Weaning from tracheostomy / Use of Decannulation Devices

Following successful cuff deflation, the patient’s clinical condition and the type of tracheostomy tube in situ will dictate the next stage in the process of weaning.  The following sections describe different weaning methods. 

NB The cuff deflation guideline should be carried out prior to completion of ALL methods of weaning as described in the following sections.

A number of different methods of weaning exist.  Consideration should be given to individual patients to ensure that the safest and most appropriate method of weaning is identified.

Weaning times can vary due to the original reason for insertion of the tracheostomy tube and length of time on mechanical ventilation. Once the following has been achieved weaning can commence.

  • The patient no longer required positive pressure ventilation
  • Supplemental oxygen requirement is less than 40% O2
  • The patient is haemodynamically stable
  • The patient is able to cough to clear chest secretions using vocal cords
  • The patient requires occasional suctioning
  • The patient has successfully passed a cuff deflation trial
  • The patient is able to maintain an upright sitting position in a bed or chair
  • The patient is able to stay awake and alert for 15 minutes while seated upright

Weaning from a tracheostomy tube by either decannulation cap or speaking valve increases the workload of breathing.  Gradually increasing this workload will help build respiratory muscle to ensure that following decannulation the patient is able to breathe and clear secretions effectively.  Weaning can commence after the patient has passed a cuff deflation trial.  The process of weaning must be planned and clearly documented (Weaning record of care/Appendix 2). 

Weaning should not occur overnight, speaking valves or decannulation caps should be removed as complications can be more difficult to identify.  

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Double lumen uncuffed trachstomy tube with fnestrated inner lumen tube and speaking valve (shown apart)

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Double lumen uncuffed trachstomy showing fenestrated inner luman and speaking valve  insitu

During the weaning process, one of the benefits that can be achieved for the patient is the ability to vocalise for short periods of time. Adjuncts which allow patients to vocalise increase the workload of breathing and therefore should only be considered for use in patients in whom it has been agreed within the multidisciplinary team to commence weaning from the tracheostomy tube.

A speaking valve must never be placed on the 15mm connector of a non-fenestrated tube when the cuff is inflated as the patient will not be able to exhale.
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The above picture shows the airflow in a patient who has a speaking valve (or decannulation cap) attached to a non-fenestrated tracheostomy tube with the cuff inflated.  This patient is unable to breathe out and is therefore at high risk of hypoxia, pneumothorax and cardiac arrest
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The above picture shows the airflow in a patient who has a speaking valve attached to an fenestrated tracheostomy tube with the cuff deflated. As can been seen, the patient is able to breathe out via the upper airway.

 

Please note using a decannulation devices involves partially or completely occulsion of the tracheostomy tube by the decannulation device, if there is any degree of airway occlusion from oedema, of the cuff is not completely deflated or a non-fenstrated tracheostomy tube is insitu, the patient may suffer complete airway obstruction.  Prior to attatching the device, an assessment of airflow via oro/nasophaynx is recommended, this can be assess by lightly applying  finger occlusion to the tracheostomy tube prior to attatching the device to observe for any signs of airway obstruction. 

 

Weaning with a Single Lumen Tracheostomy Tube

Suitable for paients who are able to wean over a short period of time

Click here for instruction on weaning patients using a single lumen tracheostomy tube

Weaning from a Decannulation Cap

Suitable for patients with a fenstrated double lumen tracheostomy tube.  The cuff MUST be deflated.

Click here for instruction on weaning patients using a double luemn tracheostomy tube and a decannulation cap

Weaning with a Speaking Valve

Suitable for patients with a fenstrated double lumen tracheostomy tube.  The cuff MUST be deflated

Click here for instruction on weaning patients using a double luemn tracheostomy tube and a speaking valve

The ability of the patient to maintain their own airway without the tracheostomy tube will depend on whether the initial  reason for the tracheostomy tube has resolved. Each patient will be individually assessed. However the ultimate responsibility for the removal of the tracheostomy lies with the Consultant in charge of the patient.

Reasons for continuation of tracheostomy

  • Presence of tumour
  • Presence of upper airway oedema/trauma
  • Reduced ability to clear secretions adequately
  • Patient requires greater than 40% oxygen
  • Patient has not completed a weaning process
  • Further surgery is indicated within a short time period
  • Cardiovascular instability
  • Initial reason for tracheostomy still exists

Click here for instruction on the process of decannulation