Prone Positioning in Patients with Tracheostomy

Safety Considerations for Prone Positioning with Tracheostomy

Tracheostomy tubes must be properly secured before prone positioning to prevent accidental dislodgement or displacement, with foam straps preferred over twill ties for securing the tracheostomy tube as they place minimal stress on the skin and decrease risk of skin breakdown 2, 3
The tracheostomy cuff should be properly inflated with pressure at least 5 cmH2O above peak inspiratory pressure to prevent leaks during position changes, and tracheostomy tube depth should be monitored and recorded before and after position changes to minimize risk of displacement 4

Closed tracheal suction systems should be used to manage secretions during prone positioning, and secretion management is critical during prone positioning as secretions may pool differently 3, 4
The American Thoracic Society recommends that patients who require continued prone positioning should not undergo tracheostomy 6

Carefully examine areas at risk for pressure ulcers during prone positioning, particularly around the tracheostomy site, and ensure proper stabilization of the patient's head to prevent unintended movement of the tracheostomy tube 5
Secretion management is critical during prone positioning, and a closed-circuit suctioning system with an inline suction catheter should be used to decrease aerosolization risk, avoiding instillation of saline before suctioning as it increases risk of coughing and provides little benefit 3

In COVID-19 patients, additional infection control measures are needed during positioning changes due to the risk of aerosol generation, including the use of heat moisture exchange (HME) filters with viral filtration efficiency >99.9% during any disconnection from the ventilator circuit, and pausing the ventilator before any circuit disconnection and clamping the tracheostomy tube to minimize aerosol generation 3, 4, 7, 8
The American Academy of Otolaryngology-Head and Neck Surgery recommends that tracheostomy tubes be properly secured before prone positioning, and that foam straps be used instead of twill ties to minimize skin breakdown 2