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If patients can tolerate cuff deflation, we will have established that they
have a patent upper airway and that they can manage their oral secretions.
Cough effort and swallowing can also be assessed at this point. If a patient
has had a tracheostomy tube in situ for a prolonged period of time, cuff
deflation should normally be tolerated for around 24 h prior to attempting
further interventions and proceeding with the decannulation plan. Patients
who are relatively well or who have had a short-term tube in situ may be
able to progress rapidly if each step is well tolerated.
Occlusion of the end of the tracheostomy tube will mean that the patient
has to breathe solely through the upper airways and all airflow in the
trachea will have to be around the tube and not through it. With the
tracheostomy tube and deflated cuff siting in the airway, this offers a
significant resistance to airflow, associated with an increase in the work of
breathing. Figure 5.29 shows the different amounts of space available to
breathe around a tracheostomy tube sited in the trachea.
Digital occlusion with a gloved finger is a simple way to assess whether
the patient is able to tolerate further attempts at weaning with the current
tube in situ. If the patient can breathe adequately past the tube, in and out
via the nose and mouth without any signs of respiratory distress, then
weaning could reasonably progress with the same-sized tube. If the patient
cannot breathe adequately via the upper airways, then the tube may be too
large and downsizing to a smaller tube (Figure 5.27) may allow more gas
to bypass the tube to the upper airways. This will offer less resistance to
gas flow in the trachea. The largest tubes that will be tolerated for weaning
in this way are usually 7.5 mm ID for males and 6.5 mm ID for females.
Failure to tolerate brief tube occlusion must raise the possibility of upper
airway obstruction, which should warrant fibreoptic inspection.
A fenestrated tube (with single or multiple holes on the outer curvature of
the tube) may be useful for weaning, especially for patients who do not
cope well with downsizing, or when downsizing is not possible. They are
used as appropriate and caution must be taken as the fenestrations may
cause the formation of granulation tissue within the trachea and/or allow
trauma to the posterior tracheal wall if suctioned through inadvertently.
The choice of whether to leave a cuffed tube in situ or change to an
uncuffed tube will depend on the patient and the circumstances. If the
patient is only tolerating short periods of cuff deflation or if intermittent or
nocturnal ventilation may still be required, a cuffed tube will need to
131
remain. Otherwise, an uncuffed tube will offer less resistance to flow to
the upper airways.
When a patient is known to have a complex airway (e.g. requiring an
adjustable flange tracheostomy) or has a previously documented difficult
intubation, extra caution is taken throughout the whole process. In these
cases, it is essential to liaise closely with the relevant parent team with
responsibility for the tracheostomy.
Speaking valves and caps
Speaking valves and occlusion caps are advocated by many and can be
used prior to tube removal. The speaking valves (labelled ‘b’ in Figure
5.28) are one-way valves, allowing gas to be inspired via the tracheostomy
tube. The valve closes in expiration, forcing gas through the upper
airways. A decannulation cap (labelled ‘a’ in Figure 5.28) blocks all
airflow via the tracheostomy tube. Both of these systems cause an increase
in the resistance to airflow through the trachea, as the tube is still present
in the lumen of the trachea. Some patients will therefore tire even after a
few minutes of this sort of intermittent or permanent occlusion and need
the valve or cap to be removed. Monitor all of these trials carefully; if a
brittle patient becomes fatigued, the weaning process may be delayed by
several days while that patient recovers. They may not always be required
if the patient has had a relatively short-term tracheostomy in situ.
One of the most important points to remember when using speaking
valves or caps is that they must never be used with a cuffed tube with the
cuff inflated. Outside of specialist areas, it is probably safer to stipulate
that these devices should simply not be used with cuffed tubes at all, as
even the potential to inflate the cuff with these devices attached can be
fatal. The patient cannot exhale through the tracheostomy tube when a
speaking valve is attached, and if the only alternative means of exhalation
(via the upper airways) is blocked with an inflated cuff, the patient will
suffocate. Both inhalation and exhalation via the tube are impossible when
a cap is used. Videos explaining the use of speaking valves can be found
here,
17
with a narrated e-learning presentation available here
18
(Figure
5.29).
132
Speaking valves can be used in breathing circuits with ventilators in some
circumstances. Normally, ventilator-dependent patients do not tolerate
attempts at speech, as this comes at the expense of oxygenation and
appropriate ventilation. However, for some patients who are weaning from
mechanical respiratory support slowly, or those who require long-term
ventilatory support, attempts at speech may be appropriate. It is important
to deflate any cuff that is used prior to inserting the speaking valve. The
ventilator will usually have to be set to deliver larger tidal volumes. The
subsequent loss of gas from the upper airways as it is exhaled via the
larynx will cause most ventilators to assume that a significant circuit leak
is occurring and the alarms should be set appropriately.
