When is downsizing of a tracheostomy (tracheal tube insertion) recommended?

Tracheostomy Downsizing: Timing and Recommendations

Tracheostomy downsizing should be performed as part of a structured decannulation process, either through sequential downsizing over several days to weeks or as preparation for a one-stage decannulation procedure following endoscopic airway evaluation. 1

Indications for Tracheostomy Downsizing

• Downsizing is indicated when the original need for the tracheostomy tube is resolving and the patient is demonstrating ability to maintain a safe and adequate airway 1
• Downsizing may be performed to facilitate the use of a speaking valve, allowing patients to experience more natural voice and airflow through the upper airway before complete decannulation 1
• Tracheostomy tube downsizing has been shown to significantly reduce airway pressures, potentially improving patient comfort and facilitating speech 2

Methods of Tracheostomy Downsizing

Sequential Downsizing Method

• Involves progressive reduction of tube size, often with partial or complete plugging, over several days to weeks 1
• Advantages:
  • Can be performed in clinic settings 1
  • Requires no instrumentation or sedation 1
  • Allows patient to gradually acclimate to breathing through the natural upper airway 1
• Disadvantages:
  • May fail due to undetected anatomic problems 1
  • Risks progressively obstructing the patient's airway 1
  • More problematic in small children as step-down in size creates proportionately larger increase in airway resistance 1
  • Increased risk of mucous plugging in smaller tubes 1

One-Stage Decannulation with Prior Downsizing

• Patient undergoes endoscopic examination of the airway with tube removal during evaluation 1
• Prior downsizing may be performed to facilitate speaking valve use before complete decannulation 1
• Advantages:
  • Allows prompt recognition and management of anatomic factors (e.g., granulation tissue) 1
  • Reduces probability of failed decannulation attempts 1
  • One-step method is generally preferred according to consensus guidelines 1

Timing of Tracheostomy Downsizing

• Early tracheostomy tube change (before day 7) has been associated with:
  • Earlier ability to tolerate speaking valve (7 days vs 12 days) 3
  • Earlier oral intake (10 days vs 20 days) 3
  • Shorter hospital stays without increased complications 3
• For decannulation preparation, downsizing should occur when:
  • The original need for tracheostomy is no longer present 1
  • The patient demonstrates ability to maintain safe and adequate airway 1
  • Endoscopic evaluation confirms adequate airway patency 1

Special Considerations

Pediatric Patients

• Selection of proper tube diameter, length, and curvature is critical to minimize complications including suprastomal collapse and granuloma formation 1
• Progressive downsizing in small children is more problematic due to proportionately larger increases in airway resistance 1
• Always have a tracheostomy tube one size smaller than usual available for emergency use 1

Safety During Downsizing

• Endoscopic evaluation should be performed before decannulation to identify potential anatomic problems like granulation tissue 1
• Patients should be monitored in the hospital for 24-48 hours after complete decannulation 1
• For patients with minimal respiratory reserve, consider delaying decannulation until after high-risk respiratory infection season 1

Complications and Pitfalls

• Failed decannulation typically occurs within 12-36 hours and may be difficult to manage due to rapid stoma closure 1
• Downsizing without endoscopic evaluation may miss high degrees of fixed airway obstruction above the stoma 1
• Common complications after decannulation include:
  • Tracheal stenosis 4
  • Granulation tissue formation 4
  • Tracheoesophageal fistula 4

Emergency Management During Downsizing

• If accidental decannulation occurs, attempt replacement with same size tube first 1
• If unsuccessful, use a tube one half-size smaller 1
• Position changes may help with reinsertion - extending the neck with a pillow under the shoulders can bring the trachea anteriorly 1
• Always assess tube patency after reinsertion using clinical assessment and waveform capnography if available 1