7.11 : Tracheostomy Decannulation

Tracheostomy decannulation is a significant milestone in the liberation of mechanically ventilated patients. Despite its importance, there is no universally accepted protocol for this procedure. This demands an evidence-based, individualized approach.

Description of the Procedure

Decannulation refers to the permanent removal of the tracheostomy tube, signaling the resolution of the condition that initially necessitated the tracheostomy. The process requires a well-coordinated interplay between the brain, swallowing, coughing, phonation, and respiratory muscles. Any disruptions in this complex coordination can lead to decannulation failure.

The procedure starts with thorough hand-washing and donning gloves. The patient should be informed about the procedure. The tracheostomy tube cuff should be deflated before decannulation, and the patient should be carefully assessed for signs of respiratory difficulty. If any respiratory distress is observed, the tracheostomy tube cork or decannulation cannula should not be removed, and the healthcare provider should step in immediately.

Indications for Decannulation

Decannulation is possible when the primary condition for which the patient received a tracheostomy has been resolved. The patient must be hemodynamically stable, have a stable and intact respiratory drive, and adequately exchange air and independently expectorate secretions.

A visual assessment of the airway, including the oropharyngeal, hypopharyngeal, laryngeal, and sometimes tracheal airway, is crucial before decannulation. A trial of successful 'corking' or occluding the tracheostomy tube for a specified period can help determine the safety of removal, but visual assessment of the airway is essential.

Before and After the Procedure Care

Before decannulation, the tracheostomy tube cuff should be deflated, and the patient's mouth should be cleared of oral secretions. The tracheostomy tube is then removed in one smooth motion. Any resistance should prompt immediate cessation of the procedure and intervention by the healthcare provider.

After removing the tube, a sterile occlusive dressing should be applied to the site, and the patient should be monitored for bleeding. Change the dressing if it gets soiled or wet. If needed, close the stoma with tape strips. Monitor respiratory status and O₂ saturation for airway compromise or difficulty breathing. Apply an alternate method of O₂ delivery (e.g., nasal prongs) if required. Teach the patient to splint the stoma with the fingers when coughing, swallowing, or speaking. Epithelial tissue begins to form in 24 to 48 hours, and the opening closes within 4 or 5 days. Surgery to close the tracheostomy is usually not needed.

Tracheostomy decannulation is a complex procedure that requires careful planning and execution. Healthcare providers can ensure successful outcomes and improve patient care by adopting a patient-centric, evidence-based approach.