routinely performed procedure in modern medicine. In the early twentieth century, Chevalier Q. Jackson developed and helped to standardize the procedure in addition to resolving the many difficulties and debates surrounding the procedure. Later in the same century, however, it became apparent that oral or nasal intubation could be performed safer and quicker with lower complication rates. As a consequence, modern practices advocate justification, rationalization, and standardized continuous care of patients with tracheostomy.
Over 83,000 tracheostomies were placed in the United States in 1999. Furthermore, Mehta et al. found a substantial increase in tracheostomy use between 1993 and 2012 in the United States. In England (United Kingdom), according to The National Tracheostomy Safety Project (NSTP) estimates, up to 15000 percutaneous tracheostomies are performed in the intensive care unit and further 5000 surgical tracheostomies in head and neck surgery.
With the increasing number of patients with tracheostomy, safe caring requires knowledge and competencies in dealing with routine care, weaning, decannulation, as well as tracheostomy-related emergencies. Tracheostomy tube change is part of routine care, but complications may occur more frequently in the absence of competence and a robust system of tracheostomy care.
This article aims to provide a basic understanding of the tracheostomy procedure and its relevant anatomy, thereby explaining the principles behind tracheostomy care with a primary focus on changing the tracheostomy tube.
Tracheostomy can be done via open surgery or percutaneously. Understanding anatomy is essential as it provides the basis for tracheostomy tube insertion, change, and removal. It would be good to imagine the path into the trachea as a tract beginning from the skin to the inner lining of the trachea.
A transverse skin incision ( avoiding anterior jugular venous ) is preferred for cosmetic reasons, is made between the cricoid cartilage and suprasternal notch ( approximately over the second or third tracheal rings). In gaining access to the tracheal lumen, the clinician exposes the following anatomical structures in layers: (I) skin, (II) subcutaneous fat, (III) platysma, (IV) superficial or investing layer of deep cervical fascia, (V) midline raphe of strap muscles( the sternohyoid and sternothyroid ), (VI) pre-tracheal fascial, (VII) thyroid isthmus, and finally, (VIII) trachea. An incision into the tracheal lumen between the second and third tracheal cartilage rings. There are several variations on the tracheal incision itself; some surgeons advocate for a longitudinal “horizontal H” incision spanning the first through third rings, whereas an alternative approach involves three careful incisions to raise a flap.
Bedside percutaneous tracheostomy (ultrasound or fiberoptic) has become an alternative to operative (open) tracheostomy performed either at the bedside or in the operating room, a technique introduced in the 1980s that has gained popularity as it is seen to be an effective alternative with comparable outcomes to surgical dissection while avoiding transfer to the operating theatre. The most widely described technique is the Seldinger technique, where gradual dilation of the tract is performed using dilators through a guidewire. Choosing between the methods to do tracheostomy depends upon the availability of each procedure and institutional expertise. It is important to note that certain patients could present unique challenges to the creation of tracheostomy as well as tube change. These are obese patients, pediatric patients, and those with cervical spine instability. Thick subcutaneous adipose tissue in obese patients means that the track is longer. Therefore a tracheostomy tube with a short length may not be appropriate as the lumen may not be placed centrally within the trachea. In addition, there is a higher risk of creating a false passage.
In the pediatric population, the tract is significantly smaller, thereby requiring short tubes and posing a risk of puncturing the tracheoesophageal wall if tube change is not performed carefully. Watters found that more than ninety percent of complications occurred more than one week after surgery, with 15% to 19% experiencing a tracheostomy-related complication. The most common tracheostomy-related cause of death is tube obstruction, followed by tube misplacement and accidental decannulation. Therefore, it is imperative to ensure that measures are in place to prevent false passage creation and to secure the tube. Stringent monitoring of vital signs is carried out as children are less likely to verbalize discomfort, pain, or difficulty in breathing.
The first recorded tracheostomies were performed for upper airway obstruction. In modern practice, the indications for tracheostomy are (1) obstruction in the upper airway; (2) establishing and maintaining a secure airway when the upper airway is unsafe, such as in the face, head and neck injuries; (3) bronchial toilet and secretion removal; (4) airway protection e.g., neuromuscular disorders; (5) prolonged mechanical ventilation and facilitate weaning. The most common indication is to assist in facilitating weaning off ventilation in intensive care patients. In children, common indications for tracheostomy include congenital and acquired airway stenosis, neurologic conditions requiring long-term ventilation or pulmonary toilet, bilateral vocal fold insufficiency, and infectious compromise of the upper airway.
