The document outlines protocols for tracheostomy care and decannulation, detailing hygiene, cuff pressure management, tube changes, and patient assessment needed to safely transition patients. It emphasizes the multi-disciplinary team's roles, including ENT surgeons and therapists, in evaluating and preparing patients for decannulation, focusing on systematic approaches to ensure patient safety. Key indicators for decannulation include patient's awareness, airway protection, cuff deflation tolerance, and maintaining adequate oxygen saturation.

1. Dr. Prahlada N.B
MS (PGIMER), MBA, MHA

2. Tracheostomy care
 Security of the tracheostomy tube
 The inner cannula hygiene
 Cuff pressures should be maintained at 20–25 cm H2O
 Regular tube changes

3. Tracheostomy care
 Secretion management
 Hydration
 Humidity
 Suctioning, and
 Physical mobility
 Respiratory Physiotherapy
 Prepare for Decanulation

4. Decanulation
 As soon as the patient’s condition permits.

5. Who should do it?
 Team

6. Who should do it?
 Ear, Nose and Throat (ENT) Surgeon
 Ward Nurse
 Tracheostomy Nurse Specialist
 Respiratory therapist
 Speech and Language Therapist (SLT)
 Physiotherapist.
 Dietician.

7. Prior work-up
 Chest X-Ray
 Naso-laryngo-bronchoscopy
 The upper airway
 Vocal cord movement and
 The tracheal mucosa.
 Swallowing assessment.

8. Evaluate bedside swallow
 Patients not alert enough to follow commands.
 Patients unable to swallow their own saliva.
 Patients with significant central neurological deficits.

9. Indications - Decanulation
 Reason for the tracheostomy resolved.
 Patient alert, responsive and consenting.
 Patient tolerating cuff deflation for a minimum of 12
hours.
 Patient managing to protect their airway and have a
clear chest.
 Patient maintaining oxygen saturations.

10. Indications - Decanulation
 Patient tolerating the use of a speaking valve and/or
digital occlusion.
 Patient able to expectorate around the tube into their
mouth.
 Tracheostomy tube type and size is appropriate.

11. Type and size of tube for weaning
 The ideal tube to use for the weaning process is one
that allows adequate airflow around the tube while the
tube is occluded.
 An uncuffed fenestrated tube will offer the least
resistance.
 The patient should be able to maintain SaO2 above
90%.

12. Uncuffed fenestrated tube

13. Patient preparation and
involvement
 Consent
 Explanation.
 Involvement.

14. Practical issues
 Explanation to the patient.
 Start on first days of the week.
 Start early morning.
 Closely monitor the patient.
 Document the progress.

15. Downsizing Algorithm

16. The weaning process
 Day 1-
 Ensure the cuff, if present, is deflated.
 Insert fenestrated inner tube if appropriate.
 Place an occlusion cap over the end of the
tracheostomy tube .
 Observe for signs of respiratory distress and
 Stay with the patient for at least the first 10 min.
 The patient’s oxygen saturation and vital signs should
be recorded after 15 min.

17. The weaning process
 Continue to occlude tube for 12 hour.
 Day 2 - Occlusion cap in situ for 24 h.
 Day 3 – Decanulation.

18. Difficulty with
weaning/troubleshooting
 Respiratory insufficiency
 Airway Obstructions
 Retention of Secretions
 Blood in secretions
 Patient anxiety

19. Summary
 The ability to decannulate the patient will be affected by
various factors:
 Selection of patients for the weaning procedure.
 Reason why the tracheostomy was formed.
 Type and size of the tracheostomy tube.
 Support from the TEAM.
 A systematic, standardised approach to the weaning
procedure by all members of the multi-disciplinary team.
 Accurate and appropriate documentation of the procedure.
 Patient and family involvement.