Tracheostomy tubes are used in pediatric patients primarily for mechanical ventilation in chronically ill patients and to overcome obstruction. Replacing an established tracheostomy is part of routine care for pediatric patients who have tracheostomy tubes. While parents or home nurses often replace tracheostomy tubes at home on a regular basis, hospital-based health care providers infrequently perform this procedure. When patients with tracheostomies are hospitalized and the procedure is indicated, it is often carried out under urgent circumstances. Thus practitioners should acquire the skills to facilitate efficient replacement.

A tracheostomy tube change is indicated for routine maintenance and also when a tube malfunctions for a variety of reasons. If a patient with a tracheostomy is in the hospital on a long-term basis, routine tracheal tube changes may be scheduled in order to decrease granulation tissue formation or to change the tracheostomy tube size.¹ Hospital-based physicians may be involved in these non-urgent changes but the physician is more likely to be present during imperative replacements. The two primary indications for urgent replacement of tracheostomy tubes in pediatric patients are a dislodged tube or an obstructed tube.¹ If a tube accidentally dislodges, a replacement tube must be inserted immediately. Respiratory distress caused by clogging from thickened secretions sometimes develops in a child with a tracheostomy tube in place. If suctioning fails to clear the blockage, the tracheostomy tube must be rapidly removed and a new tube inserted by a trained practitioner. These circumstances occur more often in infants.

If a tracheostomy tube dislodges or becomes obstructed, there are no absolute contraindications to replacement. However, extreme caution must be exercised when replacing a tracheal tube in a patient who has a fresh tracheotomy. For routine replacements, it is best to defer replacement until appropriate equipment and staffing can be obtained, and the patient’s comfort can be optimized.

The trachea begins from the cricoid cartilage and extends to the location of the T4-5 vertebrae, where it divides into the carina. In children, the length of the trachea correlates more closely to body weight than length or height. The trachea is located in the superior mediastinum and is adjacent to several neurovascular structures including the brachiocephalic trunk and the vagus nerve. It also closely borders the pleura and pleural space. It is important to be aware of the trachea’s proximity to these vital structures, as complications may arise if these structures are manipulated during the procedure.

A dislodged or obstructed tracheostomy is an unpredictable complication and must be addressed urgently. Therefore for all patients admitted to the hospital with tracheostomies, it is important to gather the equipment necessary for replacing a tracheostomy tube upon admission to the hospital. Having the equipment available at the bedside enables prompt correction that can be life-saving for patients dependent on mechanical ventilation. Establishing the patient’s weight and size of tube in place are important pieces of information that aid in collecting correct size equipment. Other useful information that may be obtained from the history are the tube size used for previous intubations, prior complications, and unusual airway anatomy. This information may be verified on admission to the hospital and subsequently recorded or displayed such that it is readily available to all providers.