A team of otolaryngologists at Weill Medical College of Cornell University in New York has posed some important questions regarding reviewing residency training for making tracheotomy tube changes. Their data, first presented at the February 2007 Triological Society meeting at Marco Island, FL, and now being published in Laryngoscope,1 reveal that there is a wide variation in how tracheostomy tube changes are taught.
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June 2007
In May 2006 the investigators conducted a survey of chief residents in accredited otolaryngology training programs to determine the management strategies, rationale, and complications associated with postoperative tracheotomy tube changes. Their data showed that the first tube change was performed after a mean of 5.3 days (range, 3-7 days) following the procedure, most frequently by junior residents. The first change was also performed in a variety of locations, including the ICU (88%), step-down unit (80%), and regular floor (78%). Twenty-five percent reported performing changes at nights/weekends. The rationale for performing routine tracheotomy changes was also variable and included examination of the stoma for maturity (46%), prevention of stomal infection (46%), and confirmation of stability for transport to a less monitored setting (41%). Of the survey respondents, 42% (n = 25) reported a loss of airway and 15% respondents (n = 9) reported a death as a result of the first tube change. A significantly higher incidence of airway loss was reported by respondents who reported performing the first tube change on the floor (96% vs 64%).
Tali Lando, MD, who was a junior otolaryngology resident last year during the collection and analysis of those data, became involved as an author of the study. As a result, she has a strong view on this issue. Ultimately I think that there has to be a much more uniform approach to our performance of the first tracheostomy changes, she says. A lot of our practice is based on tradition or anecdote that many of us, especially the residents, take for granted. Although residents do become comfortable changing trachs, it is a scenario that can quickly go downhill and we need to not be cavalier about it.
Dr. Lando is in favor of giving careful consideration to such issues as the purpose of these early changes, and questioning the origin of the norms for when trach tubes are changed. Furthermore, she suggests that alternative options that would preclude performing the first tracheostomy change in an immature tract, such as waiting for several weeks, should be considered, even if the patient is no longer in the hospital and the change may be performed by non-physician personnel.