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The efficacy of tracheostomy tube changes by speech-language pathologists:

A retrospective review

Article  in  International Journal of Therapy and Rehabilitation · November 2017

DOI: 10.12968/ijtr.2017.24.11.466

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RESEARCH

The efficacy of tracheostomy 

tube changes by speech‑language
pathologists: A retrospective review
Scott M Russell, Lindsey Highsmith, Oswaldo Henriquez, Samir Belagaje, Charles Moore

Abstract
Background/Aims: The number of tracheostomised patients in the acute care setting are increasing,
Scott M Russell resulting in an equal need of providers who can safely change tracheostomy tubes without
Senior speech-language complications. The objective of this retrospective study was to ascertain if trained speech-language
pathologist, Grady pathologists were able to safely and efficiently perform tracheostomy tube changes in the acute care
Memorial Health System, setting with minimal adverse events.
Atlanta, Georgia, USA
Lindsey Highsmith
Methods: Our retrospective case series spans from June 2010 to March 2015 and was completed at an
Senior speech-language academic hospital with a level 1 trauma designation. A total of 107 consecutive referrals undergoing a
pathologist, Grady tracheostomy tube change, with a speech-language pathologist, were identified. Success was defined
Memorial Health System, as the placement of the tracheostomy tube into the tracheal lumen with confirmation of placement. Only
Atlanta, Georgia, USA complications occurring at the time of the tracheostomy tube change were considered and were defined
Oswaldo Henriquez as an airway loss event: oxygen desaturation <85%; uncontrollable bleeding >5mL; and the inability to
Assistant professor, perform the attempted tracheostomy tube change for any other reason.
Department of
Otolaryngology-Head Results: All of the tracheostomy tubes changes were performed at the bedside at a mean of 13
and Neck Surgery, Emory days post tracheotomy (range 3–28). A total of 106 (99%) of 107 tracheostomy tubes changes were
University; Associate successfully completed without complications; 83 (79%) of the tracheostomy tubes changes performed
chief, Department of
Otolaryngology, Grady
were the initial tracheostomy tubes change completed post tracheotomy. The remaining 23 (21%)
Memorial Health System, were a combination of either the second or third change. One, (less than 1%), of the procedures was
Atlanta, Georgia, USA attempted and discontinued before the removal of the tracheostomy tubes, and referred back to the
Samir Belagaje surgical services and was successfully managed with no untoward effects to the patient.
Assistant Professor, Conclusions: This is the first study to audit the outcome of speech-language pathologists’
Emory University
Department of Neurology
ability to successfully change a tracheostomy tube. The findings suggest that specially trained
and Rehabilitation speech-language pathologists, acting as part of a multi-disciplinary care team, have the potential to
Medicine; Director, safely change tracheostomy tubes in an acute care setting with the availability of immediate physician
Stroke Rehabilitation, and respiratory therapy support. Additional clinical benefits of the speech-language pathologist
Marcus Stroke and changing tracheostomy tubes may include earlier facilitation of communication, decannulation and
Neuroscience Center,
Grady Memorial Health
initiation of nutrition/hydration.
System, Atlanta, Georgia, Key words: ■ Speech-Language Pathologist ■ Tracheotomy ■ Tracheostomy change ■ Weaning
USA
Charles Moore Submitted 21 January 2017; accepted following double blind peer review: 23 August 2017
Professor, Department
of Otolaryngology-Head

A
and Neck Surgery, Emory
University; Chief of
service, Department of s the field of medicine has evolved, the neurologic impairment requiring airway management;
Otolaryngology, Grady tracheotomy has become one of the most bronchial toileting; and upper airway obstruction
Memorial Health System, frequently occurring surgical procedures (Tabaee et al, 2007; Cheung and Napolitano, 2014).
© 2017 MA Healthcare Ltd

Atlanta, Georgia, USA performed in the acute care setting (Zhu This cohort is described as being one of the more
Correspondence to: et al, 2012). Tracheostomy management resource-intensive populations to care for (Freeman
Scottt M Russell has traditionally been managed by a surgical service, and Morris, 2012); while standardised and evidence-
Email: with indications including: acute respiratory failure; based protocols exist, they are highly variable (Tabaee
smrussell@gmh.edu prolonged need for mechanical ventilation; traumatic or et al, 2007) and not of the highest evidence (Garrubba