When patients can tolerate a deflated cuff, manage their oral secretions,
protect their airway and breathe adequately through their upper airways
(usually following some sort of tube occlusion trial), then they are ready
to have the tube removed.
Weaning documentation
The standardised weaning and subsequent decannulation practices must be
locally agreed upon and supported by multidisciplinary guidelines and
documentation.
Local guidelines and practice must ensure that:
• the team taking responsibility for a patient's tracheostomy weaning
review the patient regularly
• their assessment, interventions and plan are clearly documented to
guide the ward MDT
• observation charts including tracheostomy and respiratory
observations are accurately maintained
• the ward MDT have written guidance of how to access expert help
in an emergency at any time (bedhead signs).
Summary
Table 5.8 summarises key actions related to weaning and their rationale
(adapted from the NPSA expert working group).
133
Table 5.8 Weaning—key actions and their rationale.
Action Rationale
Explain and discuss the procedure with the patient To ensure consent,
understanding and reduce
anxiety
Have communication aids available, for example,
alphabet chart, pen and paper, interpreters if
necessary
To promote effective
two-way communication
Sit the patient upright (unless contraindicated) To promote chest
expansion and help reduce
aspiration risk
Suction the patient if necessary To remove secretions
prior to first cuff deflation
Perform the first trial cuff deflation (suctioning at
the same time) and observe for signs of acute
respiratory distress, desaturation or patient
discomfort
To ensure timely
tracheostomy wean and
reduce risk of tracheal
damage
Reinflate cuff if not tolerated and agree re-review
date; this may be as frequently as daily
If cuff deflation tolerated, proceed with wean to
point of decannulation according to local guidelines
See Table 9
Involve MDT throughout process See Table 5.9
Recognise signs of clinical deterioration or
improvement and slow/stop/restart/speed up the
weaning process as indicated
To optimise wean success
and reduce patient risk
An example of a staged weaning approach
Stage 1 Trial cuff deflation and
speaking valve (up to 30
min)
Consider downsizing or uncuffed tube
Stage 2 Increase speaking valve
use up to 12–24 h
(Cuff may still be inflated overnight if necessary)
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Stage 3 Trial tube occlusion
‘capping off’ up to 12–24
h
Stage 4 MDT assessment and
confirm decision to
decannulate
Stage 5 Decannulate and assess
stoma
Stage 6 Remove tracheostomy
equipment after
non-eventful 48-h post
decannulation
Decannulation
The removal of a tracheostomy should occur as soon as there is no further
need for it to remain in situ. The process of removing a tracheostomy tube
is referred to as decannulation. It should be considered only when a
patient has successfully progressed through a structured tracheostomy
weaning programme. The use of standardised multidisciplinary processes
will reduce the risk of complications following the removal of the tube.
Prior to the removal of a tracheostomy tube, there must be
multidisciplinary agreement. Occasionally, a tube must be removed in an
emergency (partially displaced tube in the image). There is more detail in
the emergency management section, but remember to deflate the cuff and
remove any sutures prior to attempted decannulation.
The tracheostomy MDT will regularly include:
• ward nurse
• physiotherapist
• SALT
• specialist nurse (tracheostomy, ENT or outreach)
• anaesthetist or intensivist
• respiratory physician
• head and neck surgeon.
135
The timing of the decannulation procedure needs consideration, to
minimise the risks to the patient. The clinical environment should have
sufficient competent staff and equipment available. YouTube videos
demonstrating safe decannulation are available here,
19
with e-learning
narrated presentations available here: videos of decannulation.
20
The position of the patient within the clinical setting should allow staff to
visualise the patient easily and the patient should have constant access to
an appropriate call system. It may be necessary to transfer the patient
undergoing decannulation to an area where 1 : 1 nursing care can be
offered and there is ready access to specialist staff who could
appropriately deal with a failed decannulation or other complications.
Decannulation should not occur late in the working day or at weekends
unless adequate staff and resources are constantly available to provide
advice and assessment and perform advanced airway and tracheostomy
management should the procedure not be successful.
Prior to decannulation, the tracheostomy MDT will confirm:
• the patients can maintain and protect their airway spontaneously
• they are free from ventilatory support with adequate respiratory
function
• they are haemodynamically stable
• they are free of fever or active infection
• the patients are consistently alert
• they have a strong consistent cough (able to cough into mouth)
• they have control of saliva +/− a competent swallow
• they are not planned for procedures requiring anaesthesia within
next 7–10 days
• they are considered clinically stable.
