Tracheostomy Management and Weaning

Authors: Mary Kayata-Edmond, B Parker, N Carter, E Lineen, J Krocker. – 5/9/24
Approval: Namias, Lineen – 5/9/24

Purpose

  • To standardize and clarify safe management of long-term tracheostomy care.
  • These are general guidelines and exact management, and timing should be adjusted to specific patient circumstances.

Speech valve placement

  • Order written in comments “Speech therapy evaluation and treat.”
  • Criteria:
    • Trach 8 allowed in ICU only
    • Trach 6 Shiley or less if out of ICU
    • Demonstrates effort to communicate.
    • Presents with moderate secretions that are able to be mobilized.
    • Pt off ventilator > 24 hours,
    • Pt off ventilator > 4 hours/day for 3 consecutive days
    • Patient on T-piece trials for 24 hours during periods of T-piece with manageable secretions, PCO2 less then 55, adequate cough

Speech valve to be placed per Jackson Passy Muir Valve placement policy 400.101 which includes mandatory cuff deflation when speech valve is applied.

Tracheostomy change from #8 cuffed to #6 cuffless.

  • Minimum 14 days post original trach placement after discussion with attending
  • Required prior to transfer to med-surg.

Decannulation readiness

  • Hemodynamically stable
  • Tolerating trach collar > 3 days continuously
  • Minimal need for supplemental oxygen
  • Strong consistent cough. Able to raise secretions into mouth with no deep suctioning.
  • No planned procedures requiring anesthesia within the next 7 days.
  • Must tolerate brief digital occlusion with:
    • No respiratory distress, hypoxia, stridor, tachypnea
    • Normal O2 saturation
    • Ability to phonate

*** ENT consult warranted to assess airway patency if develops stridor and/or aphonia (not explained by reduced breath support) noted during digital capping trial.

References

  1. Choate K, Barbetti J, Currey J. Tracheostomy decannulation failure rate following critical illness: a prospective descriptive study. Aust Crit Care. 2009 Feb;22(1):8-15. doi: 10.1016/j.aucc.2008.10.002. Epub 2008 Dec 4. PMID: 19062302.
  2. Bishnoi T, Sahu PK, Arjun AP. Evaluation of Factors Determining Tracheostomy Decannulation Failure Rate in Adults: An Indian Perspective Descriptive Study. Indian J Otolaryngol Head Neck Surg. 2022 Dec;74(Suppl 3):4849-4854. doi: 10.1007/s12070-020-01982-y. Epub 2020 Jul 24. PMID: 32837943; PMCID: PMC7380661.

Purpose

  • To standardize and clarify safe management of long-term tracheostomy care.
  • These are general guidelines and exact management, and timing should be adjusted to specific patient circumstances.

Speech valve placement

  • Order written in comments “Speech therapy evaluation and treat.”
  • Criteria:
    • Trach 8 allowed in ICU only
    • Trach 6 Shiley or less if out of ICU
    • Demonstrates effort to communicate.
    • Presents with moderate secretions that are able to be mobilized.
    • Pt off ventilator > 24 hours,
    • Pt off ventilator > 4 hours/day for 3 consecutive days
    • Patient on T-piece trials for 24 hours during periods of T-piece with manageable secretions, PCO2 less then 55, adequate cough

Speech valve to be placed per Jackson Passy Muir Valve placement policy 400.101 which includes mandatory cuff deflation when speech valve is applied.

Tracheostomy change from #8 cuffed to #6 cuffless.

  • Minimum 14 days post original trach placement after discussion with attending
  • Required prior to transfer to med-surg.

Decannulation readiness

  • Hemodynamically stable
  • Tolerating trach collar > 3 days continuously
  • Minimal need for supplemental oxygen
  • Strong consistent cough. Able to raise secretions into mouth with no deep suctioning.
  • No planned procedures requiring anesthesia within the next 7 days.
  • Must tolerate brief digital occlusion with:
    • No respiratory distress, hypoxia, stridor, tachypnea
    • Normal O2 saturation
    • Ability to phonate

*** ENT consult warranted to assess airway patency if develops stridor and/or aphonia (not explained by reduced breath support) noted during digital capping trial.

References

  1. Choate K, Barbetti J, Currey J. Tracheostomy decannulation failure rate following critical illness: a prospective descriptive study. Aust Crit Care. 2009 Feb;22(1):8-15. doi: 10.1016/j.aucc.2008.10.002. Epub 2008 Dec 4. PMID: 19062302.
  2. Bishnoi T, Sahu PK, Arjun AP. Evaluation of Factors Determining Tracheostomy Decannulation Failure Rate in Adults: An Indian Perspective Descriptive Study. Indian J Otolaryngol Head Neck Surg. 2022 Dec;74(Suppl 3):4849-4854. doi: 10.1007/s12070-020-01982-y. Epub 2020 Jul 24. PMID: 32837943; PMCID: PMC7380661.