466 International Journal of Therapy and Rehabilitation, November 2017, Vol 24, No 11

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et al, 2009; Mitchell et al, 2013; Enamandram et al,
2014; Zhu et al, 2014).
Management of a tracheostomy tube is important
to ensure the airway is maintained, communication is
optimised, swallow function is preserved, granulation
tissue formation is minimised, and pressure on the
tracheal mucosa and skin breakdown is reduced. The
process of changing a tracheostomy tube has been
described as being ‘straightforward’ once the stoma
has matured (Hess, 2005; White et al, 2010), although
it is recommended that the initial change is performed
by a skilled provider (Nagi et al, 2014) or physician
(Engels et al, 2009; Mitchell et al, 2013).
Traditional studies focusing on tracheostomy
tube complications have reported complications
as intraoperative, early post-operative, and late
post-operative, with rates of 1.45%, 5.6%, and
7.1% respectively (Halum et al, 2012). Additional
studies report a combined procedural, early, and late
complication rate of 4% (Goldenberg et al, 2000).
Halum et al (2012), along with other studies, report
the majority of tracheostomy tube complications occur
during the initial tracheostomy change (Das et al, 2012)
with complications including the potential for post-
operative bleeding (Halum et al, 2012), airway loss and
extratracheal tube placement resulting in subcutaneous
emphysema, pneumomediastinum, cardiac arrest or
death (Deutsch, 1998; Fikkers et al, 2002; Schmidt et
al, 2008). While these studies bring forth valuable data,
they fail to report specific complications associated
with the process of changing a tracheostomy tube.
Studies assessing the complications associated
with the initial tracheostomy tube change are sparse;
however, the ones that are available are favourable.
Fisher et al (2013) report successfully completing the
initial tracheostomy tube change for 130 adult patients
under the supervision of an attending intensivist or a
critical care fellow under direct attending supervision.
Additionally, a respiratory therapist and nurse provided
ancillary support. Kathiresan et al (2014) report
only minor complications with repeatedly changing
34 adult tracheostomy tubes in a chronic ventilator
dependent cohort under the supervision of a consultant
or trainee physician.
Paediatric studies investigating complications with
the initial tracheostomy tube change are reported to
be rare (Van Buren et al, 2015) with the initial change
being completed as early as post-operative day (POD)
3 or 4 (Deutsch, 1998; Lippert et al, 2014). Training
family to change paediatric tracheostomy tubes dates
back three decades (Kennedy et al, 1982; Lichtenstein,
1985; Siddharth and Mazzarsella, 1985), with multiple
© 2017 MA Healthcare Ltd
studies reporting patients and families being able
to change tracheostomy tubes independently upon
discharge from the acute setting (Ruben et al, 1982;
Tearl and Hertzog, 2007; Graf et al, 2008; Akenroye
and Osukoya, 2013).
International Journal of Therapy and Rehabilitation, November 2017, Vol 24, No 11
RESEARCH
These favourable tracheostomy tube change
studies are contrary to a survey distributed to the
American Academy of Otolaryngology–Head and
Neck Surgery (AAO-HNS) members, in 2012, to
determine the management strategies and complications
associated with tracheostomy tube changes. A total
of 478 respondents (mean=21.2 years; standard
deviation=11.1 years) were surveyed and reported 759
catastrophic tracheotomy related events that occurred
during the respondents’ career (mean=0.097 events
per physician year).
A statistically significant higher incidence of airway
loss was reported when the initial tracheostomy tube
change was completed in the ward setting. The
qualitative descriptions of catastrophic events reported
267 incidences. A total of 122 events were secondary
to accidental decannulation, while only 17 incidents
occurred during the planned tracheostomy tube change;
57 events were secondary to mucous plugging, while
128 incidents were because of major bleeding. The
number of events that were considered correctable
was not differentiated; however, factors related to
these events included patient positioning, nursing
knowledge, and junior physician competency, which
may be amenable to training (Das et al, 2012).
Internationally, managing communication and
swallowing disorders in the tracheostomy population
is well established and within the scope of practice
for speech-language pathologists (American Speech
Language and Hearing Association (ASHA), 2002a;
2002b; 2007), speech pathologists (Speech Pathology
Australia, 2005) and speech and language therapists
(SLT) (Royal College of Speech and Language
Therapists (RCSLT), 2014a).
The term speech-language pathologist (SLP) is
primarily used in this investigation, as it is applicable
to the USA, where this investigation research was
completed. The requisite knowledge and skills
specifically related to tracheostomy management for
SLPs include:
■ ■ Having a fundamental knowledge of the anatomy and
physiology of normal and abnormal aerodigestive
tracts and related respiration, swallowing, and
airway protection;
■ ■ Having knowledge of special medical conditions
such as pulmonary dysfunction and tracheostomy;
■ ■ Having the ability to conduct evaluations of the
upper aerodigestive tract
■ ■ Being able to participate in the selection and
evaluation of talking tracheostomy tubes and one-
way speaking valves (ASHA, 1993; RCSLT, 2014b).
