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Decannulation

Decannulation can take place following successful weaning and with MDT agreement. This procedure should be undertaken or supervised by a practitioner who has the appropriate competence to recannulate should this be required. A recent study1 identified that clinicians (physicians and respiratory therapists) rated level of consciousness, strong cough, minimal thin secretions and minimal supplemental oxygen as determinants of decannulation.

Suggested criteria for decannulation

  • Able to obey commands (In the non neurologically compromised patient)
  • Adequate cough and ability to clear secretions effectively and independently
  • Cardiovascularly stable
  • No new lung infiltrates on x-ray
  • Tolerates cuff deflation for 24 hours
  • Tolerates speaking valve 12 hours or more ( usually during daytime) or decannulation cap for up to four hours (If air flow is present on finger occlusion). In patients following head and neck surgery, the decannulation cap may be left for longer periods at the discretion of the surgeon
  • MDT agreement for decannulation

Equipment:

  • Dressing pack
  • Gauze and two transparent semi-permeable dressings such as tegaderm™ or opsite™
  • Sterile normal saline
  • Gloves, apron and protective eye wear
  • Appropriately sized tracheostomy tube and one a size smaller (available not opened)
  • Facemask or nasal specs if patient requiring oxygen
  • Microbiological swab
  • Tracheal dilators
  • Functioning suction unit and appropriate sized suction catheters
  • Stethoscope
  • Resuscitation equipment

Procedure:

  • Check emergency equipment
  • Explain procedure to patient and gain patient consent where possible
  • Position patient in semi-recumbent position
  • When required place supplemental oxygen over nose and mouth
  • Ensure assistant is clear regarding what is expected of them
  • If required, ask assistant to suction, remove old dressing and tapes and support the tube
  • Remove tube on expiration
  • Observe site, swab if required and clean stoma
  • Check patient is comfortable
  • Use a portion of gauze folded in four and place over stoma, ask assistant to place clear dressings in place overlapping them over the stoma site
  • Show patient how to apply pressure over the stoma site when talking or coughing to reduce ‘blowout’ of the dressing
  • Document the procedure in the case notes and make a final check of the patient

Patients fail decannulation for a number of reasons; therefore the patient requires close observation post decannulation. Reasons for failure include increased work of breathing, inability to clear secretions and damage to the trachea including stenosis, tracheomalacia and granuloma that may have previously been undiagnosed. Clinical indications of these latter complications include stridor, change in voice quality and/or an increase in work of breathing.2 A patient should be referred to the ENT team if concerned or the emergency team if acute respiratory distress is observed.

It is suggested that the emergency tracheostomy bag is kept by the patients bedside for 24 hours post decannulation in case of emergency.

References

  1. Stelfox HT, Crimi C, Berra L, Noto A, Schmidt U, Bigatello LM, Hess D (2008) Determinants of tracheostomy decannulation: an international survey Critical care 12:R26.
  2. Norwood S; Vallina V; Short K; Saigusa M; Fernandez L ; McLarty J (2000). Incidence of tracheal stenosis and other late complications after percutaneous tracheostomy. Annals of Surgery, vol. 232, no. 2, pages 233 – 241.