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Tracheostomy decanulation

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

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Tracheostomy decanulation

  1. 1. Dr. Prahlada N.B MS (PGIMER), MBA, MHA
  2. 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. 3. Tracheostomy care  Secretion management  Hydration  Humidity  Suctioning, and  Physical mobility  Respiratory Physiotherapy  Prepare for Decanulation
  4. 4. Decanulation  As soon as the patient’s condition permits.
  5. 5. Who should do it?  Team
  6. 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. 7. Prior work-up  Chest X-Ray  Naso-laryngo-bronchoscopy  The upper airway  Vocal cord movement and  The tracheal mucosa.  Swallowing assessment.
  8. 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. 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. 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. 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. 12. Uncuffed fenestrated tube
  13. 13. Patient preparation and involvement  Consent  Explanation.  Involvement.
  14. 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. 15. Downsizing Algorithm
  16. 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. 17. The weaning process  Continue to occlude tube for 12 hour.  Day 2 - Occlusion cap in situ for 24 h.  Day 3 – Decanulation.
  18. 18. Difficulty with weaning/troubleshooting  Respiratory insufficiency  Airway Obstructions  Retention of Secretions  Blood in secretions  Patient anxiety
  19. 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.

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