SLPs are increasingly managing more complex
and diverse tracheostomised caseloads (McGrath
and Wallace, 2014) and are being recognised as key
members of the critical care (Baumgartner et al, 2008)
and multidisciplinary tracheostomy team (Pandian
et al, 2012; McGrath and Wallace, 2014; Hunt and
467
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RESEARCH
McGowan, 2015), resulting in greater opportunities
to contribute their expertise to tracheostomy-related
matters beyond communication and swallowing
(McGrath and Wallace, 2014).
These contributions include recommending
tracheostomy tube modifications to facilitate
communication, swallowing and tracheostomy tube
weaning (Pandian et al, 2012; RCSLT, 2014b). Hunt
and McGowan (2015) report knowledge of tracheostomy
teams having developed core competencies enabling
SLPs to troubleshoot complications, provide tracheal
suction, change tracheostomy tubes and decannulate
(Hunt and McGowan, 2015).
SLPs at Grady Memorial Hospital have practiced
changing tracheostomy tubes for over a decade. All
SLPs complete a formal department tracheostomy
tube training programme under the supervision
of an SLP with extensive experience changing
tracheostomy tubes, an advanced practice provider,
or an otolaryngologist to develop competency with
changing tracheostomy tubes. Training is completed
over a year through didactic lectures and hands-on skills
training. Specific changing processes incorporated into
training include the use of the classical and railroad
techniques (Engels et al, 2009).
Collaboration between the SLP and physician is
imperative to ensure patient safety (McGrath and
Wallace, 2014). Therefore, prior to introducing the
procedure, the SLP and physician collaborate to
determine the optimal tracheostomy tube (e.g. shape,
dimensions, and cuff status) related to the patients’
anatomy and physiology, such as morbidly obese
patients requiring extended length tracheostomy tubes
(Hess, 2005; White et al, 2010).
As a result of this practice and the lack of published
research regarding this topic, this study was completed
to ascertain if trained SLPs are able to safely and
efficiently perform tracheostomy tube changes in the
acute care setting with minimal adverse events.
METHODS
This project was initiated following approval through
the Internal Review Board at Emory University and the
Grady Research Oversight Committee. A retrospective
chart audit was completed for patients referred to the
speech-language pathology service at an academic
hospital for a tracheostomy tube change between
June 2010 and March 2015. The data were collected
from a prospectively maintained and password
protected electronic database and through the review
of the patients’ electronic medical record by two of
the authors. The electronic database documentation
included demographic data related to the referring
medical service, tracheotomy related diagnosis,
tracheotomy date, date of SLP consult, tracheostomy
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brand/dimensions, tracheostomy tube change date,
confirmation of placement method, overall success,
and complications.
Our predefined inclusion criteria included having
an acute tracheotomy, physician referral and being
deemed medically stable for a tracheostomy tube
change, along with successful liberation from the
ventilator. Our definition of success was placement
of the tracheostomy tube through the stoma into
the tracheal lumen with confirmation of placement
either by passing a sterile suction catheter through
the cannula or by performing via tracheoscopy. Our
exclusion criteria included being medically unstable
and ventilator dependent.
For the purpose of this retrospective audit,
complications occurring at the time of the tracheostomy
tube change were recorded and were defined as an
event resulting in airway loss; oxygen desaturation
<85%; uncontrollable bleeding >5mL; and as any
event that prevented the successful placement of the
tracheostomy tube. After 24 hours, documentation
in the electronic medical record was reviewed to
evaluate for any indication that the tracheostomy
tube placement was compromised, e.g. inability to
pass suction catheter.
RESULTS
From June 2010 to March 2015, a total of 95 acute
care patients were referred to the SLP service who
met the inclusion criteria, resulting in a total of
107 tracheostomy tube changes. The number of
patients excluded from the retrospective review was
not included in the data set. All tracheostomy tube
change procedures were authorised by a physician
and performed by a SLP at the bedside following a
standard tracheostomy tube change protocol. Physician
and respiratory therapy support were immediately
available during the tracheostomy tube change. The
two primary referring medical services were trauma
(n=48) and neurology (n=40). The two primary
diagnoses associated with the acute tracheostomy were
cerebrovascular accident (n=37) and traumatic brain
injury (n=27). A detailed list of the referring medical
and surgical services and diagnoses is available in
Table 1.
The referral for the tracheostomy tube change
was placed a mean of 11.7 (range 1–41) days post-
tracheotomy. The SLP completed the tracheostomy
tube change a mean of 1.3 (range 0–13) days following
the referral and a mean of 13.3 (range 5–33) days post-
© 2017 MA Healthcare Ltd
tracheotomy. The tracheostomy tube changes were
completed in the general inpatient ward, step-down
unit and intensive care units (ICU). The frequency of
tracheostomy tube changes occurring in these units
specifically was not recorded.
 RESEARCH

