How To Remove And Replace Tracheostomy Tubes: Step-by-Step Guide

When disease or trauma severely compromises a patient’s ability to breathe independently through the mouth or nose, the tracheostomy tube plays an irreplaceable protective role. It re-establishes a vital airway, allowing air to bypass the obstructed or weakened upper respiratory tract and directly enter the lungs. This technique has saved countless lives and has become a key method of critical care support. However, this artificial bypass of the natural respiratory pathway also brings an unavoidable consequence—long-term dependence. Patients may no longer be able to maintain adequate ventilation through the usual route, and survival largely depends on this small tube.

This lifeline is not a permanent solution. It is essentially a foreign object inserted into fragile human tissues. Whether made of silicone or polyvinyl chloride, once placed in the body, the tube faces constant challenges: the body may react to it, sticky secretions continuously accumulate, and the material itself gradually ages and wears down in the physiological environment. Therefore, regular removal and replacement are not mere routine tasks, but crucial medical interventions. Neglecting or delaying this process entails serious risks. Secretions deposited on the inner wall of the tube can lead to dangerous obstruction and impaired ventilation; continuous friction at the fixed position may cause inflammation or even granulation tissue formation; and most importantly, microbial growth inside and outside the tube significantly increases the risk of both local and systemic infections. Avoiding these risks and ensuring airway safety are the core reasons for mastering the proper timing and technique of tube replacement.

Tracheostomy Tube Removal

When a patient regains sufficient spontaneous breathing capacity and no longer requires assisted ventilation through the tube, or when the tube itself shows aging cracks, severe obstruction from secretions that cannot be cleared, peristomal infection, or other related complications, removal of the tracheostomy tube becomes a necessary procedure. This must be carried out with extreme caution to protect the fragile artificial airway.

Before beginning the removal, thorough assessment and preparation are essential. First, confirm that the patient’s vital signs are stable, with adequate spontaneous respiratory reserve and no risk of acute respiratory distress. Inspect the skin around the tracheostomy stoma to ensure good healing without signs of redness, discharge, infection, or fragility. The procedure must follow strict aseptic principles: staff must perform proper hand hygiene and prepare sterile instruments and a clean working environment. A functioning suction device should be available at the bedside, ready to clear secretions. Most importantly, a sterile replacement tracheostomy tube with ties must be prepared within reach, along with emergency airway management equipment such as a resuscitation bag and mask, in case of sudden respiratory compromise.

Steps for tube removal:

· Patient assessment and positioning: Just before removal, re-confirm the patient’s level of consciousness, oxygen saturation, and that breathing effort is sufficient and stable. Place the patient in a comfortable supine or semi-upright position, with the head centered and the neck extended (but not overextended).

· Deflation of the cuff: Using a calibrated syringe, completely withdraw the air or saline from the tube cuff to relieve pressure on the tracheal wall. During this step, closely observe the patient’s response for coughing or discomfort.

· Tube withdrawal: Hold the external end of the tube firmly and gently, then slowly and smoothly withdraw it along its natural curve. Movements should be continuous, avoiding abrupt pulling or twisting.

· Stoma care and observation: After tube removal, immediately cover the stoma with sterile gauze or a suitable dressing. Encourage the patient to exhale or cough if possible. At this stage, be highly alert to the patient’s respiratory status: observe closely for signs of labored breathing, stridor, hoarseness, cyanosis of the lips, or a sudden drop in oxygen saturation.

Although tube removal is a routine procedure, it carries specific risks and key points requiring attention. The most urgent concern is potential airway compromise; acute obstruction may occur after removal. Deflating the cuff may allow residual secretions to slip into the lower airway, causing aspiration or blockage. Removal can also trigger bleeding or tissue injury, particularly if the stoma has not matured. Finally, the stoma must be managed to remain open or closed as planned—if it does not heal as expected, active intervention is required. Throughout the procedure, the clinician must stay focused and prepared to respond to emergencies at any moment.

Tracheostomy Tube Change

Regular maintenance and timely replacement of a tracheostomy tube are critical to ensuring long-term airway safety. Even if the tube shows no visible damage, the material will inevitably degrade and wear over time. If the tube becomes cracked, deformed, irreversibly obstructed, or no longer fits the patient’s airway anatomy, replacement must be carried out without hesitation. Choosing the right timing for replacement is essential, as it effectively prevents potential complications.

Thorough preparation is the foundation of a successful replacement. The procedure must be performed under strict aseptic conditions to minimize infection risk. The operator must carry out hand hygiene and wear necessary protective equipment such as sterile gloves, a mask, and a surgical cap. All required items should be prearranged in an orderly fashion in the sterile field: prepare a new sterile tube of the same size as the original (or an alternative size based on assessment), ensuring its packaging is intact. The obturator should be properly lubricated beforehand. A second sterile backup tube with ties should also be kept within reach. A functional suction machine with a sterile suction catheter is indispensable. Oxygen supply devices, such as humidified high-flow oxygen or other respiratory support systems, must be pre-connected and ready for immediate use. Finally, all essential emergency equipment—including a resuscitation bag, face mask, laryngoscope, and endotracheal intubation kit—must be available at the bedside.

