TRACHEOSTOMY DECANNULATION

1. DECANNULATION/WEANING OF TRACHEOSTOMY DR NOR AMILAH BINTI MOHD RAMLI

2. DECANNULATION/weaning off tracheostomy • Process of tracheostomy tube removal once the underlying indication for the tracheostomy has been resolved or corrected-for example : • failure to wean from mechanical ventilation • inability to protect the airway due to impaired mental status • inability to manage excessive secretions • upper-airway obstruction Tracheostomy decannulation, Respiratory Care, http://www.rcjournal.com/contents/08.10/08.10.1076.pdf

3. Decannulation/weaning off tracheostomy • Tracheostomy tubes can cause complications - tracheal stenosis, bleeding, infection, fistula formation from the trachea to either the esophagus or the innominate artery. • Final removal of the tracheostomy tube is an important step in the recovery from chronic critical illness and can usually be done once the indication for the tube placement has resolved • Advantages-improves vocal cord and swallowing functions, improves patient comfort and perceived physical appearance Tracheostomy decannulation, Respiratory Care, http://www.rcjournal.com/contents/08.10/08.10.1076.pdf

4. Spigot/decannulationDo’s and don’t’s • To be done as in-patient setting-admit patient • DO NOT REFER TO DECANNULATE A DAY BEFORE DISCHARGE/AT NIGHT/OVER THE WEEKENDS • If outpatient,usually patient will be on permanent,double lumen tracheostomy tube(Portex/Shiley) • If inpatient,patient will be on uncuff tracheostomy tube-DO NOT SPIGOT/DECANNULATE WITH CUFF TUBE • If patient has been weaned off from ventilator,change to uncuff tracheostomy tube first

5. Decannulation – staged process : Decannulation criteria/protocol fulfilled Spigot 12 hours(8am till 8pm) Spigot 24 hours Removal of tracheostomy tube

6. When to off spigot/capping? • Observe closely for any signs of respiratory distress including: • Tachypnoea • Tachycardia • Oxygen desaturation or low oximetry reading • Restlessness or anxiety • Secretions ++ • Active URTI

7. Decannulation CRITERIA • 1. Baseline oxygen saturation level (SpO2) 2. Need for mechanical aspiration • Abundant tracheal secretions and need for frequent aspiration are considered a relative contraindication to decannulationas mucosal plugs can cause lung collapse • 3. Assessment of protective reflexes • Cough reflex, by assessing the intensity of the cough either spontaneous or induced by tracheal aspiration. The absence of an effective cough is a contraindication to decannulation. • 4. Chest X-ray (when indicated) • Such as pneumonia or pleural effusion, may contraindicate decannulation. • 5. Flexible endocopy (when indicated) • Evaluate vocal cord mobility and tracheal patency. Vocal cord paralysis in adduction does not allow the patient to be decannulated-risk of upper airway obstruction 6. GCS/suitable level of consciousness Any pending/planned surgeries? DECANNULATE ONLY IF ALL THE ABOVE CRITERIA FULFILLED ShreeharshaMaruvala, RavishankarChandrashekhar, Ruchi Rajput, Tracheostomy Decannulation: When and How?, Research in Otolaryngology, Vol. 4 No. 1, 2015, pp. 1-6

8. Flexible endoscopy http://www.rcjournal.com/contents/08.10/08.10.1076.pdf

9. Patient level of consciousness, cough effectiveness, secretions, and oxygenation are important determinants of clinicians' tracheostomy decannulation opinions. • Most surveyed clinicians defined decannulation failure as the need to reinsert an artificial airway within 48 to 96 hours of planned tracheostomy removal. • Determinants of tracheostomy decannulation: an international survey, Critical Care,2008, Biomed Central

10. PRE-DECANNULATION • Change to uncuff, fenestrated tube-air leak surrounding the tube makes phonation and coughing better • Downsize the trachy tube-to see how well the patient manages with a smaller tracheostomy in the airway and to encourage the use of the upper airway, example: uncuff size 7.5 to 7.0

11. Decannulation steps • 1.Nurse in acute bed • 2.Prepare & inform patient and equipments • observation monitor,sp02 • suction machine and catheter • gauze,scissors,saline • Emergency equipments • spare tracheostomy tubes(x1 same size + x1 smaller size) • tracheal dilator DECCANULATION PROCEFURE,NHS TRUST

12. Decannulation steps • 3.Place the patient in neck extended position • 4.Monitor Spo2 throughout the procedure • 5.Suctioning (it will reduce coughing during decannulation) • 6.With the help of another assistant, unfasten trachy ties, while the assistant holds the tracheostomy tube • 7.If possible, get the patient to cough as the tube is removed, pulling it forward in up and over motion DECANNULATION PROCEDURE,NHS TRUST

13. DECANNULATION STEPS 8.Clean the stoma with gauze and normal saline, apply dressing with sterile gauze 9.Encourage the patient to support the dressing whenever they speak or cough-as may exhibit reduced voice quality due to air-flow diversion through the healing stoma on exhalation. 10.Continue observation/Sp02,4-hourly if well 11.Keep the recommended emergency tracheostomy tube equipments bedside for the next 24hours-in case re-insertion is required Decannulation procedure, NHS Trust https://www.hopkinsmedicine.org/tracheostomy/living/decannulation.html

14. Following decannulation: • Monitor the patient's vital signs - respiratory rate, heart rate, oxygen saturation, colour and work of breathing continuously throughout the procedure then observe and document • WHAT TO DO IF PATIENT HAS SOB POST-DECANNULATION? -INFORM STAT,SPO2 MONITORING -TRY TO RE-INSERT TRACHEOSTOMY TUBE BACK -OR RE-INTUBATE !!! BEWARE! TRACHEAL OPENING CLOSES WITHIN 7 HOURS& SKIN STOMA BY 3 DAYS

15. FOLLOWING DECANNULATION : • The acceptable decannulation failure rate is reported to range from 2–5%. • Failure may be apparent within 48 – 96 hours, and a stoma that has not fully closed may be reopened using serial dilators • Despite being fully weaned from mechanical ventilation and tolerant of capping of their tracheostomy tubes, a subset of patients may not be safe for decannulation. • The tracheostomy stoma heals by secondary intention within 5–7 days in the majority of patients. In <10 % patients, the opening into the neck skin has to be surgically closed-secondary suturing. • Tracheostomy-stoma-closure rates are variable and closure may occur in a single day or may take weeks. http://www.rcjournal.com/contents/08.10/08.10.1076.pdf

16. stoma care • The patient is to remain on the ward for 24 hours post decannulation and should not leave the ward without medical approval and supervised by nursing staff competent in tracheostomy care.  • Ensure the caregivers are provided with adequate supplies and are aware of how to care for stoma site - this includes daily cleaning of the site and dressing changes as required. Advise the family/caregiver to contact the hospital and/or medical team if there are any signs of infection at the stoma site including any: • Redness • Odour • Swelling • Discharge Tracheostomy Management,Clinical Guidelines(Nursing), The Royal Children's Hospital Melbourne

17. The Practice of tracheostomy decannulation- a systemic review,Journal of Intensive Care, 2017

18. Decannulation algorithm Decannulation criteria/protocol fulfilled Spigot 12 hours(8am till 8pm) • Review back later as in-patient • Change to permanent double lumen tracheostomy tube & discharge • TCA ENT CLINIC 4-6 months,if fit, then admit for spigot then, decannulation DO NOT DISCHARGE WITH CUFF/UNCUFF TUBES! If tolerable, spigot 24 hours DECANNULATE STOMA CARE TCA ENT CLINIC to review stoma

19. No trachy….no worry… thank you