Reinserting Tracheostomy Tube

Emergency Intervention, Respiratory

*THIS PROCEDURE IS TYPICALLY PERFORMED BY A REGISTERED NURSE

The use of this procedure guideline assumes that the registered nurse has the nursing education and skills to perform this task. This procedure guideline does not replace nursing clinical judgment.

Considerations:

The changing of a tracheostomy tube in the school setting should be considered an emergency situation.
Any concern that the situation is potentially life-threatening requires the activation of the EMS/911 system while the procedure is being performed.
When caring for a student who has a tracheostomy, the school nurse should always know the reason for the tracheostomy, the student’s underlying health conditions and whether the student needs the tracheostomy to breathe.
The two most common emergency scenarios are:
- accidental decannulization; and
- tracheostomy tube obstruction unrelieved by reasonable suction attempts.
There should always be a “GO BAG” (Emergency Travel Bag) accessible when completing any tracheostomy procedure.
If the student’s “GO BAG” contains a battery charged suction machine, the school nurse should check the battery charge level daily to ensure that it is fully charged.
The school nurses should establish a schedule to periodically check the “GO BAG” to ensure all necessary supplies are available, not expired, and are in working condition.
A shoulder roll is recommended to assist with the visualization and access to the tracheostomy site.
Obstruction can be caused by thick secretions/mucous plugging, foreign body, or airway granuloma tissue.
- Airway granuloma tissue can persist to obstruct a new tracheostomy tube, resulting in the highest degree of medical emergency.

Supplies:

“GO BAG” (Emergency Travel Bag) Equipment:

The essential equipment to be kept with the student at all times is as follows:

Gloves
Portable oxygen (if ordered) with appropriate sized Ambu-bag
Appropriate size Ambu-bag face mask (for emergencies when unable to reinsert a new tracheostomy tube)
portable suction machine that can operate with battery or electricity
- Battery should have a full charge
Sterile suction catheters
Sterile saline vials
Water-based lubricant
Distilled or sterile water
4×4 gauze
Split gauze dressing (if student uses)
Unscented and dye free soap
Syringe, if needed for tracheostomy tube cuff
Sterile water for cuffed trach filled with water
Two spare tracheostomy tubes (including obturator) — one the size the student currently uses and one that is a size smaller in the event that the tube needs to be changed and there is difficulty passing it through the stoma
obturator, if applicable
Spare tracheostomy ties
- It is recommended to have a set of spare tracheostomy ties already secured to spare tracheostomy
Blunt scissors
Emergency phone numbers
Pulse oximeter — may be optional if student is not on oxygen or mechanical ventilation

Additional Supplies:

Stethoscope
Medical tape
Personal protective equipment
- goggles
- mask
- gloves
Blanket role to place under the student’s shoulders
Accessible phone
Individualized Health Care Plan (IHCP) and Health care provider’s orders
Parent/Guardian authorization form

Procedure:

Activate EMS/911, if student is unresponsive
Review health care provider’s order
Ensure proper documentation of parent/guardian authorization to perform this procedure
Reassure student
Wash hands, if student’s condition permits
Assemble equipment as student’s condition permits or utilize equipment in emergency travel bag
If ordered, place pulse oximeter on student’s finger, toe, or ear lobe during and after the procedure
Ensure the presence of another responsible adult, preferably another nurse, if available, to assist with stabilizing the tracheostomy tube
Put on gloves, goggles, and mask if student’s condition permits
Have adult assisting with procedure put on gloves, goggles, and mask if student’s condition permits
Suction the student’s tracheostomy tube (see Tracheal Suctioning-Clean Technique)
If able, position the student supine on the floor with a shoulder roll to gently hyperextend the neck
Open the new tracheostomy tube kit that is the same size as is currently in the student
1. Have the size smaller new tracheostomy tube readily available if needed
2. If new tube is not available, clean the old tube if possible
Take care to not touch the curved part of the tracheostomy tube, lubricate the distal end of the new tracheostomy tube with water-based lubricant
Return the tracheostomy tube to the clean package that it was sealed in
1. If the tube has an obturator, be sure the obturator is in the tube
2. If the tube has an obturator, move it back and forth to be sure it will slide out easily
Remove tracheostomy mask, artificial nose or ventilator connection, as necessary
Give student two to four breaths with manual resuscitator bag
1. If unable to pass suction catheter, do not attempt to give breaths to a plugged trach CHANGE THE TRACH TUBE
Have adult assisting with procedure hold old tracheostomy tube in place by placing two fingers on the faceplate
Assure tracheostomy tube cuff has been fully deflated, if applicable
1. Deflate the cuff per manufacturer’s instructions
Remove or cut old tracheostomy ties
With one hand remove the old tracheostomy tube and set it out of the way
Insert new tube
1. If tube does not have an obturator, insert new tube at a right angle to the stoma, rotating it downward as it is inserted
2. If tube has an obturator, insert tube straight into stoma
  1. Immediately remove the obturator and insert inner cannula with a motion that follows the curve of the tube
  2. Insertion of new tube should take no longer than 30 seconds
3. Have adult assisting with the procedure hold the new tracheostomy tube in place
4. If the new tube has an obturator, remove the obturator with a motion that follows the curve of the tube
5. Administer a minimum of three breaths with a manual resuscitator bag
6. Secure the new tracheostomy tube in place by fastening the tracheostomy ties
  1. The ties should allow enough space for one pinky finger between ties and neck
7. If this is a cuffed tracheostomy tube, inflate at this time per manufacturer’s instructions
8. Re-attach tracheostomy mask, artificial nose or ventilator connection, as necessary
9. Position the student comfortably and observe to ensure that the student remains stable on their baseline level of supplemental or ventilator support (if any)
10. Continue the respiratory assessment, using pulse oximetry, if available, until EMS has arrived (if called)
11. Discard used equipment per school policy
12. Remove gloves
13. Wash hands
14. Document assessment, intervention and outcomes in student’s health care record
15. Notify parents/guardian and medical provider that student required a tracheostomy change procedure
16. Replenish supplies in emergency travel bag