Currently, there is no convincing data to indicate the best timing for performing tracheostomy on patients ventilated via endotracheal tubes. However, in non-acute settings, tracheostomy should be considered after ten days. Nevertheless, the physiological changes associated with tracheostomy, benefits, and potential risks are issues that need to be considered, and in all cases, be discussed with patients and family members.
Postoperative complications vary and depend on the timing and insertion technique. Early postoperative complications tend to arise in the first few days to weeks that include hemorrhage, postoperative tube dislodgement or obstruction, subcutaneous emphysema, soft tissue infection, pneumothorax, pneumomediastinum. Late complications that occur more than three weeks post tracheostomy include tracheal stenosis or tracheal malacia (granulation tissue), tube dislodgement or obstruction, equipment failure, tracheoinnominate artery fistula, tracheoesophageal fistula, and infections such as aspiration pneumonia.
Routine tracheostomy maintenance involves (1) regular cleaning of the tube, (2) frequent stomal care, and (3) periodic monitoring of cuff pressure. Adequate air humidification must be provided to patients with a tracheostomy. Inadequate humidification can result in obstruction of the tube from thick secretions, sputum retention, keratinization or ulceration of the tracheal mucosa, and impaired gas exchange as a result of lung atelectasis.
There are many different types of tracheostomy tubes. They are divided based on the material used in construction PVC, silicone, or metal. Tracheostomy tubes can be cuffed or uncuffed. Cuffed tracheostomy tubes are used for patients on long-term mechanical ventilation and those at risk for aspiration. Cuffed tubes also prevent loss of volume during positive pressure ventilation while preventing air leaks across the vocal cords. Uncuffed and metal tubes are used in patients with adequate ventilatory effort who are alert and at low risk for aspiration. Uncuffed and metal tubes are used in patients with adequate ventilatory effort who are alert and at low risk for aspiration.
Lack of cleaning and maintenance of the inner cannula is the primary cause of tube obstruction. The primary indications for tracheal suctioning are to remove secretions, enhance oxygenation, or obtain samples of lower respiratory tract secretions for diagnostic tests. It is important to understand that tracheal suctioning should be performed only when it is clinically indicated; frequent, routine suctioning is not recommended.
There are no absolute contraindications to tracheal suctioning. Relative contraindications include severe bronchospasm, which may worsen with suctioning, and persistently elevated intracranial pressure (ICP), which is exacerbated by suctioning.
The indications for a tracheostomy tube change are (I) minimizing the risk of infection and granulation tissue formation, (II) downsizing as part of a weaning or decannulation process, and (III) verifying the formation of a mature tract for other healthcare professionals, particularly nurses and allied health members. The maturation of the tracheostomy tract is generally completed by postoperative day 7. There is conflicting evidence on how frequently tracheostomy tubes should be changed. Most manufacturers recommend that tracheostomy tubes be changed approximately 30 days after placement.
There are no absolute contraindications to exchanging a tracheostomy tube in the emergency department as long as the stomal tract has matured. Before undertaking the exchange, consider whether further tissue trauma or hemorrhage might occur as a result of it.
On the other hand, tracheostomy tube change may not be suitable if the patient is in an unstable condition, requires high levels of ventilatory support with oxygen, or at high risk of losing the airway, such as when the tract is not yet mature.
There are many pieces of equipment required for the procedure, but they can be divided into several categories for ease of memory. The authors prefer to categorize according to specific steps or parts of the procedure: (I) tube, (II) procedure, (III) safety, (IV) monitoring prior and after the procedure, (V) emergency equipment, and (VI) documentation.
The equipment required for (I) tube change are:
Next, the equipment required for (II) procedure are:
For patient and personnel safety:
For monitoring prior to and after the procedure:
Equipment that must be present during tube change for emergency or to assist in difficult situations are:
Other types of equipment that may be useful during tracheostomy tube change are microbial swab if an infection is suspected, and silver nitrate cautery sticks for superficial granulation tissue.
An initial tube change in general wards is associated with a higher risk of airway loss in comparison to the intensive care unit or step-down unit (96.1% vs. 63.6%). In pediatric settings and critical airway situations, ENT surgeons/residents perform initial trach change.
While routine changes on general wards are typically safe provided there are adequately trained staff, equipment, and support, first tube changes may require higher levels of nursing and ancillary support not found on general wards.
