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Tracheostomy Tube Change and Weaning (3.45)

Tracheostomy Tube Change and Weaning (3.45) - Policies, Clinical, UWHC Clinical, Department Specific, Respiratory Care Services, Airway Care

3.45

3.45 Tracheostomy Change and Weaning
Category: UWHC Patient Care Policy
Effective Date: August 31, 2016
Version: Revision
Manual: Respiratory Care Services

I. PURPOSE

This policy provides guidelines for Respiratory Therapy (RT) to wean and change tracheostomy tubes.

II. POLICY

A. All patients will be assessed by the Respiratory Care Practitioner (RCP) to determine if the appropriate
indications for the therapy are present.
B. Therapy will be provided in accordance with an approved provider’s order.
C. The patient’s first trach change should be done by the service that placed the initial trach.
D. Respiratory Therapy will not change a tracheostomy tube that:
1. has been in place less than one week.
2. is sutured in place.
3. does not have a well healed tract.
4. in non-emergent pediatric patients.
E. All trach changes will be done with at least 2 health care providers in the room, one of which is competent in
trach changes.
F. A pediatric patient’s trach wean will be determined by the pediatric pulmonary physician.
G. Routine trach changes are performed for:
1. Adult every month
2. Pediatric every week
3. Pediatric trach sizes 00 or smaller biweekly
H. Notify a physician if a complication occurs, such as:
1. Excessive bleeding.
2. Subcutaneous emphysema of the neck, face or upper chest.
3. Excessive resistance in tube placement.
4. Respiratory distress associated with the procedure.
I. Refer to related link “Trach Weaning Guideline.”

III. EQUIPMENT

A. Obtain the appropriate personal protective equipment (PPE).
B. Two clean or sterile tracheostomy tubes of the appropriate size, a smaller tube for patients
whom you will be up sizing.
C. Sterile gloves.
D. Sterile water soluble lubricant.
E. Sterile 10-15 cc syringe (for cuffed tube).
F. Sterile forceps or hemostat and scissors.
G. Two suction kits.
H. Trach ties.
I. Blankets.
1. To swaddle a small infant or child.
2. To hyperextend the neck. Hyperextension of a small infant or child’s neck can cause
compression of the trachea during the procedure.
J. Manual resuscitator with appropriate size mask.
K. Oxygen.




IV. PROCEDURE


A. Review and acknowledge the provider’s order.
B. Review patient's chart.
C. Obtain the appropriate equipment.
D. Introduce yourself to the patient and/or family. Explain the reason for the procedure.
E. Assess the patient throughout the procedure.
F. Changing the trach tube:
1. If tolerated, put the patient in a supine position with optimal lighting to visualize the stoma.
2. Person #1 readies the new airway being careful to maintain a sterile technique at all times.
3. Open the gloves and use the inside of the package as a sterile work area.
4. Open the package containing the tracheostomy tube, obturator and inner cannula (if applicable)
and place on sterile work area.
5. If the tube is cuffed, open the sterile syringe and place on sterile work area.
6. Open the lubricant and put an appropriate amount on the corner of the sterile work area.
7. Open sterile water/saline basin package. Pour sterile water/saline into basin.
8. Suction the patient's airway and oropharynx thoroughly
9. Deflate the patient’s cuff and suction oral airway as needed.
10. Rewash hands and put on the sterile gloves and examine the new airway system for any defects.
11. Check the tube cuff (if applicable) using the sterile syringe to inflate the cuff to check for leaks by
immersing the cuff in the sterile water basin.
12. Completely deflate the cuff while pushing it upwards toward the flange to taper back and smooth
out the end that will be entering the stoma first.
13. Insert the obturator into the tracheostomy tube (if applicable).
14. Lubricate the bottom half of the tube and obturator and leave it on the sterile field.
15. Person #2 readies the patient.
a. Confine a small child by swaddling them with a blanket.
b. Position the patient to allow hyperextension of their neck. This can be done by placing a
pillow or rolled blanket under their shoulders.
c. Carefully remove the old trach ties while maintaining control and stability of the old trach.
d. Visually inspect the area around the stoma noting the presence of irritation or granuloma
tissue.
e. Continue to oxygenate as indicated.
16. When all preparations are complete:
a. Person #2 fully deflates the cuff (if applicable) and gently pulls the old tube from the
patient's airway. Suction as indicated.
b. Person #1 firmly grasps the new tube with sterile hands and inserts the new tube into the
tracheal stoma. Use an arched motion to advance the tube while stretching the skin on
either side of the stoma taunt with the other hand to provide maximum visualization and
access to the airway tract. Prompt the patient to inhale deeply during insertion of the tube.
c. The tube may also be inserted at a 90 degree angle to the patient's airway and then rotated
while being advanced posteriorly and inferiorly. Some resistance to tube placement may
be encountered especially with cuffed tubes. Never force the tube. The patient may cough
or gag during the procedure. Care must be taken to avoid inserting the tube into the soft
tissues of the neck and mediastinum outside the trachea. Hemorrhage and/or airway
obstruction may result.
17. Immediately remove the obturator taking care to not displace the airway. Check for air flow
moving through the tube and for bleeding. Insert the inner cannula and secure it in place. If
airflow is inadequate or the tube cannot be properly placed, remove the tube, provide ventilation (if
indicated) and then attempt to reinsert a smaller tube.
18. Inflate the cuff using a minimum occlusion pressure to seal the airway, and re-oxygenate the
patient.
19. Secure the tube with the new trach ties.
20. Suction the patient as indicated.
21. Clean around the stoma using sterile cotton tipped swabs place a pre-cut dressing.
22. Assess the patient's tolerance of the procedure.
a. Observe for signs or symptoms of hypoxia or increased respiratory effort.

b. Auscultate the patient's chest, noting equality and character of the breath sounds,
especially, not the presence of adventitious sounds.
c. Check vital signs.
d. Check for bleeding (slight bleeding may occur and is normal when placing cuffed tubes).
23. Clean up materials. Plastic tubes are disposable, although uncuffed pediatric tubes are cleaned by
Nursing. Metal tubes and obturators are reprocessed. Keep an extra trach tube and obturator of
appropriate size and brand at the bedside for use in case of inadvertent decannulation.

VI. REFERENCES

A. Respiratory Care Services (RCS) P&P;
1. 3:42 "Suctioning"
2. 3.46 “Speaking Valves”
B. Tracheostomy Tube Product Literature











Approved by Director and Medical Director of Respiratory Care:

Original copy of this Policy & Procedure is available in the Respiratory Care Office, E5/489.