If unable to replace tracheostomy tube:

Reposition the student and re-attempt to place the tube
If unsuccessful, attempt to place the smaller tube
If unable to place a size smaller tube, assess student’s respiratory status to determine the need for rescue breathing
a. If rescue breathing is needed, call 911 for assistance
i. Open the natural airway (the student’s mouth
1. Be aware that some patients may not have a natural airway due to surgical procedures or anatomical abnormalities
ii. Tape over the tracheal stoma
iii. Give breaths using a manual resuscitator bag with a face mask
b. If rescue breathing is not needed and student’s respiratory status is stable, observe the student and notify parent or guardian of situation.
i. Continue to monitor respiratory status.

References:

Children’s Hospital St. Louis. (n.d.) Tracheostomy home care. Retrieved June 7, 2023, from https://media.bjc.org/sitelinks/tracheostomy/a001_changing_the_trach_tube_changing_the_trach_tube.html

Children’s Mercy Kansas City. (2018). Office of evidence based practice (EBP) – Critically appraised topic: Tracheostomy emergency supplies. Retrieved June 8, 2023 from https://www.childrensmercy.org/contentassets/878a471901cd4e858cc27ae0d82f441e/trach-go-bag-cat.pdf

Children’s Mercy Kansas City. (n.d.). Tracheostomy care- Changing the tracheostomy tube. Retrieved June 8, 2023, from https://www.childrensmercy.org/siteassets/media/departments-and-clinics/otolaryngology/tracheostomy-care-changing-the-tracheostomy-tube.pdf

Children’s Mercy Kansas City. (n.d.). Tracheostomy tube. Retrieved June 7, 2023, from https://www.childrensmercy.org/siteassets/media/departments-and-clinics/otolaryngology/tracheostomy-care-parent-card.pdf

Children’s Wisconsin. (n.d.). 1-Person emergency trach change demonstration. . Retrieved June 8, 2023, from https://childrenswi.org/medical-care/tracheostomy-home-ventilator/educational-resources

Children’s Wisconsin. (n.d.). One person trach change demonstration. . Retrieved June 8, 2023, from https://childrenswi.org/medical-care/tracheostomy-home-ventilator/educational-resources

Children’s Wisconsin. (n.d.). Two person trach change demonstration. . Retrieved June 8, 2023, from https://childrenswi.org/medical-care/tracheostomy-home-ventilator/educational-resources

Lawrence, P. R., Chambers, R., Faulkner, M. S., & Spratling, R. (2021). Evidence-based care of children with tracheostomies: Hospitalization to home care. Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses, 46(2), 83–86. https://doi.org/10.1097/RNJ.0000000000000254

Pediatric Home Services. (2016). Emergency trach tube change (Cambio de emergencia de tubo traqueal). .Retrieved June 8, 2023, from https://www.pediatrichomeservice.com/tips-how-tos/emergency-trach-change/?play=1

Porter, S.M., Page, D., Engholm. H., Somppi, C. (2019). Students supported by medical technology. In J. Selekman, Shannon, R.A., Yonkaitis, C.F. (Eds.). School nursing, a comprehensive text (3rd ed., pp. 721-740). Philadelphia PA.: F.A. Davis Co.

The StayWell Company, LLC.. (2021). Step-by-step: Changing a child’s tracheostomy. Retrieved June 8, 2023, from https://stlouischildrens.staywellsolutionsonline.com/MultimediaRoom/VideoLibrary/?e=0#player:138,A90943

UC Davis Children’s Hospital, Olarewaju, A. (2019). Ear, nose, and throat (ENT) pediatric tracheostomy handbook. Retrieved June 7, 2023, from https://health.ucdavis.edu/media-resources/children/documents/patient-education-A-to-Z/peds-tracheostomy-handbook.pdf

UpToDate. (2023). Patient education: Emergency care for infants and children with tracheostomy (the basics). Retrieved June 8, 2023, from https://www.uptodate.com/contents/emergency-care-for-infants-and-children-with-a-tracheostomy-the-basics?search=care%20of%20pediatric%20tracheostomy&source=search_result&selectedTitle=8~150&usage_type=default&display_rank=8
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Acknowledgment of Reviewers:

Angie Bulmahn, MSN, RN, NCSN
School Nurse Specialist
Missouri Department of Health and Senior Services

Marjorie Cole, MSN, RN, FASHA
State School Nurse Consultant
Missouri Department of Health and Senior Services

Renee Falkner, BSN, RN
School Nurse Supervision Specialist | Therapylog

Katherine Park, DNP, RN, NCSN
Nationally Certified School Nurse, Pierremont Elementary
Adjunct Professor, Maryville University School of Nursing

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Page last updated: February 16, 2024/no video
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The information and materials presented in this Website are intended for informational purposes only and are not designed to diagnose or treat a health problem or disease, or assist in diagnosis or treatment of the same. The information is not intended to substitute for, supplement or replace clinical judgment. If there are any concerns or questions about or relating to a nursing or medical procedure, contact the individual’s healthcare provider. The information provided on this Website is not intended to be a substitute for medical orders and persons without the proper education, training, supervision and/or licensure should not perform the procedures.

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