How to change tracheostomy tube:

· Removal of the old tube: Following the same process as described for removal, gently and completely withdraw the old tube from the airway. Immediately assess the stoma and monitor the patient’s respiratory response.

· Insertion of the new tube: Insert the obturator into the new sterile tracheostomy tube to provide structural support. Gently guide the beveled tip and tube along the natural curvature into the stoma, advancing steadily along the established anatomical path until the estimated depth is reached. Movements should be smooth and continuous, minimizing exposure of the stoma. Once the tube is in place, promptly remove the obturator.

· Cuff inflation and tube fixation: Using a syringe, inflate the cuff with the appropriate amount of air to achieve a proper seal. After inflation, confirm that the tube’s flange is securely positioned against the stoma. Fix the tube in place with clean, comfortable ties around the neck, ensuring one-finger space beneath the ties. Ties that are too tight may damage the skin, while ties that are too loose risk accidental dislodgement.

· Verification of airway patency: The first task after placement is to confirm that ventilation is effective. Auscultate both lungs for clear, symmetrical breath sounds. Monitor end-tidal CO₂ waveform to verify accurate placement. Continuous observation of chest rise and oxygen saturation trends is also essential.

It is vital to remain aware of the inherent uncertainty of this procedure. Even with thorough preparation, the process of exchanging tubes may cause unexpected complications such as patient distress or reflex airway spasm leading to obstruction. Therefore, constant vigilance is required throughout the procedure. One assistant should be dedicated solely to monitoring the patient’s respiratory and circulatory status. Backup tubes and complete sets of emergency drugs and equipment must remain immediately accessible. Any lapse in attention could endanger the patient’s life. Safety must remain the guiding principle at every step.

Why Regular Removal and Replacement Are Necessary

The human respiratory system is intricately designed to filter, humidify, and regulate the temperature of air as it passes through the nose and mouth. A tracheostomy tube, however, bypasses this essential natural barrier and creates a direct shortcut into the lungs. Without this protective process, inhaled air is no longer filtered or conditioned, and thick secretions are more likely to form and accumulate inside the tube. Over time, these stagnant secretions dry out and harden, adhering firmly to the tube wall. Eventually, they can develop into stubborn plugs that significantly narrow the airflow passage and compromise effective ventilation.

More importantly, this direct passage also provides an open gateway for microorganisms from the mouth and surrounding environment to enter the airway, substantially increasing the risk of infection. These infections may present locally at the stoma site or progress into the lower respiratory tract, leading to more severe conditions.

Additionally, any foreign object that remains inside the body over a long period inevitably disrupts the natural balance of tissues and triggers a series of potential responses. Continuous irritation may stimulate the tracheal wall or surrounding tissues, causing the formation of granulation tissue. These growths can obstruct airflow, leading to narrowing or blockage, and may also bleed or tear during tube removal.

Even the most durable tube materials cannot resist long-term degradation in the body’s warm, moist environment. Microcracks, deformation, and brittleness in the tube wall are only a matter of time. Such structural damage may cause air leakage and impair ventilation. In more severe cases, fragments from a broken tube may dislodge into the airway, posing a dangerous foreign body risk.

In summary, regular removal and replacement are not simple routine maintenance measures, but essential medical interventions to ensure safe and effective tracheostomy management. They proactively eliminate potential obstructions, minimize infection risks, and allow timely identification and correction of tube-related or tissue-related abnormalities. A clear understanding of this necessity—and strict adherence to the practice—form the foundation for maintaining a secure and reliable airway for tracheostomy patients.

Conclusion

The removal and replacement of a tracheostomy tube are critical technical procedures in the management of a patient’s airway. Every step must be performed strictly according to standardized protocols, from initial assessment and equipment preparation to the execution of the procedure itself. Throughout the process, aseptic principles and patient safety must always be prioritized, with no compromise.

When performed correctly and meticulously, these procedures not only ensure immediate airway patency and patient safety but also serve a deeper purpose: proactively preventing complications that arise from prolonged foreign body retention, secretion buildup, and microbial invasion. In the long run, this reduces patient discomfort and risk while also lightening the burden of subsequent complex care.

Achieving optimal outcomes depends not only on the skill of the operator but also on the quality of the tracheostomy tube selected. Using products with appropriate specifications and high-quality materials, combined with strict adherence to standardized protocols, establishes a safe and reliable system for airway management.

Only through such standardized, high-quality medical practices can we ensure that this vital airway remains safe and secure, while simultaneously improving overall treatment effectiveness. This, in turn, enhances patient recovery experience and satisfaction. Ongoing review and optimization of operational standards will always remain a central theme in advancing healthcare quality.