Various guidelines and local protocols exist for required personnel and practices in tracheostomy changes. Typically, the first tube change is performed or supervised by at least a senior resident and not during nights or weekends. Otherwise, changes can be performed by an otolaryngologist or anesthesiologist trained in the procedure and tube change, tracheostomy-trained nurse practitioner, trained intensive care nurses, experienced speech and language therapists, respiratory therapists, or nurses.
It is essential to ensure that all airway equipment is at the patient's bedside before performing the tube exchange.
In addition to having airway equipment ready, place the patient on continuous pulse oximetry, cardiac monitoring, and capnography, if available, to confirm tube placement.
Identify the tracheostomy tube model and determine its size. Most tracheostomy tubes have three standard components: an outer cannula, an obturator, and an inner cannula
Inspect all equipment for proper function, including the replacement tube cuff for leaks and the obturator for ease of insertion and removal
Anesthesia is generally not required for tube exchange.
Inspect all equipment for proper function, including the replacement tube cuff for leaks and the obturator for ease of insertion and removal. Coat the replacement tracheostomy tube with a water-based lubricant
It is important to ensure that consent is appropriately obtained from the patient prior to the procedure.
The key to preparation is the positioning of the patient.
The bed should be adjusted to an adequate height without any obstruction in the way of the practitioner, such as bed rails or tables. The patient should be supine with the neck in hyperextension over a shoulder roll or pillow so that the tracheal orifice is closer to the surface with the neck structures stretched adequately.
A right-hand dominant practitioner should stand to the right of the patient, and the reverse is recommended for a left-hand dominant person. An assistant should stand on the opposite side, ready to assist before tube change occurs. Usually, the assistant provides suction and helps with securing the tube.
It is good practice for practitioners to rehearse or verbally go through the steps with their assistant prior to the procedure, as this makes sure that they are familiar with the steps and are able to coordinate accordingly with each other.
Studies have compared the complication rates between surgically and percutaneously performed a tracheostomy. Oliver et al. in 2007 found that percutaneous dilatational tracheostomy was significantly quicker than surgically created tracheostomy, but there were more early complications associated with the percutaneous technique. However, later meta-analyses and studies favored percutaneous tracheostomy despite comparable complication rates, owing to quicker procedure time and lower risk of infection.
In general, minor complications associated with tracheostomy are (I) minor bleeding, (II) infection, (III) temporary oxygen desaturation, (IV) tube occlusion, (V) false passage, (VI) tracheocutaneous fistula, (VII) poor cosmetic scar, and (VIII) infection. The major or serious complications are (I) hemorrhage requiring transfusion or due to tracheo-innominate artery fistula, (II) trachea-oesophageal fistula, (III) subglottic stenosis, (IV) tracheal stenosis, (V) tracheomalacia, and (VI) death.
Although routinely performed, tracheostomy tube change is not without complications or potential pitfalls; thus, it is imperative to understand the procedure in addition to anticipating potential problems. Certain institutions may have established protocols or guidelines in place to facilitate an uneventful tracheostomy tube change, whereas continuous education and quality improvement projects certainly aim to improve competence and reduce complications.
The commonly encountered complication, if at all, of tracheostomy tube change is displacement or creation of a false passage. This is more likely to occur at the first tube change when the tract is not yet mature. It is recommended that the first tube change be performed under direct vision and preferably not sooner than 7 days since the tracheostomy procedure. A reassuring observation is that the rate of accidental decannulation has reduced significantly between 1985 and 2004, probably due to improved tracheostomy care. Signs of creation of a false passage or tract are subcutaneous emphysema and respiratory failure. If a false passage is suspected, remove and replace the tracheostomy tube expeditiously. An airway exchange catheter may be used to reduce the risk of tube displacement. Tube obstruction and accidental dislodgement appear to be more common in obese patients. Dislodgement is specifically associated with increased rates of morbidity and mortality
When this rare complication occurs, it is important to follow the basic life support or advance life support algorithms, and help must be called so that experienced personnel, typically anesthetists or otolaryngologists may help to re-establish an airway. The usual practice in this instance is to reinsert the tracheostomy tube with the use of an obturator or tracheal dilator. Oral or nasal intubation may be attempted to establish a definitive airway, especially in cases of respiratory arrest.
