Tracheostomy Decannulation

Tracheostomy decannulation:

This is a staged process and should not be resorted to rather casually. This process differs in adults and children. It is a little bit easy in adults and can be performed as an outpatient procedure. In children more care needs to be taken. Weaning a patient from a short term tracheostomy is rather simple because these patients would not have fully acclimatized to tracheostomy breathing.

Decannulation process in a patient who has been on tracheostomy for a week or less:

This should be considered as short term tracheostomy decannulation and can safely be performed under outpatient setting.

Short term tracheostomy tube decannulation in an adult:

Stage I:

This involves assessment of the patient to ensure that tracheal / subglottic obstruction which had caused the patient to undergo tracheostomy has resolved / has been treated. This is done by performing bronchoscopy. During bronchoscopy efforts should be made to look for presence of granulation tissue in the trachea, presence of supra stomal collapse. If any of these are present then the decannulation procedure should be postponed pending treatment of the potential cause for obstruction. Bronchoscopy will also ensure that the patient will be able to maintain ventilation adequately in the absence of trachesotomy. In short term tracheostomy patients this evaluation is performed 3 days before planned decannulation.

Stage II:

In this stage the tracheostomy tube is closed using an occlusion cap or spiggot. This step can again be peformed in out patient setting. Patient is observed for the following signs following occlusion of tracheostomy tube:

1. Breathlessness

2. Change in color

3. Tachycardia

4. Stridor

Before occluding the tracheostomy tube one important aspect should be ensured. The tracheostomy tube before occlusion should be ensured that it has fenestra for air passage through the trachea. If the tube does not have a fenestra then it should be changed to the one that has a fenestra. The author prefers replacement of the portex tracheostomy tube to that of Metal tube (Fuller's) because it contains fenestra allowing alternate air passage. The plastic needle cap can be used as a spiggot to occlude the Fuller's tracheostomy tube. Fenestrated tubes are available made of plastic material also. One should ensure that the tube which is going to be occluded is a fenestrated one otherwise patient wont be able to breath at all.

After observation of the patient for a couple of hurs following occlusion of the tracheostomy tube the patient can be sent home with instructions to remove the cap if there is breathlessness or any other difficulty in breathing. The patient is also encouraged to remove the occlusion cap during night before going to sleep as an abundant caution. After 48 hours of successful day time occlusion the patient is again reviewed in the outpatient department. This time patient is examined completely while the occlusion cap is in place. This time patient is asked to keep the tracheostomy tube occluded day and night for a couple more days. 48 hours after successful day and night occlusion the patient is again reviewed in the outpatient clinic. If the patient is tolerating 24 hours occlusion of the tube then it can safely be removed. The wound should be cleaned and the edges of the skin are brought together so as to close the wound and are plastered in place. The patient can immediatly be sent home after this process. After 10 days patient can be reviewed again to ensure that the tracheostomy wound has healed adequately. If there is persistent tracheocutaneous fistula on the 10 day then patient should be taken to the operation theatre for secondary wound closure by flap elevation and suturing.

Decannulation process in adult patients who were on tracheostomy for a long time:

This is a little bit tricky situation. As soon as a decision to decannulate the patient has been made then plain x-ray chest is performed to ascertain the status of the lung. Lung pathology like COPD wound make the patient more vulnerable to decannulation problems. If the x-ray chest is showing changes suggestive of COPD then the patient should be subjected to nebulization in order to dilate the bronchi. The patient should then be encouraged to cough out secretions. Suction can also be applied through the tracheostome to faciliate this process. After the pulmonary status has been found to be favorable for decannulation the patient should be subjected to bronchoscopic examination to rule out the presence of granulation tissue / supra stomal collapse which could compromise the airway following decannulation. If bronchoscopy is normal all the steps described above can be carried out safely.

