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.
Variables
There are no standardized guidelines on making trach tube changes, according to Michael G. Stewart, MD, MPH, Professor and Chairman of the Department of Otorhinolaryngology at Weill Medical College, and another author of the study. In a way, he speculates, that would be like having standards for removing stitches. That is considered the art of medicine and the practitioner will make that decision based on a number of criteria, including whether the tube should be changed at all, when it should be changed, how frequently it should be changed, and any special techniques or precautions that should be taken.
Christine G. Gourin, MD, Associate Professor of Otolaryngology at the Medical College of Georgia (MCG) in Augusta, agrees that the issue has been traditionally considered more of an art. In her institution there are generally three things that residents are taught that they need: good lighting, suction equipment, and a stable patient.
As for timing of the first tube change, I was trained with the classic dictum that the trach should not be changed before postoperative day number 5, she says. In general, she says, by day 5 there is a well formed tract, but still, there’s no magic to five days. There is also variability on the postgraduate year in which residents do their first tube change (Fig. 1).
The variability regarding trach tube changes means that physicians have to consider the overall patient situation. For instance, we see more and more morbidly obese patients as the population expands in girth, says Dr. Gourin. There’s a greater depth of soft tissue between the skin and the trachea and those are patients in whom a trach change could be difficult and even dangerous. Dr. Gourin, who is also Chief of the Division of Head and Neck Surgery at MCG, says that in her practice, stay sutures are placed around the trachea rings above and below to provide an extra measure of safety, but this was one factor that the Weill Cornell study showed varies from institution to institution.
We really do treat trach changes in many ways as an individual choice that the physician makes based on the patient and what happened with the case and so on, says Dr. Stewart, who is also Otorhinolaryngologist-in-Chief at New York Presbyterian Hospital-Weill Cornell Medical Center. From one hospital to the next, different providers make changes, in different settings, and with different equipment and circumstances. People are doing it very differently, he says, and in fact, it’s not an innocuous thing, it’s not like taking stitches out. Things that can happen during trach changes mean that we should take it potentially more seriously, like a procedure. But these investigators have begun to ask questions in terms of an evidence base, looking at, first, the extent of variation in practice, and next, whether this is an issue that otolaryngology-head and neck surgery should look at more systematically.
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.
- Do not remove the skin sutures or change the original tracheotomy ties until the first tube change.
- The first routine tube change is directly supervised by a senior resident and is not performed on weekends or nights.
- 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.
- 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.
- 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
- 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).
©2007 The Triological Society