Tracheostomy tube change is probably the single most critical procedure after tracheostomy is made. It is important in the continuous care of patients with tracheostomy, and regular changes are associated with reduced risk of granulation and infection. However, competence and experience in tube exchange are necessary to ensure that the procedure remains uneventful with minimal discomfort to patients, morbidities, and complications.
Although there are currently no published recommendations for the standards in tracheostomy tube change, many institutions and hospitals have a local protocol or guideline in place to facilitate uneventful tube changes and improve outcomes.
The Global Tracheostomy Collaborative was formed in 2012 by Dr. David Robertson, an otolaryngologist from Harvard. Five ‘key drivers’ are identified to be critical in bringing about improvements in tracheostomy care: (I) multi-disciplinary care, (II) standardization of care, (III) broad staff education, (IV) patient and family involvement, and (V) entering and tracking data. Indeed, evidence shows that collaborative and coordinated tracheostomy care is achievable, implementable, and improves care. Similarly, a systematic review found that a dedicated interprofessional team approach resulted in reductions in time to decannulation, length of stay, and adverse events. [Level 1]
On the other hand, it is recognized that tracheostomy care outcomes are better where there is a concerted effort between various parties, including patient, surgeon, primary physician, otolaryngologist, and interdisciplinary teams such as nurses and speech and language therapists. [Level 4] An interprofessional tracheostomy program at the John Hopkins Hospital resulted in improved outcomes and quality of care due to decreased incidence of tracheostomy complications and increased cost-effectiveness. [Level 3]
In the U.K., the National Tracheostomy Safety Project is a nationwide initiative aimed at improving the care of patients with tracheostomy. Similar to their North American counterparts, the team dedicated to looking after patients with tracheostomy tubes comprise of otolaryngologists, anesthetists, chest physicians, specialist nurses, speech and language therapists, and respiratory therapists. There is increasing evidence that coordinated interprofessional teams influence the safety and quality of care delivered to patients with tracheostomy and their families. [Level 3]
Studies have described deficits in knowledge and comfort with tracheostomy care among health care providers. Experience from the Texas Children’s Hospital found that a tracheostomy educational program resulted in significant improvements in self-efficacy and knowledge scores.
The main roles of the interprofessional team members are described here. Respiratory therapists or physiotherapists primarily look after the chest function and clearance of tracheostomized patients, in addition to pulmonary rehabilitation. They administer therapy that includes manual hyperinflation, passive positive pressure breaths, clearance of sputum, and recruitment of collapsed or dependent areas of the lung. Speech and language therapists have an integral role in tracheostomy tube change, as their assessment and therapy may dictate the type of tubes required, such as changing a cuffed tube to an uncuffed tube, etc. Specialist nurses provide continuous coordination of care, education, and dissemination of knowledge, as well as ensuring standards are always maintained or improved.
Other allied health members involved in the care of tracheostomized patients are dietitians, psychologists. Outside the remit of healthcare, patients’ friends and families are perhaps the next most important aspect of care, especially in the pediatric population.
Evidence shows that tracheostomy-related complications are minimized, and outcomes are improved when there is a multidisciplinary, ward-based approach to tracheostomy care.
Weekly tracheostomy ward rounds should be the ideal practice, with the team comprising of a physician (commonly an intensivist, respiratory physician or otolaryngologist), chest physiotherapist, speech and language therapist, and specialist nurse. The team ensures standards of routine tracheostomy care are achieved, provides a weaning or decannulation plan, and troubleshoots potential issues surrounding tracheostomy care, such as competencies, logistics, and shortfalls.
The care of tracheostomy requires both competencies and experience. The latter is especially true when ‘troubleshooting’ issues or potential problems that may arise. The most important aim of caring for patients with a tracheostomy is to prevent tube blockage. As the native upper airway is bypassed, numerous physiological changes occur, therefore care that mimics the normal functions of the upper airway should be undertaken e.g., humidification, secretion clearance, stoma or wound care, native speech, airway protection, and safe swallowing.
The commonest measures or elements of care that are carried out and monitored regularly are: (I) going through daily tracheostomy care checklist, (II) humidification, (III) suction clearance, (IV) stoma care, (V) inner cannula care, (VI) oral care and swallowing, and (VII) cuff management.
Monitoring of these elements by the various team members is paramount in ensuring the safety and quality of tracheostomy care. Especially after tracheostomy tube change, monitoring of respiratory function (such as respiratory rate, oxygen saturation, work of breathing, waveform capnography) and secretions management are critical as this is when any complications, such as tube dislodgement or false passage creation, may be detected promptly.
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