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Variability in Practice Patterns for Tracheotomy Tube Changes: A Call to Action

by Andrea M. Sattinger •

Implications

The wide variation in practice revealed in the Weill Cornell survey indicates that it may not be all that critical, concedes Dr. Stewart. If taking them out too early routinely caused problems, no one would take them out too early. However, this variability has certain implications: First, he says, it speaks to the lack of a standard and the lack of agreement about best practice. Also, the study findings reveal that serious problems do occur and this may not be as well recognized as it should be. Finally, he says, he is of the opinion-although this was not borne out by study-that much of the teaching on this was developed by the professors of 25 years ago. Back in those days people stayed in the ICU. We didn’t really have step-down units. We didn’t have such [severely ill] patients on the floor. If a patient needed a trach or a breathing machine, they were probably in the ICU.

But the delivery of care has changed such that there are more potential settings where changing a trach tube might be an issue. My opinion is that it is not clear that our practices and standards about whether to change trach tubes, when to change them, where to change them, and how to do it, has really evolved as the sites of delivery of health care have evolved, says Dr. Stewart, and he adds that their recommendations are a call to action (see sidebar). We are calling for institutions to look at their own practices, and perhaps for us as a specialty to begin to develop a consensus.

Dr. Gourin thinks that is a good idea. I think it would be good to have some standard guidelines endorsed by the American Academy of Otolaryngology, because we are the airway experts. It is a little disturbing to hear that there is great variability in trach tube care teaching and trach tube changing. I think that as specialists we ought to be the thought leaders in this area and we probably need to stand united and present some uniform consensus.

Recommendations for Trach Tube Changes

Although further investigation would need to be performed, Tabaee et al.1 make the following general recommendations based on universal protocols created at their institution.

  1. Do not remove the skin sutures or change the original tracheotomy ties until the first tube change.
  2. The first routine tube change is directly supervised by a senior resident and is not performed on weekends or nights.
  3. Training for junior residents emphasizes the need for optimal lighting, neck positioning, and suction as well as having a plan for airway management with availability of the required equipment should adverse issues arise.
  4. Patients on mechanical respirators are briefly ventilated with 100% oxygen before the change and patients who are hemodynamically unstable or who have limited pulmonary reserve may be considered for delay until a later date.
  5. Interventions including the use of a fiberoptic endoscope, tube-changing stylet, or guidewire should also be considered in patients with known airway issues including kyphoscoliosis, cervical spine immobility, head and neck masses, and obesity. In these cases, an experienced surgeon should be present and an instrument tray is recommended.

Reference

  1. Tabaee A, Lando T, Rickert S, Stewart MG, Kuhel WI. Practice patterns, safety, and rationale for tracheotomy tube changes: a survey of otolaryngology training programs. Laryngoscope. 2007;117 (in press).

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©2007 The Triological Society