Tracheostomy decannulation is always challenging and this presentation address the various issues, indications, contra-indications, problems and solutions.

1. Dr. Prahlada N.B
MS (PGIMER), MBA, MHA

2. Tracheostomy care
 Security of the tracheostomy tube
 The inner cannula hygiene
 Cuff pressures should be maintained at 20–25 cm H2O
 Regular tube changes

3. Tracheostomy care
 Secretion management
 Hydration
 Humidity
 Suctioning, and
 Physical mobility
 Respiratory Physiotherapy
 Prepare for Decanulation

4. Decanulation
 As soon as the patient’s condition permits.

5. Who should do it?
 Team

6. Who should do it?
 Ear, Nose and Throat (ENT) Surgeon
 Ward Nurse
 Tracheostomy Nurse Specialist
 Respiratory therapist
 Speech and Language Therapist (SLT)
 Physiotherapist.
 Dietician.

7. Prior work-up
 Chest X-Ray
 Naso-laryngo-bronchoscopy
 The upper airway
 Vocal cord movement and
 The tracheal mucosa.
 Swallowing assessment.

8. Evaluate bedside swallow
 Patients not alert enough to follow commands.
 Patients unable to swallow their own saliva.
 Patients with significant central neurological deficits.

9. Indications - Decanulation
 Reason 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.

10. Indications - Decanulation
 Patient 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.

11. Type and size of tube for weaning
 The 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%.

12. Uncuffed fenestrated tube

13. Patient preparation and
involvement
 Consent
 Explanation.
 Involvement.

14. Practical issues
 Explanation to the patient.
 Start on first days of the week.
 Start early morning.
 Closely monitor the patient.
 Document the progress.

15. Downsizing Algorithm

16. The weaning process
 Day 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.

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

18. Difficulty with
weaning/troubleshooting
 Respiratory insufficiency
 Airway Obstructions
 Retention of Secretions
 Blood in secretions
 Patient anxiety

19. Summary
 The 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.