Changing a tube can be more difficult if the patient is oxygen or ventilator dependent, or the stoma is known to be difficult.

Question: Can you think of scenarios where the stoma might be difficult?

Answer: First tube changes (where the difficulty is unknown), obese patients, any anatomical variations or an early change following percutaneous tracheostomy are all potentially difficult. An inflamed or infected stoma can be uncomfortable for the patient (local anaesthetic lubricating gel can be helpful here).

Any patient in an ICU has the potential to become unstable, and the time pressures can make the tube change difficult.

If difficulty is anticipated, make sure appropriate staff and equipment are available. Oxygen should be applied to the upper airway and pre-oxygenation should occur. If re-insertion proves difficult, a smaller tube may pass. Sometimes, formal re-dilatation may be required.

The video in Fig 1 demonstrates an elective tube change on a dummy. The tube is first suctioned as the cuff is deflated, and the tube is changed over a gum elastic bougie. An Aintree catheter, bronchoscope or even a suction catheter could similarly be used.