How to safely remove the tracheostomy tube
Decannulation is removal of the tracheostomy tube. Tracheostomy decannulation is best performed as a multidisciplinary team effort with input from various members including the respiratory care practitioner, speech-language pathologist and nurse, with the physician making the ultimate decision. Decannulation is typically performed after the indication for the tracheostomy tube has been resolved. In the Centers for Disease Control and Prevention’s Guidelines for Preventing Healthcare Associated Pneumonia (2004), the first recommendation is to remove the tracheostomy (or endotracheal tube) as soon as possible. The sooner patients are decannulated, the faster their risk for acquiring pneumonia decreases.
There is still debate in the literature as to which clinical factors and parameters are required for safe removal of the tracheostomy tube. Internationally, within the United States, as well as individual facilities have different criteria for decannulation. The different levels of experience between medical care providers also results in variation of practice. Although there may be a wide variety of factors, having a multidisciplinary tracheostomy team and a protocol for decannulation can help to improve decannulation rates.
Clinicians should be aware of cuff management practices as soon as the patient requires an artificial airway (endotracheal tube or tracheostomy tube). Cuff management is important in reducing the risks caused by over-inflation of the cuff. Cuff over-inflation has been a growing concern with patients with Covid-19 as clinicians have increased pressures in order to reduce the potential for aerosols generated from around the cuff. However, with proper PPE, cuff pressures should be maintained between 15-22mm Hg (20-30 cm H2O) to reduce the risk of injury to the tracheal walls. Complications from over-inflation may lead to unnecessary long term tracheostomy (Epstein, 2005).
Information on this page is for adults with tracheostomy and does not apply to pediatric decannulation.
Determinants of Decannulation
The tracheostomy tube is removed when the initial indications for the tracheostomy have been resolved. There is growing research and guidance in the area of which factors predict successful decannulation. In a survey of physicians and RTs, patient level of consciousness, ability to tolerate tracheostomy tube capping, cough effectiveness, and secretions were rated as the most important factors in the decision to decannulate (Stelfast et al, 2009).
Once mechanical ventilation is no longer necessary, the literature indicates the following aspects are of particular importance to evaluate prior to decannulation:
2. Airway patency of the upper airway and ability to tolerate capping
4. Level of consciousness
5. Ability to shrug in patients with cervical spinal injury
Contraindications to decannulation
It is contraindicated to remove the tracheostomy tube if the patient is hemodynamically unstable or if there is an upper airway obstruction and the patient is unable to breathe through the upper airway. Caution should be used in patients with difficult intubations.
Multidisciplinary tracheostomy weaning protocols have demonstrated an increase in the amount of patients decannulated and shorter length of time (Frank, U et al 2007). The protocol can assign clear responsibilities to team members for aiding a patient with decannulation and can lead to better efficiency in intervention time.
Oxygen saturation, heart rate and respiratory rate should be monitored before and after each step of a decannulation protocol, including cuff deflation, speaking valve use, and capping. Oxygen saturation should be over 92% when breathing on room air or with supplemental oxygen. Some individuals may benefit from oxygen delivered by nasal cannula once the cuff is deflated. High flow oxygen is also an option. Heart rate and respiratory rate should be stable prior to attempts at decannulation protocols. A normal resting heart rate for adults is between 60-100 beats per minute. The normal resting respiratory rate for adults is between 12 and 20 beats per minute.
Stop Criteria commonly used for decannulation protocols (these are facility dependent):
- Sustained HR greater than 20 beats/min from baseline
- RR greater than 35 breaths/min
- FiO2 greater than or equal to 60% to keep oxygen saturations above 90%
- Rating of perceived dyspnea greater than 6
Most decannulation protocols involve increasing periods of time for cuff deflation. In a randomized trial of critically ill patients, cuff deflation has been shown to reduce ventilator weaning time. The patients were randomized into cuff deflated or not during spontaneous breathing trials (Hernandez, G, 2013). When the individual is breathing spontaneously, deflating the cuff and downsizing the tracheostomy tube increases the effective airway diameter because the patient is no longer only breathing in and out through the tracheostomy tube, but also breathing around the tracheostomy tube and through the upper airway. Respiratory infections were also lower in the cuff deflated group (Hernandez, G, 2013). Benefits also include ability to produce some speech, reduced aspiration, and improved pharyngeal and laryngeal sensation. See the section on cuff deflation for more information.
