When can oral feeds be started in a patient who has undergone decannulation of a tracheotomy (tracheostomy tube removal)?

When to Start Oral Feeds After Tracheostomy Decannulation

Oral feeding can be initiated immediately after successful decannulation once the patient demonstrates adequate swallowing function and airway protection, which should have been confirmed as part of the pre-decannulation assessment.

Pre-Decannulation Swallowing Assessment is Critical

The timing of oral feeding after decannulation depends entirely on swallowing function assessment that should occur before the tube is removed, not after:

• Swallowing evaluation must be performed during or after decannulation to assess saliva pooling, spontaneous swallowing, and laryngeal sensitivity 1
• For patients with low dysphagia risk, a blue dye test may suffice; higher-risk patients require flexible endoscopic evaluation of swallowing (FEES) 1
• Patients are candidates for decannulation only when coughing/swallowing is adequate and aspiration is minimal 1

Immediate Post-Decannulation Feeding Protocol

If swallowing function was confirmed adequate pre-decannulation, oral intake can begin immediately:

• Patients who pass swallowing assessment can start oral diet the same day of decannulation 2
• In one study of supraglottic laryngectomy patients, 5 of 6 patients were started on oral diet the same day of decannulation 2
• The median time to commencement of oral intake post-tracheostomy insertion across clinical populations was 10.5 days, but this includes the period before decannulation 3

Clinical Progression Pathway

The typical sequence for tracheostomy patients follows this pattern:

1. Continuous cuff deflation (median 7.5 days post-insertion) 3
2. Commencement of oral intake (median 10.5 days post-insertion) - often occurs with cuff deflated or uncuffed tube in situ 3
3. Decannulation (median 15 days post-insertion) 3
4. Cessation of enteral nutrition (median 17 days post-insertion) - most patients cease EN following decannulation 3

Importantly, 86% of tracheostomy patients return to oral intake, though oral feeding often begins before decannulation occurs 3

Multidisciplinary Dysphagia Management Approach

For patients with swallowing concerns, implement a structured four-part program:

• Patient education on swallowing mechanics and safety 2
• Indirect therapy to strengthen swallowing musculature 2
• Swallowing evaluation using instrumental assessment 2
• Nutrition education for safe diet progression 2

This aggressive in-hospital dysphagia management program following decannulation allows certain patients to achieve functional swallowing goals prior to discharge, avoiding the need for percutaneous endoscopic gastrostomy (PEG) placement 2

Key Prognostic Factors

Increased time to commencement of oral intake correlates with increased time to decannulation (r = 0.805) and increased hospital length of stay (r = 0.687) 3

Patients less likely to achieve functional swallowing include those with:

• Extensive surgical resection (supraglottic + base of tongue or supraglottic + vocal fold) 2
• Non-compliance with therapy 2
• Prolonged mechanical ventilation (higher frequency of swallowing dysfunction) 1
• Impaired neurological status 4

Critical Safety Considerations

Do not attempt oral feeding if:

• Swallowing assessment reveals significant aspiration risk 1
• Patient cannot tolerate cuff deflation or capping trial 4, 5
• Secretion management is inadequate (copious thick secretions) 5
• Level of consciousness is impaired 5

The decannulation success rate using proper assessment protocols is 87.5%, with 95.45% safety/reliability 4

Monitoring and Adjustment

• Continue enteral nutrition support until oral intake meets >50% of caloric requirements 6
• Monitor for signs of aspiration pneumonia in the first 3 months post-decannulation 2
• Reassess swallowing function if any respiratory complications develop 7

The mean cannulation time can be significantly reduced with proper multidisciplinary protocols, and patients show clear functional improvements after decannulation 7