Extra caution is essential if the patient is known to have a complex airway
(e.g. requiring an adjustable flange tracheostomy), or has a previously
documented difficult intubation.
Equipment
For all decannulation procedures, you will need standard bedside
equipment and:
• oxygen available
136
• continuous oxygen saturation monitoring
• microbiological swab for stoma
• new tracheostomy tubes (for possible reinsertion)
• sterile dressing pack
• 0.9% saline
• semi-permeable occlusive dressing
• suction equipment
• relevant MDT documentation
• locally available resuscitation equipment
• access to advanced airway expert, with appropriate equipment.
Additional equipment may include:
• stitch cutter
• 10 ml syringe
• gum-elastic bougie
• bag valve mask circuit
• rebreathe circuit
• facial nebuliser circuit/adrenaline available for nebulisation.
Procedure
Decannulation is a two-person procedure. After checking all relevant
equipment, the patient is placed in a comfortable position with access to
the neck. A full explanation is required as this is often a time of great
anxiety for the patient.
Any tapes, ties or sutures are removed while the assistant holds the tube in
position. The tube will usually have had the cuff deflated for some time
prior to decannulation, or be of the uncuffed type. Suction is performed
and the tube is removed in expiration, to try and ensure any secretions are
coughed out.
The stoma site (Figure 5.30) can be inspected, swabbed and cleaned as
necessary. Most stomas will heal well, provided that the general condition
and nutritional status of the patient is good, and the stoma is kept dry and
infection-free. The diameter of the stoma may be expected to shrink by
around 50% in the first 12 h following removal of the tube. Stomas may
heal completely in as little as 3–4 days, but may also take several weeks.
A small number may require formal surgical closure. Initially, the stoma is
137
covered with sterile gauze and an appropriate semi-permeable dressing
(such as Tegaderm
TM
or Opsite
TM
).
Figure 5.30 Stoma site.
On coughing and talking, it is common for the dressing to bulge outwards
while the stoma remains patent (Figure 5.31). The patient can place a
finger over the dressing to prevent this (Figure 5.31). The dressing is
usually inspected and changed at least daily. The patient and carers must
be instructed to seek appropriate attention if there is a residual leak in
expiration, redness, wetness or discharge from the stoma over the days
following decannulation.
Figure 5.31 The dressing can bulge on coughing or talking; this can be
prevented by placing a finger over the dressing.
138
Documentation
Local policy and practice must ensure that:
• the team performing a decannulation document all associated
events in the patient notes immediately following the procedure
• the team performing a decannulation document if they plan to
re-review routinely or have discharged from caseload
• if the team performing the decannulation have discharged the
patient from review, they must provide written criteria and contact
details for urgent re-referral should the patient's condition
deteriorate
• the level of respiratory observation required is identified
• the ward MDT have written guidance of how to access expert help
in an emergency at all times
• tracheostomy emergency equipment should be left at the bedside
for a further 48 h following decannulation.
139
Post decannulation
Following the removal of the tracheostomy tube, the patient is left with an
opening into the trachea. This needs protection form entry of water or
foreign bodies and needs assistance to close. An airtight dressing is
required to prevent the ongoing passage of air through the tract
(tracheocutaneous fistula), which will delay wound healing. Where
possible, the patient should be encouraged to apply gentle pressure to the
dressing while coughing or speaking. This will reduce the air pressure
through the fistula to the underside of the dressing, which will loosen the
dressing's contact with the skin, necessitating frequent dressing changes.
The wound should be airtight within 2 weeks and if not, then a referral to
the ENT team should be considered. Tissue forming along the fistula may
require specialist assessment and treatment.
The use of a standardised weaning procedure should reduce the risk of
patients ‘failing’ a decannulation attempt. However, a patient's condition
can alter, which may necessitate consideration for reinsertion of the
tracheostomy. The emergency tracheostomy equipment should be left at
the patient's bedside for 48 h following decannulation to enable access to
tracheostomy equipment for this period post decannulation. This is
particularly important to maintain for those patients transferred to other
clinical settings within 48 h post decannulation.
Summary
Table 5.9 summarises the key actions related to decannulation and their
rationale (adapted from the NPSA expert working group).
Table 5.9 Decannulation—key actions and their rationale.
Action Rationale
Discuss the procedure with the patient. Have
communication aids available, for example,
interpreters
To ensure consent,
understanding and reduce
anxiety
Initiate continuous oxygen saturation monitoring
for procedure
To identify and alert staff to
desaturation following
procedure
140