Patient candidacy for cuff deflation has been suggested in the literature to predict successful cuff deflation. The clinical indicators recorded as present in the 24 hours preceding cuff deflation included (1) medical stability, (2) respiratory stability, (3) fraction of inspired oxygen ≤0.4, (4) tracheal suction ≤1-2 hourly, (5) sputum thin and easy to suction, (6) sputum clear or white, (7) ≥moderate cough strength, (8) above cuff secretions ≤1ml per hour and (9) alertness≥eyes open to voice. Ninety-five achieved continuous cuff deflation on the first attempt (Pryor et al, 2016).
Cuff Deflation Protocol:
- Explain the procedure to the patient as appropriate. Explain that they may experience movement of airflow and secretions through the upper airway and a possibility of producing voicing. An anatomical drawing of the airway with the cuff inflated and deflated may help the patient to understand the process.
- Monitor the patient’s vital signs during cuff deflation, particularly when it is the initial time.
- If vitals are stable, next suction via the mouth and/or stoma as necessary to remove any secretions prior to cuff deflation. If available, above the cuff suctioning can be utilized.
- Connect the syringe to the pilot balloon and slowly remove air (perhaps 2cc of air) from the syringe. This removes air from the cuff of the tracheostomy tube. Slow cuff deflation can help the patient get acclimated to secretions and airflow through the upper airway to improve tolerance.
- Perform tracheal suctioning while deflating the cuff to attempt to remove secretions that have passed into the lower airways, preventing them from falling into the lungs.
- Assess the patient’s tolerance of cuff deflation and reinflate the tracheostomy tube if any stop criteria has been met.
Management of secretions and swallowing status
The patient’s ability to manage secretions should be assessed throughout the process of decannulation by a speech-language pathologist. During cuff deflation, observe the strength of the cough and ability to mobilize secretions.
A Blue Dye assessment is a screening tool to assess for aspiration in patients with tracheostomy and, if utilized, should be performed after the cuff is deflated. A few drops of methylene blue are placed on the tongue. The patient is monitored for blue dye at the stoma site or during tracheal suctioning. It is recommended to monitor oxygen saturations during the process. The presence of blue dye indicates aspiration. If aspiration occurs, the clinical relevance must be defined by instrumental data (eg, severity and duration of desaturation); if the inhalation is mild, there is no arterial desaturation and there are no other signs of respiratory complications, it is possible to start keeping the cannula deflated for increasing periods (first during the day, then at night) checking for episodes of arterial desaturation and occasional or recurring lower respiratory tract infections. If the inhalation of saliva takes place in the absence of such two complications, the decannulation protocol can continue. Evidence of saliva inhalation is per se significant, implying a specific risk for the patient, but not always of clinical relevance, since dysphagic patients can be observed with inhalation of saliva demonstrated with methylene blue but without episodes of arterial desaturation or pulmonary complications (Garuti, G et al, 2013).
Flexible endoscopic evaluation of swallowing (FEES) provides a direct view of the larynx and pharynx during swallowing and is useful in assessing secretion management. Again, even if the patient is noted to aspirate secretions this does not preclude cuff deflation unless there are also desaturations and/or signs of pulmonary complications.
Assessing Upper Airway Patency
Upper airway patency has been cited as an important indicator for decannulation (Warnick et al, 2013; Matesze et al, 2014). Once the cuff is deflated, the clinician may assess for airway patency by looking for signs that the patient is exhaling adequately through the upper airway. Signs that there is airflow through the upper airway include observing the patient coughing, vocalizations, reflexive oral movements, throat clearing, or feeling the flow of air on the hand held at the patient’s mouth and/or nose. Finger or digital occlusion may also help to assess upper airway patency. This is performed by placing a gloved finger on the posterior end of the tracheostomy tube during exhalation.
Airway patency can also be measured with transtracheal pressure manometry. It can be measured once a speaking valve is in place. See the speaking valve section below for more information about assessing upper airway patency with a valve in place.
The Clinical Consensus Guideline states that fiberoptic laryngoscopy be used for decannulation to confirm airway patency to the level of the glottis and immediate subglottis (Mitchell et al, 2012).
After the cuff has been completely deflated and airway patency established, a speaking valve may be placed. Cuff deflation and speaking valve use can begin while a patient is still receiving mechanical ventilation. Early rehabilitation of the upper airway can reduce the complications that may result from an inflated cuff. A speaking valve is a one way valve that allows air to continue to flow in through the tracheostomy tube. Exhalation is redirected through the upper airway and out the nose and mouth to allow for phonation. The Passy-Muir Valve is the most widely used and is the only bias-closed position speaking valve which means that the valve is always in the closed position except during inhalation. The valve closes at the end of inspiration resulting in a column of air filling the tracheostomy so that secretions do not occlude the tube. Exhaled air passes through the vocal folds allowing for speech, but due to the closed system other benefits are realized including: improved swallowing, may reduce aspiration, restored sensation, improved taste and smell, restored positive airway pressure.