Decannulation in pediatric patients:

In pediatric patients decannulation should not be attempted in out patient settings. All children who needs to be decannulated after the decision to decannulate has been taken should be admitted before starting the process. First the child should be assessed to ascertain whether decannulation is possible. This assessment should ensure that the child would be able to ventilate normally without the tracheostomy tube. This assessment which includes X-ray chest, and bronchoscopy should be performed 6 weeks prior to admission to the ward for decannulation. In fact only if this assessment proves that the child can be decannulated safely should the process be started. The decannulation plan should include otolaryngologist, pediatritian and chest physician and should be child specific.

In decannulating short term tracheostomy children:

After the initial assessment is over the patient is admitted to the ward. Intermittent day time / awake capping of the tracheostomy tube is performed to start with. This should always be done in front of the care giver / mother as the case may be. If the patient is able to tolerate capping during the first few hours of awake time then it can be resorted for longer duration. During the capping phase the following parameters should be checked constantly:

1. Tachypnoea

2. Stridor

3. Chest retraction

4. Tachycardia

5. Change of color of the patient (bluing)

6. Low pulse oximetry reading

7. Anxiety / restlessness

8. Poor voice quality

Progressively the tracheostomy tube is kept occluded for longer durations during the day time till the child is able to tolerate occlusion during awake hours. One day later night time capping is resorted to. During this time the child should be monitored using pulse oximeter and signs of desaturation should be carefully looked for. The child should be observed every 10 minutes during the first sleeping hour, then every half hour during the next two hours. Then observation is staggered to every hour during the entire duration of sleep during night.

From the second day of nocturnal sleep occlusion the child's tracheostomy tube is kept occluded for a couple more days before the tube is completely removed and wound skin strapped using plaster. As stated previously during decannulation ensure that the tracheostomy tube has alternate breathing holes (fenestra). If the tube is a cuffed one then the cuff should be deflated before the process of capping begins.

Decannulating a child who was under long term tracheostomy care:

This is a tricky process. This should be performed as in patient.

Evaluation of patient airway status should be performed 6 weeks before the actual process of decannulation. Facilities of reintroducting the tracheostomy tube if the need arises should be available in the ward.

On the first day downsizing of the tracheostomy tube should be performed before occlusion. It is ideally downsized to 3.5 mm. The tube used for downsizing should be a fenestrated one. Occlusal cap should be applied. Patient should be provided with 1 : 1 nursing care during the entire duration of decannulation. Oxygen saturation of the patient should be evaluated using pulse oximeter during the entire duration. Baseline observations like Spo2, Blood pressure and pulse rate should be documented. If the child tolerates down sizing and occlusion of the tube then increasing awake hours of occlusion can be resorted to. If the child does not tolerate occlusion then the process of decannulation should be deferred pending complete air way examination. If the child tolerates downsizing and capping of the tracheostomy tube then patient's vitals should remain within the appropriate parameters for age and as per VICTOR chart.

During day 2 of decannulation the downsized tube is kept occluded for 24 hours during which the patient is kept under constant monitoring. If this step progresses without any hitch after the second day then decannulation can be completed on the third day.

On the third day the tracheostomy tube should be removed during morning hours between 9 - 10 AM when all staff of the hospital will be available. The tube is removed and the wound is closed by strapping the skin edges. After removal and strapping of the skin edges the patient is observed in the ward for one more day before deciding to send the patient back home. During the entire duration of observation the patient's vitals should be constantly monitored and oxygen saturation carefully monitored using pulse oximeter.

After successful decannulation the patient is observed for the fourth day. The patient can be discharged on the 5th day morning if every thing is fine.

Care of stoma site:

The care givers are given adequate training to take care of the tracheostomy stoma. They should be taught how to clean the site, change the dressing as and when required. They should also observe for:

Redness

Odor

Swelling

Discharge

If any of the above said features are present the patient should be instructed to come back to the hospital. Otherwise the patient can be reviewed on the 7th day of decannulation. The wound can be inspected. It progressively becomes narrow and closes completely by the second week. Till the wound closes completely the patient should be advised to attend out patient clinic periodically. In the event of persistent tracheo cutaneous fistula the child should be taken up for surgical closure of the tracheostome.