Tracheostomy Decannulation Guidelines
Direct Recommendation
Decannulate when the patient has been successfully weaned from mechanical ventilation for 24 hours, demonstrates adequate cough and swallow function with minimal secretions requiring suctioning, maintains appropriate consciousness level, tolerates cuff deflation, and has resolution of the original condition necessitating tracheostomy—preferably using a one-stage approach with endoscopic evaluation rather than gradual downsizing. 1, 2
Essential Prerequisites Before Decannulation
Core Clinical Criteria
- Complete weaning from mechanical ventilation for at least 24 hours is mandatory before any decannulation assessment 1
- Resolution of the original condition that required tracheostomy placement must be documented 1, 2
- Adequate spontaneous breathing without ventilatory support is required 1
- Effective cough mechanism with ability to clear secretions independently 1, 3
- Minimal suctioning requirements—the frequency of suctioning is a key indicator of readiness 4, 5
- Adequate swallowing function to prevent aspiration 4
- Appropriate level of consciousness with ability to protect the airway 1, 3
- Successful cuff deflation tolerance or ability to use a cuffless tube 1
Critical Pitfall to Avoid
Never attempt decannulation without endoscopic evaluation, as unexpected anatomic problems (granulation tissue, subglottic stenosis, tracheomalacia) are common and frequently lead to failure 1, 2. The one-stage method with bronchoscopy allows immediate identification of these issues 2, 6.
Recommended Decannulation Protocol
Preferred Method: One-Stage Approach
The one-stage decannulation method is generally preferred over gradual downsizing because it allows prompt recognition and management of anatomic factors preventing successful decannulation 1, 2
Step-by-step protocol:
- Deflate the tracheostomy tube cuff when the patient is breathing spontaneously (GRADE 2+ recommendation)—this reduces decannulation failure and shortens weaning time 1
- Perform endoscopic examination during spontaneous breathing to assess for:
- If anatomic and functional airway patency is adequate, proceed with immediate decannulation 1, 2
- Apply an occlusive pressure dressing after removal to facilitate wound closure and limit exposure to tracheal secretions 4
Alternative: Gradual Downsizing Method
The gradual technique involves sequential downsizing of the tracheostomy tube over several days to weeks, often with partial or complete tube plugging during the process 1, 2. This approach may be considered when:
- Patient has borderline respiratory reserve 1
- Anatomic concerns require progressive assessment 7
- Speaking valve use is desired before complete decannulation 7
However, this method has disadvantages: multiple clinic visits, increased patient discomfort, and delayed decannulation which increases risk of pharyngolaryngeal lesions and aspiration 1, 6
Post-Decannulation Monitoring
Mandatory Observation Period
Monitor all patients in the hospital for 24-48 hours after decannulation, as the vast majority of failures occur within 12-36 hours 1, 2, 7
Signs of Decannulation Failure Requiring Emergency Recannulation
- Respiratory distress or increased work of breathing 1
- Stridor indicating upper airway obstruction 1
- Inability to manage secretions 1
- Hypoxemia or hypercapnia 1
Emergency Preparedness
Keep a tracheostomy tube one size smaller immediately available at all times in case emergency recannulation is needed 1. Rapid anatomic closure of the stoma may make emergency recannulation difficult 1.
Special Population Considerations
COVID-19 Patients
Defer decannulation until SARS-CoV-2 testing of lower respiratory tract sputum is negative twice, and use proper PPE during tube removal 4, 1
Pediatric Patients
- Higher complication risk in younger children requires more careful consideration 1, 2
- Proper tube diameter, length, and curvature selection is critical to minimize complications 1, 7
- Either one-stage or gradual method may be used, though one-stage is generally preferred 1
- SARS-CoV-2 testing should be negative prior to any planned operative airway exam and hospital admission, which are often part of the pediatric decannulation process 4
Patients with Prolonged Ventilation
These patients have higher frequency of swallowing dysfunction and increased risk of aspiration and pharyngolaryngeal injuries when decannulation is delayed 1. Avoid excessive delay once criteria are met, as prolonged tracheostomy increases complications 1.
Patients with Multiple Comorbidities
Those with 4 or more comorbidities show significantly higher rates of failed decannulation and require closer monitoring 1. Neurological comorbidities significantly affect success rates 1.
Additional Clinical Pearls
Capping Trials vs. Suctioning Frequency
Recent evidence suggests that basing decannulation decisions on suctioning frequency plus continuous high-flow oxygen therapy reduces time to decannulation (median 6 days vs. 13 days) compared to traditional 24-hour capping trials, with no difference in failure rates 5. This challenges the traditional emphasis on capping tolerance 3.
Speaking Valve Use
One-way speaking valves require toleration of a deflated cuff or cuffless tube to allow air passage through vocal cords 4. These can facilitate speech and prompt weaning 4, 7.
Acceptable Failure Rate
Both respiratory therapists and physicians identify 2-5% as an acceptable rate of decannulation failure 3. Most clinicians define decannulation failure as occurring within 48-96 hours 3.
Hemorrhage Risk
Tracheostomy-related hemorrhage occurs at 1.74 per 1000 tracheostomy bed days and is associated with a two- to four-fold increase in mortality risk 1. Causes include bleeding diathesis, granulation tissue, wound breakdown, and mucosal or vascular injury 1.