Assessing airway patency: When the speaking valve is in place the patient must be able to exhale around the tracheostomy tube and through the upper airway. If pressure is noted when the speaking valve is removed (ie. whoosh sound), this indicates an upper airway obstruction. Airflow attempts to escape out the tracheostomy tube because there is not space for the air to travel through the upper airway. A more objective means to assess for airway patency is to measure the tracheal pressures via manometry, which can be measured with the valve in place. If the tracheal pressure is > 5 cm H2O during passive exhalation (without speech) with the speaking valve in place, this may indicate excessive expiratory resistance (Johnson, DC et al, 2009).
If the tracheal pressure is too high, consider downsizing the tracheostomy tube to allow for more airflow through the upper airway. Cuffless tracheostomy tubes or tight-to- shaft cuffs may also be a consideration as the cuff itself, even when deflated, can result in some resistance to airflow. Direct visualization of the airway can aide in determining the cause of inadequate airflow through the upper airway. Reasons may include edema, granulation tissue, stenosis, vocal fold paralysis.
Once the speaking valve is in place, the patient has the potential to use the upper airway to clear secretions. The cough is fully redirected through the upper airway.
Tolerating capping is often cited in the literature as an important indicator to decannulation (Tobin et al, 2008; Stelfast et al, 2008, 2009; O’Connor et al, 2009, Budweiser et al, 2012). Once a patient is able to use a speaking valve, capping (plugging) is typically the next step toward decannulation. During capping, the airflow is blocked in and out through the tracheostomy tube. Instead, both inhalation and exhalation are performed through the upper airway.
The amount of time the tracheostomy tube is capped prior to decannulation varies across institutions. It is important to remember that the patient will have to breathe around the tracheostomy tube on both inspiration and expiration. Therefore, leaving the cap in place for multiple consecutive days or weeks at a time is not recommended. The Clinical Consensus Guideline states that a prerequisite for successful decannulation is tolerating a cap on an appropriately sized cuffless tracheostomy tube without stridor (Mitchell, R et al, 2012).
Patients having difficulty with capping may require additional downsizing (consider all aspects of the tracheostomy size including length, inner and outer diameter). It is best practice to cap the tracheostomy tube when it is cuffless as the cuff itself, even when deflated may impede airflow through the upper airway. If the cap is required to be removed for suctioning or due to distress, the patient may not be ready for decannulation.
Consider placing a sign on the door indicating that capping trials are in place.
The patient must be able to cough to effectively clear secretions. An effective cough is a prerequisite under the Clinical Consensus Guidelines for safe decannulation (Mitchell, R et al, 2012). Patients requiring frequent removal of a trach cap for tracheal suction or other airway interventions may not be candidates for decannulation until such interventions are no longer necessary.
- Decannulation should be delayed if the patient will have a procedure that requires general endotracheal anesthesia.
- Noninvasive mechanical ventilation may be an option as well.
- Consider the diagnosis of sleep apnea as a sleep study may be warranted. Noninvasive mechanical ventilation such as CPAP can be used at night during sleep.
Interim Stoma Stent
An interim stoma stent may be indicated in patients who are at high risk of decannulation failure. A stoma button consists of a hollow outer cannula and a solid inner cannula. It fits from the skin to just inside the anterior wall of the trachea. With the solid inner cannula in place, the patient breathes through the upper airway. When the inner cannula is removed, the patient can breathe through the button, and a suction catheter can be passed through the button to provide a means of airway clearance. Other devices used for stomal maintenance include the Montgomery Safe-T-Tube and the Montgomery long-term cannula.
After the tracheostomy tube has been removed, the stoma is cleaned and covered with sterile gauze. Instruct the patient to apply pressure to the site during speaking and coughing. Change the dressing daily and as needed. Monitor the patient for decannulation failure and need to reinsert the tracheostomy tube.
The definition of failed decannulation varies in the literature from 48 hours to 96 hours. The Global Tracheostomy Collaborative definition is 72 hours. Literature indicates an average of 1.2% of decannulation failure.
This protocol does not apply to pediatric decannulation.
For a patient at home with tracheostomy, the decannulation procedure may be slower as the patient is not being monitored by clinical staff around the clock. Consider if the individual would require an inpatient stay during the decannulation process. When in an outpatient setting, the cap should be trialed to determine if the patient is able to breathe comfortably.
- Assess the patients physical and mental abilities to care for the tracheostomy tube
- Determine if the patient or family member is able to place and remove the cap
- Patient family member to remain in the room at night when the patient is capped
Sample Decannulation Protocol
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