All of the patients (n=107) presented with a able to perform tracheostomy tube changes with similar
Shiley brand of tracheostomy tube. A total of 91 or fewer complications than experienced physicians
(85%) tracheostomy tubes were cuffed at the time of (Mitchell et al, 2013).
the evaluation, while the remaining 16 (15%) were The primary purpose of this study was to determine
cuffless. Ninety-five (90%) of the tracheostomy tubes if trained SLPs were able to perform a tracheostomy
were cuffless following changes by the SLP with the tube change in the acute care setting with minimal
remaining 11 (10%) being cuffed. A total of 102 (96%) adverse events. The review of 107 tracheostomy
procedures resulted in downsizing the tracheostomy tube changes indicated 106 (99.3%) were completed
tube, while 4 (4%) of the procedures increased the
size of the tracheostomy tube. A detailed list of the
tracheostomy tube changes is detailed in Table 2.
Placement was confirmed in 81 cases (76%) by
Table 1. Referring medical service and diagnosis associated
passing a sterile suction catheter through the cannula with reason for the acute tracheostomy
to assess for any distal obstruction and 25 (24%)
Referral Service n Diagnosis n
via tracheoscopy.
Of the total tracheostomy tube changes performed, Trauma 42 Multiple trauma 48
83 (78%) were initial changes post-tracheotomy, while
Neurology/neurosurgery 40 Cerebrovascular accident 37
the remaining changes were a combination of second
(n=24; 22%) and third changes (n=1; 1%). One patient Medicine/pulmonology 9 Respiratory failure 7
underwent three tracheostomy tube changes. The General surgery 8 Head and neck cancer 4
majority (98.8%) of the initial and all of the subsequent
tracheostomy tube changes were free of complications. Otolaryngology 6 Brain tumour resection 3
Nearly all (n=106; 99%) of the 107 tracheostomy Oral and maxillofacial 2 Obesity hyperventilation 3
tube changes were successfully completed without a surgery syndrome/obstructive
sleep apnoea
complication. The retrospective audit did not reveal any
loss of airway during the change, oxygen desaturation Tracheal stenosis 2
<85%, or uncontrollable bleeding >5 mL. One (0.07%)
Anterior cervical discectomy 1
of the procedures was discontinued secondary to fusion
significant resistance at the stoma during the attempt
Meningitis 1
to remove a cuffed tracheostomy tube. This patient
was referred back to the otolaryngology service, with N-methyl-D-aspartate receptor 1
the original tracheostomy tube in situ, for successful encephalitis
management without any untoward effects. 107 107
Records were available for review for 91 of the
tracheostomy tube change procedures after 24 hours.
All 91 of the tracheostomy tube procedures completed
were tolerated without documented need to change
the tracheostomy tube or noted obstruction. No Table 2. Shiley tracheostomy
documentation was available for 15 (14%) of the change characteristics
tracheostomy tube change procedures secondary to Change characteristics n
the patient being discharged from the facility.
8 cuffed to a 6 cuffless 49

