Tracheostomy Weaning

Introduction

A tracheostomy is a surgical opening in the anterior wall of the trachea to facilitate breathing, this can be made either surgically or by a percutaneous method. The tracheostomy tube enables airflow to enter the trachea and lungs directly, thus bypassing the pharynx and larynx. [1][2]

The majority of tracheostomies are inserted as a temporary respiratory support measure. The removal process is known as decannulation. This is usually carried out on the critical care unit; however, weaning programmes take place on the ward in many hospitals. It is vital that the staff involved are competent and have an understanding of the weaning process, they may be required to undertake specific training in their hospital. [1]

What is Tracheostomy Weaning?

The aim of weaning is to gradually return airflow to the upper airway and restore normal physiological functions.[3] The process of weaning involves the manipulation of the tracheostomy tube which may increase the workload of breathing.[4]

Criteria to Commence Weaning

The patient will be assessed by the MDT using the below criteria and, if suitable, a weaning programme will begin.

  • Indicators for the tracheostomy have been resolved
  • Can the patient protect their own airway?
  • Oxygen saturation of >90% with Oxygen therapy less than 40%
  • The patient is haemodynamically stable
  • The patient is cardiovascularly stable
  • 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
  • Can they cough and clear secretions independently?
  • Is the patient able to swallow? Speech and language therapist should perform a swallow assessment
  • There are no signs of deteriorating bronchopulmonary infection or excessive pulmonary secretions
  • Are they infection free?
  • Do they have any known respiratory disease that may require consideration when agreeing a weaning programme?
  • Do they have any forthcoming, planned procedures requiring an anaesthetic in the next 7-10 days?
  • Is the care environment suitable to commence a tracheostomy weaning programme?[1][2][5]

Contraindications to Weaning

  • Unable to tolerate cuff down/deflation
  • Airway obstruction
  • Medically unstable
  • Severe anxiety about removal of the tracheostomy
  • Cognitive impairment
  • Severe narrowing of the larynx or trachea
  • End-stage pulmonary disease
  • Risk of severe aspiration/recurrent aspiration pneumonia [5]

Stages of Weaning

Throughout the weaning process the patient needs to be monitored for respiratory distress.

  1. Cuff deflation
    • This removes the protection from aspiration
    • The patient is required to manage their own secretions and swallowing
  2. Gloved finger occlusion
    • Established if the patient can achieve adequate airflow around the tracheostomy tube up into the upper airways (mouth and/or nose)
    • Stridor or minimal/absent breath sounds above the level of the tracheostomy tube indicates reduced airflow around the tube.
  3. One-way speaking valve
    • Ensuring the cuff is deflated a one way speaking valve is placed over the opening of the tracheostomy tube allowing inspiration through the valve, but closes on expiration, allowing air to flow over the vocal cords
    • The length of time the speaking valve is tolerated will vary from patient to patient and can only be gauged from observing the patient’s work of breathing.
    • Building up tolerance of using the speaking valve aiming for more than four hours in one block.
    • It is not advisable to leave on overnight as secretions or sleeping position may occlude the one way valve.
  4. Decannulation cap
    • The cuff is always deflated.
    • This is the final stage of the weaning process where the tracheostomy tube is blocked off, resulting in the use of the mouth and nose for inspiration and expiration.
    • The aim is to build up to four hours with the decannulation cap on.
  5. Decannulation (removal of tracheostomy tube)
    • Can tolerate the cuff down for 24 hours
    • Can tolerate the speaking valve for 12 hours or the decannulation cap for 4 hours.
    • MDT in agreement for decannulation[5]

Resources

St George’s University Hospitals NHS Foundation: Trust Tracheostomy guidelines: https://www.stgeorges.nhs.uk/gps-and-clinicians/clinical-resources/tracheostomy-guidelines/weaning/

References

  1. 1.0 1.1 1.2 Everitt E. Tracheostomy 2: Managing the weaning of a temporary tracheostomy. Nursing Times. 2016; 112:20:17-19. Available from: https://www.nursingtimes.net/clinical-archive/respiratory-clinical-archive/tracheostomy-2-managing-the-weaning-of-a-temporary-tracheostomy-16-05-2016/ (Accessed 12 Apr 2020)
  2. 2.0 2.1 NHS Greater Glasgow and Clyde. What is a Tracheostomy? Available from: https://www.nhsggc.org.uk/about-us/professional-support-sites/shock-team/guidelines-for-care-of-patients-with-a-tracheostomy-tube/what-is-a-tracheostomy/ (accessed 09 April 2020).
  3. NHS Greater Glasgow and Clyde. Weaning from tracheostomy. Available from: https://www.nhsggc.org.uk/about-us/professional-support-sites/shock-team/guidelines-for-care-of-patients-with-a-tracheostomy-tube/weaning-from-tracheostomy/ (accessed 09 April 2020).
  4. Rumbak M J, Graves A, Scott M P, Sporn, G K, Walsh F W, Anderson W, McDowell; Goldman, A.:  Tracheostomy tube occlusion protocol predicts significant tracheal obstruction to air flow in patients requiring prolonged mechanical ventilation. Critical Care Medicine. 1997; 25:3: 413-417. Available at https://www.ncbi.nlm.nih.gov/pubmed/9118655 (accessed 11 Apr 2020).
  5. 5.0 5.1 5.2 St George’s Healthcare NHS Trust, Guidelines for the Care of Patients with Tracheostomy Tubes. Available from: https://www.rcplondon.ac.uk/file/2021/download (accessed 12 Apr 2020)