When can decannulation be considered in a patient with a tracheostomy?

When Decannulation Can Be Done in Tracheostomy

Decannulation should be considered when the patient has been successfully weaned from mechanical ventilation for 24 hours, demonstrates adequate airway protection with effective cough and minimal secretions, maintains appropriate level of consciousness, and can tolerate cuff deflation or tube capping. 1

Essential Prerequisites for Decannulation

Primary criteria that must be met:

• Complete weaning from mechanical ventilation for 24 hours - this is the fundamental prerequisite before any decannulation assessment begins 1, 2
• Resolution of the original condition that necessitated tracheostomy placement 3
• Adequate spontaneous breathing without ventilatory support 3, 2
• Effective cough mechanism - rated as the most critical factor by clinicians internationally 4, 5
• Minimal secretions (scant, thin secretions preferred) - patients with heavy secretions are poor candidates 4, 5
• Alert and interactive mental status - level of consciousness is a primary determinant, with alert patients having 4.76 times higher odds of successful decannulation 5
• Minimal oxygen requirements - patients requiring minimal supplemental oxygen have 2.04 times higher odds of successful decannulation 5

Decannulation Protocol Approach

The French Intensive Care Society strongly recommends implementing a multidisciplinary decannulation protocol in all ICUs. 1, 2

Cuff Management

• Deflate the tracheostomy tube cuff when the patient is breathing spontaneously (GRADE 2+ recommendation with strong agreement) 1, 2
• Cuff deflation reduces decannulation failure, shortens mechanical ventilation weaning time, and decreases tracheostomy-related complications 1

Assessment Components

Neurological and pharyngolaryngeal examination:

• Pharyngolaryngeal examination should be performed at or following decannulation (GRADE 2+ recommendation) 1, 2
• Sequential assessment must include: salivary stasis evaluation, silent aspiration screening, spontaneous swallowing assessment, and laryngeal sensitivity testing 1, 2
• Swallowing tests with paste then liquid should only be attempted after passing the above assessments 1

Endoscopic evaluation:

• Endoscopic airway examination is essential before decannulation to identify anatomic problems such as granulation tissue, tracheal stenosis, or suprastomal collapse 1, 3, 6, 7
• The examination should be performed during spontaneous breathing with the tube removed during evaluation 1

Decannulation Methods

One-Stage Method (Preferred)

The American Thoracic Society generally prefers the one-stage decannulation method. 3

• Patient undergoes endoscopic examination during spontaneous breathing 1
• Tube is removed during the evaluation 1
• If anatomic and functional airway patency is adequate, immediate decannulation proceeds 1
• Advantages: Prompt recognition and management of anatomic factors preventing successful decannulation, reducing probability of failed attempts 1, 3

Gradual Downsizing Method (Alternative)

• Sequential downsizing of tracheostomy tube over several days to weeks 3, 6
• Often includes partial or complete tube plugging during the downsizing process 3, 6
• Advantages: Can be performed in clinic without instrumentation or sedation, allows patient acclimation to upper airway breathing 1
• Disadvantages: Often fails due to unexpected anatomic problems, risks progressive airway obstruction 1
• Particularly problematic in small children due to proportionately larger increase in airway resistance with each size reduction 1

Capping Trial Approach

• Traditional approach involves 24-hour capping trial to assess breathing tolerance 8
• However, a 2020 randomized trial (330 patients) demonstrated that using suctioning frequency as the indicator for decannulation readiness with continuous high-flow oxygen reduced time to decannulation by 7 days (median 6 vs 13 days) compared to 24-hour capping trials 8
• The suctioning-based approach also reduced pneumonia and tracheobronchitis incidence without increasing decannulation failure 8

Post-Decannulation Monitoring

Patients should be monitored in the hospital for 24-48 hours after decannulation. 1, 3, 6

Defining Decannulation Failure

• Most clinicians define decannulation failure as need to reinsert an artificial airway within 48-96 hours of tracheostomy removal 5
• 45% of clinicians use 48 hours as the cutoff, while 20% use 96 hours 5
• Acceptable recannulation rate is 2-5% according to 44% of surveyed clinicians 4, 5

Special Populations and Considerations

Pediatric Patients

• Require more careful consideration due to higher complication risk in younger children 1, 3
• Children under 1-3 years have more problems than older children 1
• Emergency tracheostomies have higher complication rates (75%) versus elective procedures (35%) 1
• Either one-stage or gradual method may be used, though one-stage is generally preferred 1

COVID-19 Patients

• Decannulation should ideally be deferred until SARS-CoV-2 testing of lower respiratory tract sputum is negative twice 3

Patients with Prolonged Ventilation

• Higher frequency of swallowing dysfunction in tracheostomized patients ventilated for prolonged periods 1, 2
• Longer ICU stays and increased risk of aspiration and pharyngolaryngeal injuries when tracheostomy is prolonged or decannulation delayed 1, 2
• Neurological status significantly affects decannulation success and duration of tracheostomy dependence 7

Critical Pitfalls to Avoid

• Do not attempt decannulation without endoscopic evaluation - unexpected anatomic problems are common and lead to failure 1, 3, 7
• Do not decannulate patients with heavy, thick secretions - this is associated with high failure rates 4, 5
• Do not proceed if patient cannot tolerate cuff deflation - this predicts poor outcomes 1
• Avoid excessive delay in decannulation once criteria are met - prolonged tracheostomy increases risk of pharyngolaryngeal lesions and aspiration 1, 2
• In small children, avoid aggressive downsizing - proportionately larger airway resistance increases and mucous plug risk 1