From the Guidelines
A patient is ready to have a tracheostomy tube removed when they can maintain a safe and adequate airway independent of the tracheostomy tube, and the original need for the tracheostomy tube is no longer present. This decision is based on the criteria outlined in the American Thoracic Society's official statement, adopted in 1999, which emphasizes the importance of assessing the patient's ability to breathe independently and the resolution of the underlying condition that necessitated the tracheostomy 1.
When considering decannulation, the patient's airway should be evaluated endoscopically to identify any potential anatomic problems that may hinder successful removal of the tracheostomy tube. The traditional decannulation technique involves sequential downsizing of the tube, often with partial or complete plugging of the tube, over a period of several days to several weeks. However, this approach may not be suitable for all patients, particularly small children, due to the increased risk of airway obstruction and mucous plugging.
An alternative approach is the one-stage decannulation procedure, which involves endoscopic examination of the airway during spontaneous breathing, followed by removal of the tube if the airway is deemed adequate. This method allows for prompt recognition and management of anatomic factors that may prevent successful decannulation, reducing the likelihood of failed attempts.
Key considerations for decannulation include:
- The patient's ability to maintain a patent airway without the tracheostomy tube
- Adequate respiratory function and ability to clear secretions effectively
- Resolution or significant improvement of the underlying condition that necessitated the tracheostomy
- Successful tolerance of tracheostomy tube capping for an extended period
- Effective swallowing function without significant aspiration risk, as evaluated through a modified barium swallow study, if necessary.
Ultimately, the decision to remove a tracheostomy tube should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances, and guided by the principles outlined in the American Thoracic Society's statement 1.
From the Research
Decannulation Criteria
The decision to remove a tracheostomy tube is based on several factors, including:
- Ability to tolerate capping of the tracheostomy tube 2
- Secretion management 2
- Cough effectiveness 2
- Level of consciousness 2
- Neurological status of the patient 3
- Ability to manage excessive secretions 4
- Resolution of the indication for tracheostomy tube placement 4
Assessment Protocols
Different protocols are used to assess a patient's readiness for decannulation, including:
- Office-based flexible laryngotracheoscopy and tracheostomy capping trial 3
- Evaluation of airway and swallowing function 3
- Assessment of the patient's ability to tolerate capping of the tracheostomy tube for a certain period, such as 72 hours 2
Patient Selection
Patient selection for decannulation is crucial, and the following factors are considered:
- Strong cough 2
- Scant thin secretions 2
- Minimal supplemental oxygen requirements 2
- Alert and interactive patients 2
- Patients with chronic obstructive pulmonary disease (COPD) as the etiology of respiratory failure 2
- Patients with good swallowing function clinically 3
Safety and Efficacy
The safety and efficacy of decannulation protocols have been evaluated in several studies, with reported success rates of 87.5% 3 and safety profiles of 95.45% 3. However, the decision to remove a tracheostomy tube should be individualized and based on a comprehensive assessment of the patient's condition.