6 cuffed to a 6 cuffless 18
DISCUSSION
6 cuffless to a 4 cuffless 12

SLPs are increasingly being considered valuable 8 cuffed to 6 cuffed 11

members of multidisciplinary tracheostomy teams, 6 cuffed to a 4 cuffless 5
resulting in increased opportunities to contribute their
expertise to tracheostomy-related matters beyond 4 cuffless to 6 cuffless 4
swallowing and communication (Hunt and McGowan, 8XLT cuffed to a 6XLT cuffless 3
2015; McGrath and Wallace, 2014). The initial
6 XLT cuffed to 6XLT cuffless 2
tracheostomy tube change procedure is routinely
© 2017 MA Healthcare Ltd

completed in the acute care setting by a variety of 4 cuffed to 4 cuffless 2

disciplines, such as respiratory therapy (Welton et al,
8 cuffed change to 6 cuffless 1
2016), intensivists (Fisher et al, 2013), and different aborted prior to removal of 8 cuffed
surgical services. The AAO-HNS has recommended
XLT: extended length tracheostomy tube
research to assess if an advanced practice provider is

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RESEARCH
‘SLPs are increasingly being considered valuable
members of multidisciplinary tracheostomy teams,
resulting in increased opportunities to contribute their
expertise to tracheostomy-related matters beyond
swallowing and communication.’
with no complications in the acute care setting.
Most of the tracheostomy tube changes downsized
the diameter and resulted in a change from cuff to
cuffless tube (n=70; 65%), which is considered less
complex than other changes (Hess, 2005). During
the tracheostomy tube change process, the utility of
tracheoscopy was immediately available, along with
nursing, respiratory, and physician support. This
success is attributed to the experience and extensive
training provided, the haemodynamic stability of
the cohort, case mix, consistently following a strict
tracheostomy tube change protocol, multidisciplinary
collaboration, and physician patient selection.
The majority of the cohort presented as a multiple
trauma (n=48) admission requiring a tracheotomy
to manage their acute medical condition. It is
presumed that a large number of these patients had
a pre-existing patent airway. As the acute medical
condition necessitating the tracheotomy improved,
their potential for complications associated with the
tracheostomy tube change reduced, likely influencing
the low complication rate. This is in contrast to those
in the cohort who underwent a tracheotomy for a
chronic medical condition (e.g. laryngeal cancer,
obesity hyperventilation syndrome/obstructive sleep
apnoea, tracheal stenosis) who were not anticipated to
have any immediate improvement resulting in a more
complicated airway and tracheostomy tube change.
These patients include those who were morbidly
obese requiring extended length tracheostomy
tubes (Hess, 2005) and are known to have greater
complications (El Solh and Jaafar, 2007) with the
tracheostomy tube change process secondary to
special anatomic considerations.
During the change, if the caudal turn is initiated
prematurely, the tracheostomy tube may be inserted
into the anterior mediastinal space and bypass the
airway (O’Connor and White, 2010). There were five
patients in our study who required the placement of an
extra length proximal tracheostomy tube secondary to
obesity; therefore, fiberoptic endoscopy was utilised
to confirm the placement. Complications during the
tracheostomy tube change in our study were rare and
occurred in 1 of 107 (0.7%) changes. In this patient,
the attempt to remove the tracheostomy tube was
met with significant resistance at the stoma at the
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deflated cuff. The encountered resistance appears to
be related to the tracheostomy tube placement being
classified as percutaneous and the prolonged period of
time between the tracheotomy and first tracheostomy
tube change. The attempted tracheostomy tube change
was discontinued, and the patient was referred back
to the otolaryngology service for management, with
no untoward effects.
The outcomes in this study are consistent with
the available studies that specifically reported
complications associated with the tracheostomy
tube changing process (Deutsch, 1998; Fisher, 2013;
Lippert et al, 2014; Van Buren et al, 2015). Fisher
and colleagues’ (2013) study closely resembles this
study and reported no complications for 130 adults
undergoing a tracheostomy tube change by a physician
with similarly pre-defined complications. The first
tracheostomy tube was initiated, for the majority of
their cohort, prior to POD 7 and despite the need for
mechanical ventilation, all tracheostomy tube changes
were successfully completed without complications.
A few paediatric studies report the success of the
initial tracheostomy tube change with similar outcomes
as this study. Van Buren et al (2015) reported
successful outcomes with nearly all (n=150; 99.3%)
of their cohort undergoing an initial tracheostomy
tube change between POD 2 to 5. The one reported
complication was characterised by a traumatic
reinsertion resulting in a pneumothorax. Deutsch
(1998) reported 20 of 21 paediatric patients underwent
a successful tracheostomy tube change, on the initial
attempt on POD 3 or 4 without complications. One
change was deferred secondary to the development
of a false passage on POD 2, resulting in the need
for intervention.
Another paediatric study reported all tracheostomy
tube changes were successfully completed in the post-
protocol group on POD 3 or 4 free of complications
(Lippert et al, 2014). Despite these cohorts being
paediatric based, they highlight that the majority of
tracheostomy tube changes performed by physicians
are completed without complications.
While the current outcomes are comparable to these
studies, they do differ with regard to the elapsed time
to allow for maturation of the endotracheal-cutaneous
tract. Premature changing of a tracheostomy tube
before maturation of the tract increases the potential
for complications (Deutsch, 1998), secondary to the
risk of the endotracheal-cutaneous tract collapsing
and recoiling. The endotracheal-cutaneous tract is
considered mature once it has epithelialised and
the edges of the tracheal wall have secured onto the
© 2017 MA Healthcare Ltd
subcutaneous tissues (Perkin et al, 2008). The initial
tracheostomy tube change included in this study was
completed at a mean of 13 PODs, which is consistent
with the recommendations of the AAO-HNS (White et
al, 2010) and likely reduced the cohort’s potential for

