How Often Should Tracheostomy Tubes Be Changed?

1 LIVING BSummer 2009 BVol. 23, No. 2 5 Services on the AircraftAir carrier personnel must provide thefollowing assistance, when requested,for a person with a disability .. assis-tance in stowing and retrieving carry-on items, including mobility aids andother assistive devices stowed in thecabin. Carriers must permit passen-gers with a disability to bring the fol-lowing .. for stowage or use withinthe cabin .. POCs, ventilators andrespirators that use non-spillable batteries, as long as they comply with applicable safety, security andhazardous materials a carrier refuse to allow a passenger tostow on the aircraft any respirator, ventilator,CPAP machine or FAA-approved POC thatdoes not have a manufacturer s label indicat-ing compliance with the standards of RTCA/DO-160 (current edition) or other applicableFAA or government requirements for medical portable electronic devices?No. Carriers must allow passengers to carrya respirator, ventilator, CPAP machine or FAA-approved POC on-board aircraft, subject to applicablesafety requirements, even if the devicemay not be usedonboard the the required manufacturer s label is not present on a ventilator, respirator, CPAP machine or FAA-approved POC, what safetyrequirements apply to the stowage of thedevice on the aircraft?

2 To be accepted for stowage on an air-craft, a ventilator, respirator, CPAP machine or FAA-approved POC thatdoes not have the required manufac-turer s label on the device must com-ply with FAA size and weight limitsand have the battery removed, pack-aged and protected from short circuitand physical damage in accordancewith the FAA s Special Federal AviationRegulation (SFAR) 106, Section 3(b)(6). sUnfortunately the healthcare industryhas not established clear-cut guide-lines for how Often , if at all, routinetrach changes Should occur, especiallyin the homecare setting. One shouldnot base the practice purely upon tra-dition, , Our hospital alwayschanges the trach tube every month, but upon evidence. Regrettably theevidence for this practice is , the industry has providedseveral recommendations regardingthe process of changing the recommendations include thefollowing: initial Tracheostomy tubechange (outer cannula) Should alwaysbe performed in the acute care settingand preferably by the surgeon or ENT,continued, page 8 How Often Should Tracheostomy Tubes Be Changed?

3 Jerry Hammersley, RCP, RRT, Simi Valley, California, the general manager of a DME company that specializes in Tracheostomy (invasive) positive pressure ventilation, I have noticed an increase over the past two to three years inrequests to perform Tracheostomy tube changes in ventilator users homes. It seems that there are fewer and fewer providers who arewilling to performthis procedure that can be risky and potentiallylife-threatening. For those who are willing to brave this endeavor,here are a few practical LIVING BSummer 2009 BVol. 23, No. it Should occur between three toseven days after the initial the initial change has occurred,the homecare provider can take overthe changes in the home. tube changes shouldbe performed by a qualified individualwho is well-trained, experienced andprepared for untoward circumstancesthat may occur during the change,such as malplacement of the tube (falsechannel), a blown cuff, bleeding andpatient decompensation, to list a individual changing the tubeshould always have a back-up trachtube that is one size smaller than thetube being functional andtested resuscitation bag with maskshould be present at the bedside, andsupplemental oxygen would be bottom line for trach changes isdon t change them too Often if thereis no evidence of infection, bleedingand the trach tube cuff (if present) isintact; it s not encrusted; and there isno stenosis (narrowing) or tracheo-malacia (flaccidness).

4 And, don tchange them too infrequently, particu-larly if there is a cuffed tube involved,because there is nothing worse andmore painful for a ventilator userthan having to remove a cuffed trachtube that has not been changed for anextended period. Caregivers shoulddiscuss with the user and the physi-cian the possibility of extending atrach change from every month toevery two months, as long as thereare no issues; they have effectivelydecreased trach changes by 50%.Complications of Long-TermTracheostomyMy company cares for many patientswho have used Tracheostomy ventila-tion for years, some more than , there are few complicationsassociated with long-term tracheosto-my, but they do sometimes occur. Infection is of course a risk to some sources, 75% oftrached patients are colonized withPseudomonas aeruginosa within 10days of the aeruginosais an opportunistic pathogen that willmanifest itself when an individual simmune defenses are low.

5 The keys toresisting P. aeruginosa and other staphinfections are maintaining hygienictrach care practices (caregivers mustlearn to religiously wash their hands!)and suction techniques, and notifyingone s physician when secretion colorchanges. Another complication is granuloma, alump or nodule of granulation tissue,that can result from abrasion by thetrach tube at the stoma. If largeenough, a granuloma may cause air-way obstruction. Tracheomalacia is a significant riskfor patients who have a cuffed trachtube. It is imperative that the cuff not be overinflated. We see it all toooften caregivers or family membersoverfill the cuff and inevitably theventilator user ends up with a dis-tended trachea, esophageal fistula orother complications. The best practiceis to use minimal leak technique forcuff inflation just enough airinjected into the cuff in order to allowonly a slight leak at peak inspirationfrom the the healthcare industry maynot have clear-cut guidelines regard-ing trach changes, it is heading in theright direction.

6 How Often Should Tracheostomy Tubes Be Changed? continued from page 5 References1. AARC Clinical PracticeGuideline: Long-Term InvasiveMechanical Ventilation in theHome 2007 Revision &Update, Private communication,December 1, 1994, Michael , MD, Bobby R. AlfordDepartment of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine,Houston, Texas.