How Should You Position a Patient When You're Changing a Tracheostomy Tube?

October 2, 2025 •

5 min read

According to medical protocols, patient positioning is a critical step for the safety and success of a tracheostomy tube change. Learn exactly how should you position a patient when you're changing a tracheostomy tube to ensure their safety and comfort during this vital procedure.

Quick Summary

For a tracheostomy tube change, position the patient supine with the neck mildly hyperextended, using a shoulder roll to bring the tracheal opening forward. Ensure all supplies are ready and the airway is clear before beginning.

Key Points

Supine with Neck Hyperextension: The standard and safest position for most patients involves lying on the back with a shoulder roll to extend the neck, bringing the trachea closer to the surface.
Consider Contraindications: Patients with a cervical spine injury cannot be hyperextended and require alternative positioning, such as sitting upright.
Thorough Preparation is Key: Before changing the tracheostomy tube, ensure the patient is pre-oxygenated, the airway is suctioned, and all sterile equipment is readily available.
Immediate Obturator Removal: The obturator must be removed immediately after the new tube is inserted to allow the patient to breathe.
Secure the New Tube Firmly: New ties should be secured to prevent accidental dislodgement, but not so tight as to cause discomfort or pressure.
Be Prepared for Emergencies: Always have a spare tracheostomy tube of the same size and one smaller size at the bedside in case of accidental decannulation.

Importance of Proper Patient Positioning

Proper patient positioning is not merely a comfort measure; it is a fundamental safety precaution during a tracheostomy tube change. The correct position provides optimal exposure of the stoma, shortens the distance to the trachea, and reduces the risk of accidental decannulation or creating a false passage. Positioning helps to align the trachea and secure a clear line of sight for the healthcare provider, whether in a clinical or home care setting.

Step-by-Step Patient Positioning

Ensuring the patient is in the best position is the first and most critical step before beginning a tracheostomy tube change. The specific positioning technique may vary slightly depending on the patient's condition and physical characteristics, but the core principles remain the same.

Standard Supine Position

The most common and recommended position for an adult patient is supine with neck hyperextension.

Adjust the Bed: Ensure the bed is flat and at a comfortable height for the practitioner to avoid straining.
Remove Pillows: Remove any pillows from under the patient's head to facilitate neck extension.
Use a Shoulder Roll: Place a rolled-up towel or small blanket under the patient's shoulders. This action helps to hyperextend the neck and bring the trachea forward, making the stoma more accessible.
Confirm Patient Comfort: While the neck should be extended, ensure the position is tolerated by the patient. Communicate with them throughout the process to monitor for any discomfort.

Considerations for Alternative Positions

In certain situations, the standard supine position may not be possible. For example, if a patient has a cervical spine injury, hyperextension is contraindicated. Alternative positioning may include:

Upright Sitting Position: For patients who cannot tolerate a reclined position, an upright sitting position can be used, with the neck extended as much as is safely possible.
Positioning for Obese Patients: Obese patients may require a larger shoulder roll or specific bed adjustments to achieve proper neck extension and elevate the stoma.

Patient Preparation Prior to Positioning

Before positioning, it's essential to prepare the patient and gather all necessary equipment. This includes:

Communication: Explain the procedure clearly to the patient to minimize anxiety and encourage their cooperation.
Pre-oxygenation: If clinically safe, increase the patient's FiO2 to 100% to build oxygen reserves.
Suctioning: Clear the patient's airway of any secretions by suctioning the tracheostomy tube.

A Comparison of Positioning Techniques


Feature	Supine with Shoulder Roll	Upright Sitting Position	Considerations
Stoma Exposure	Excellent; optimal visualization of the tracheal orifice.	Good; provides sufficient access for many patients.	Requires proper setup to maintain neck extension.
Neck Position	Hyperextended; ideal for aligning the trachea.	Extended as safely as possible; avoids hyperextension.	Essential for patients with cervical spine issues.
Patient Comfort	Varies by patient; should be monitored closely.	Preferred by some patients who cannot tolerate lying flat.	May require additional support to prevent slumping.
Trained Personnel	Standard technique taught in clinical settings.	Adaptable for various settings, including home care.	Provider must be trained to adapt technique safely.
Emergencies	Provides clear access for emergent reinsertion.	Effective for maintaining airway while upright.	Emergency procedure readiness is key regardless of position.