complications during the tracheostomy tube change. A
total of eighty-three (78%) of the tracheostomy tube
changes were the initial change, which tends to be more
technically challenging (Bodenham et al, 2014) than
subsequent changes (White et al, 2010). Despite this
increased potential for complications, there were no
episodes of the endotracheal-cutaneous tract collapsing
or recoiling and the procedural success rate for this
cohort remained at 98.8%. Despite the success and
the process of changing a tracheostomy tube typically
being straightforward and free of complications, the
authors recognise the potential for complications and
the need to plan for unforeseen consequences through
the coordination of physician support.
Limitations
The main limitation to this study is that it is
retrospective, resulting in a reliance on the accuracy of
thorough medical record documentation. Additionally,
the generalisation in the findings may be limited
secondary to only including one facility. We were
unable to account for physician practice variation
with regard to their tracheostomy tube referral patterns
secondary to the availability of multiple services in
our facility that provide tracheostomy tube changes.
The authors believe it is reasonable to assume that
more complex patients with complicated airways and
mechanical ventilation needs were managed through
another service, reducing the complexity of the cohort.
Additionally, the failure to include characteristics
of the excluded patients may be considered a
limitation. The final limitation to this study is that it
is descriptive, and as a result of the small sample size
and only one complication occurring, no meaningful
regression model for predictors of complications could
be established.
CONCLUSIONS
This 5-year retrospective investigation represents the
first study, to the authors’ knowledge, to report the
SLP’s ability to successfully change tracheostomy
tubes in any setting. The review of the procedural
success and complication data is comparable to other
published research. The authors’ experience suggests
that SLPs who receive formal training have the potential
to be able to perform tracheostomy tube changes in
the acute care setting, where physician support is
immediately available, as part of a multidisciplinary
tracheostomy team.
As a result of the SLPs’ involvement in changing
© 2017 MA Healthcare Ltd
tracheostomy tubes in the authors’ facility, more timely
initiation of speaking valves for communication,
initiation of diets and decannulation resulting in reduced
length of stay and more discharge setting options
were observed. Further investigation is warranted
International Journal of Therapy and Rehabilitation, November 2017, Vol 24, No 11
RESEARCH
to define the required education and experience that
is required to attain professional proficiency with
changing tracheostomy tubes. The authors are hopeful
that this study will provide the foundation for future
research. IJTR
Conflict of interest: none declared.
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