What is decannulation?

Decannulation: Process and Approaches

Decannulation is the process of removing a tracheostomy tube once the original need for it is no longer present and the patient can maintain a safe and adequate airway independently. 1

Fundamental Criteria for Decannulation

• Two essential requirements must be met before proceeding with decannulation:
  • The original condition necessitating the tracheostomy has resolved 1
  • The patient demonstrates ability to maintain a safe and adequate airway without the tracheostomy tube 1

Decannulation Methods

Traditional (Gradual) Technique

• Involves sequential downsizing of the tracheostomy tube over several days to weeks 1
• Often includes partial or complete plugging of the tube during the downsizing process 1
• When the patient tolerates the smallest tube size, the tube is removed completely 1
• Advantages:
  • Can be performed in outpatient settings 1
  • Requires no instrumentation or sedation 1
  • Allows gradual acclimation to breathing through the natural upper airway 1
• Disadvantages:
  • Higher failure rate due to undetected anatomic problems 1
  • Risk of progressively obstructing the patient's airway 1
  • Particularly problematic in small children due to proportionately larger increase in airway resistance 1

One-Stage (Abrupt) Technique

• Patient undergoes endoscopic examination of the airway 1
• Airway is assessed during spontaneous breathing 1
• Tube is removed during the evaluation if anatomic and functional patency of the airway is adequate 1
• Advantages:
  • Allows prompt identification and management of anatomic factors like airway granulation tissue 1
  • Reduces probability of failed decannulation attempts 1
  • The American Thoracic Society generally prefers this method 1

Post-Decannulation Care

• Patients should be monitored in the hospital for 24-48 hours after decannulation 1
• In most cases, the tracheostomy stoma closes spontaneously after decannulation 1, 2
• A small percentage of patients may require formal closure of a persistent tracheocutaneous fistula 1, 2
• Occasionally, surgical closure of the stoma may be needed at the time of decannulation 1
• For COVID-19 patients, decannulation should ideally be deferred until SARS-CoV-2 testing of lower respiratory tract sputum is negative twice 1

Predictive Factors for Successful Decannulation

• Strong cough reflex and effective secretion management 3, 4, 5
• Alert and interactive mental status 3, 4, 5
• Minimal secretions, particularly thin ones 4, 5
• Minimal oxygen requirements 4, 5
• Ability to tolerate tracheostomy tube capping 4, 5
• Younger age 3

Potential Complications

• Decannulation failure (need for reinsertion of artificial airway)
  • Most clinicians define this as occurring within 48-96 hours of removal 4, 5
  • Acceptable recannulation rate is generally considered to be 2-5% 4, 5
• Persistent stoma requiring surgical closure 1, 2
• Tracheal stenosis or granulation tissue formation 6
• Tracheoesophageal fistula (rare) 6

Clinical Considerations

• Comparative studies show similar success rates between gradual and abrupt decannulation techniques 6, 7
• Clinical setting influences decannulation decisions, with chronic care facilities being more conservative than acute care, rehabilitation, or weaning facilities 5
• Endoscopic evaluation is essential before decannulation to identify potential anatomic problems 1, 2

Special Populations

• Pediatric patients require more careful consideration due to:
  • Higher risk of complications in younger children (especially under 1-3 years) 1
  • Proportionately larger impact of tube downsizing on airway resistance 1
  • Increased risk of mucous plugging with smaller tubes 1