The Tracheostomy Tube Change Procedure

Once the patient is correctly positioned, the healthcare provider can proceed with the tube change. This comprehensive overview of the steps follows the best practices recommended by medical authorities.

Prepare Equipment: Gather all necessary sterile supplies, including the new tracheostomy tube with obturator, a spare tube of the same size, a smaller tube, sterile saline or lubricant, and tracheostomy ties. Test the new tube's cuff integrity if applicable.
Ensure Sterile Field: A sterile drape should be placed on a clean, dry surface to hold the equipment.
Deflate Cuff: If the old tube has a cuff, use a syringe to fully deflate it.
Remove Old Tube: While an assistant holds the old tube in place, cut the old ties. Gently and smoothly remove the tube in a downward and outward motion as the patient exhales, following the natural curve.
Insert New Tube: Immediately insert the new, lubricated tube into the stoma, with the obturator securely in place. Follow the curve of the trachea to avoid trauma.
Remove Obturator: Immediately withdraw the obturator once the new tube is in place. The patient cannot breathe through the tube with the obturator inside.
Inflate Cuff (if applicable): Inflate the cuff to the ordered pressure using the syringe and check for proper inflation.
Secure New Tube: Secure the new tracheostomy ties, ensuring they are snug but not too tight. A good rule of thumb is to allow one finger to fit comfortably underneath.
Confirm Placement: Listen for proper air movement and observe the patient's breathing pattern and color. Suctioning can confirm placement by easily passing the catheter down the tube.
Apply Dressing: Apply a sterile tracheostomy dressing to the skin around the stoma.

Managing Complications

While proper positioning and technique significantly reduce risk, complications can occur. One of the most urgent is accidental decannulation, where the tube comes out before a new one is successfully inserted. It is crucial to have a plan in place.

Have a Spare Ready: Always have a spare tracheostomy tube of the same size and a smaller one readily available at the bedside.
First Attempt: If the tube comes out, attempt to reinsert it gently. Do not force it.
Use the Smaller Tube: If the original size doesn't go in easily, try the smaller tube. The stoma may have contracted slightly.
Maintain Airway: If reinsertion fails, use a suction catheter to keep the stoma open, and provide oxygen support via the mouth or by directing it at the stoma.
Call for Help: In a home care setting, this is the time to call emergency services. In a hospital, immediately alert a physician or rapid response team.

Conclusion

Changing a tracheostomy tube is a critical medical procedure that requires meticulous attention to detail. Understanding how should you position a patient when you're changing a tracheostomy tube is the cornerstone of a safe and successful exchange. Following standard protocols, being prepared for complications, and maintaining clear communication with the patient are vital for ensuring patient safety and a positive outcome. For more detailed clinical guidelines, consult authoritative resources such as Medscape's comprehensive protocol on periprocedural care Tracheostomy Tube Change Periprocedural Care.

Frequently Asked Questions

Neck hyperextension, often achieved by placing a shoulder roll, is important because it aligns the trachea and brings the stoma closer to the surface, providing a clear and direct path for inserting the new tube.

No, you should not perform a tracheostomy tube change with neck hyperextension if the patient has a known or suspected cervical spine injury. In this case, alternative positioning, like a cautious upright or neutral position, must be used, and this should only be done by experienced medical staff.

The 'sniffing position' refers to a slight elevation of the head with the neck extended, which is another term for positioning to achieve the optimal alignment of the trachea for access. For a tracheostomy tube change, this is generally achieved with a shoulder roll while the patient is supine.

If the patient coughs during the procedure, remain calm and hold the new tube securely in place. Coughing is a normal reaction as the airway is stimulated. Wait for the coughing to subside before proceeding with securing the tube.

While not always mandatory, it is highly recommended to have a second trained staff member present during a tracheostomy tube change, especially in a clinical setting. This person can provide support and assist with managing the airway, if necessary.

If you cannot reinsert the tube, do not force it. First, try a smaller size tracheostomy tube. If that fails, a suction catheter can be inserted into the stoma to keep the airway open while waiting for emergency medical assistance. Always have a smaller backup tube ready.

Before positioning, you must have the new tracheostomy tube (with obturator and new ties), a spare tube of the same size, a smaller backup tube, sterile saline, water-soluble lubricant, a sterile drape, a cuff syringe (if applicable), and suction equipment ready and easily accessible.