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

When to Start Decannulation in Tracheostomy Patients

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 Before Decannulation

The following criteria must be met before any decannulation assessment begins:

• Complete weaning from mechanical ventilation for 24 hours is the fundamental starting point 1
• Resolution of the original condition that necessitated tracheostomy placement must be documented 1, 2
• Adequate spontaneous breathing without ventilatory support is required 1
• Appropriate level of consciousness is critical for airway protection 1, 3
• Effective cough mechanism with ability to clear secretions 1, 3
• Minimal secretions (scant, thin secretions preferred) 1, 3

Critical Step: Cuff Deflation Trial

Before proceeding with decannulation:

• Deflate the tracheostomy tube cuff when the patient is breathing spontaneously (GRADE 2+ recommendation) 1
• Do not proceed if the patient cannot tolerate cuff deflation, as this predicts poor outcomes 1
• Cuff deflation reduces decannulation failure, shortens mechanical ventilation weaning time, and decreases tracheostomy-related complications 1

Mandatory Endoscopic Evaluation

Never attempt decannulation without endoscopic evaluation, as unexpected anatomic problems are common and lead to failure 1, 2:

• Perform flexible laryngotracheoscopy to assess for granulation tissue above the stoma 4, 5
• Evaluate for unresolved subglottic narrowing 4
• Check for tracheomalacia or other functional obstruction 4
• Office-based flexible laryngotracheoscopy combined with a capping trial has demonstrated 87.5% efficacy in predicting successful decannulation 5

Decannulation Methods

One-Stage Method (Generally Preferred)

The one-stage approach is favored by the American Thoracic Society 1, 2:

• Perform endoscopic examination during spontaneous breathing 1
• If anatomic and functional airway patency is adequate, proceed with immediate decannulation 1
• Allows prompt recognition and management of anatomic factors preventing successful decannulation 1
• Reduces probability of failed attempts 1

Gradual Downsizing Method (Alternative)

This approach involves 1, 2:

• Sequential downsizing of tracheostomy tube over several days to weeks 1, 6
• Partial or complete tube plugging during the downsizing process 1, 2
• May facilitate use of a speaking valve before complete decannulation 6
• Recent research shows comparable outcomes between gradual blocking and tube size reduction methods 7

Post-Decannulation Monitoring

All patients must be monitored in the hospital for 24-48 hours after decannulation 1, 2, 6:

• The vast majority of decannulation failures occur within 12-36 hours 4
• Monitor for respiratory distress, stridor, inability to manage secretions, and hypoxemia or hypercapnia 1
• Keep a tracheostomy tube one size smaller immediately available for emergency recannulation 1
• Rapid anatomic closure of the stoma may make emergency recannulation difficult 4

Special Population Considerations

Pediatric Patients

• Require more careful consideration due to higher complication risk in younger children 1, 2
• One-stage method is generally preferred 1
• Proper tube diameter, length, and curvature selection is critical to minimize complications 4, 6

COVID-19 Patients

• Defer decannulation until SARS-CoV-2 testing of lower respiratory tract sputum is negative twice 1, 2

Neurologically Impaired Patients

• Neurological status significantly affects decannulation success 1
• These patients may have decreased mobility but paradoxically lower accidental decannulation risk 1
• Decannulation success is significantly affected by neurological status 5

Patients with Multiple Comorbidities

• Those with 4 or more comorbidities show significantly higher rates of failed decannulation 1
• Consider stepwise increased risk of complications 1

Critical Pitfalls to Avoid

• Never skip endoscopic evaluation - unexpected anatomic problems are common 1
• Do not proceed if cuff deflation is not tolerated - this predicts poor outcomes 1
• Avoid excessive delay once criteria are met - prolonged tracheostomy increases risk of pharyngolaryngeal lesions and aspiration 1
• Do not decannulate during high-risk respiratory infection season in patients with minimal respiratory reserve 4
• Do not rely solely on cultures of tracheostomy secretions as tracheostomies rapidly become colonized 4

Defining Decannulation Failure

Most clinicians define decannulation failure as:

• Need to reinsert an artificial airway within 48-96 hours of tracheostomy removal 3
• Respiratory therapists prefer shorter time frames (median 48 hours) compared to physicians (median 96 hours) 8
• An acceptable recannulation rate is 2-5% 8, 3

Emergency Preparedness

• Accidental decannulation occurs at a rate of 2.28 per 1000 tracheostomy bed days and can lead to catastrophic outcomes 1
• Reduction in neck circumference due to weight loss predisposes to accidental decannulation 9
• Tracheostomy-related hemorrhage occurs at 1.74 per 1000 tracheostomy bed days with two- to four-fold increase in mortality risk 1