Standards Procedure (Skill)
Clinical Indications: Levels: EMT-I & EMT-P
Ø Presence of a tracheostomy site.
Ø Urgent or emergent indication to change the tube, such as obstruction that will not clear with suction, dislodgement, or inability to oxygenate, and/or ventilate the patient without other obvious explanation.
Procedure:
a. Have all airway equipment prepared and ready for standard airway management, including equipment for orotracheal intubation and failed airway.
b. Have airway device (endotracheal tube or tracheostomy tube) of the same size as the currently placed tracheostomy tube as well as 0.5 smaller size available (if the patient has a #6.0 Shilley, a 6.0 and a 5.5 endotracheal tube is required.)
c. Lubricate the replacement tube(s) and check the cuff.
d. Remove the tracheostomy tube from the mechanical ventilation device and ventilate with a bag valve mask to pre-oxygenate the patient.
e. Once all equipment is in place, remove the devices that secure the existing tracheostomy tube, including sutures and-or supporting bandages.
f. If applicable, deflate the cuff on the tracheostomy tube. If unable to aspirate air with a syringe, cut the balloon off and allow cuff to loose pressure.
g. Remove the tracheostomy tube.
h. Insert the prepared replacement tube.
i. Confirm placement via standard measures excluding esophageal detection (as it is ineffective for surgical airways.)
j. If resistance is met upon insertion, remove and re-attempt with the smaller tube.
k. If difficulty is still encountered, use standard airway procedures such as bag valve mask or endotracheal intubation (as per protocol). More difficulty with a tube change can be anticipated for tracheostomy sites that are immature (less than two weeks old). Great caution should be exercised with these types of sites.
l. Document procedure, confirmation, patient response, and any complications in the ACR.
Certification Requirements:
Successfully complete an annual skill evaluation including the indications, contraindications, technique, and possible complications of the procedure.