Tracheostomy decanulation

Tracheostomy Care & Decanulation

Dr. Prahlada N.BMS (PGIMER), MBA, MHA

Tracheostomy careSecurity of the tracheostomy tubeThe inner cannula hygieneCuff pressures should be maintained at 20–25

cm H2O Regular tube changes

Tracheostomy careSecretion management

HydrationHumiditySuctioning, and Physical mobilityRespiratory Physiotherapy

Prepare for Decanulation

Decanulation

As soon as the patient’s condition permits.

When?

Who should do it?Team

Who should do it?Ear, Nose and Throat (ENT) SurgeonWard NurseTracheostomy Nurse Specialist Respiratory therapist Speech and Language Therapist (SLT)Physiotherapist.Dietician.

Prior work-upChest X-RayNaso-laryngo-bronchoscopy

The upper airwayVocal cord movement and The tracheal mucosa.

Swallowing assessment.

Evaluate bedside swallowPatients not alert enough to follow

commands.Patients unable to swallow their own saliva.Patients with significant central neurological

deficits.

Indications - DecanulationReason for the tracheostomy resolved. Patient alert, responsive and consenting. Patient tolerating cuff deflation for a

minimum of 12 hours. Patient managing to protect their airway and

have a clear chest. Patient maintaining oxygen saturations.

Indications - DecanulationPatient tolerating the use of a speaking valve

and/or digital occlusion. Patient able to expectorate around the tube

into their mouth. Tracheostomy tube type and size is

appropriate.

Type and size of tube for weaningThe ideal tube to use for the weaning process

is one that allows adequate airflow around the tube while the tube is occluded.

An uncuffed fenestrated tube will offer the least resistance.

The patient should be able to maintain SaO2 above 90%.

Uncuffed fenestrated tube

Patient preparation and involvementConsentExplanation.Involvement.

Practical issuesExplanation to the patient.Start on first days of the week.Start early morning.Closely monitor the patient.Document the progress.

Downsizing Algorithm

The weaning processDay 1-Ensure the cuff, if present, is deflated.Insert fenestrated inner tube if appropriate.Place an occlusion cap over the end of the

tracheostomy tube . Observe for signs of respiratory distress and Stay with the patient for at least the first 10

min. The patient’s oxygen saturation and vital

signs should be recorded after 15 min.

The weaning processContinue to occlude tube for 12 hour.Day 2 - Occlusion cap in situ for 24 h. Day 3 – Decanulation.

Difficulty with weaning/troubleshootingRespiratory insufficiencyAirway ObstructionsRetention of SecretionsBlood in secretionsPatient anxiety

SummaryThe ability to decannulate the patient will be

affected by various factors:Selection of patients for the weaning procedure.Reason why the tracheostomy was formed.Type and size of the tracheostomy tube.Support from the TEAM.A systematic, standardised approach to the weaning

procedure by all members of the multi-disciplinary team.

Accurate and appropriate documentation of the procedure.

Patient and family involvement.