Tracheostomy Weaning

The pace of progression will vary depending on the the patient, but a fairly standard path involves:

Depending on respiratory mechanics and individual preferences, different patients may fare better with CPAP, HFTM, or speaking valve.

• Transition from controlled ventilation to pressure support ventilation
• Gradually ↓ pressure support and PEEP
  • ↑ RR is an earlier sign of failure than ↓ V_T
  • Avoid over-tiring a patient, sustained steady progress is preferable to a rapid wean followed by exhaustion and stagnation
• Once comfortable on pressure support, introduce trials of:
  • CPAP
    Generally 5-10cmH₂O, without pressure support.
  • High-flow trache mask
    Humidified oxygen.
  • Speaking valve
    Requires cuff down, and therefore has associated aspiration risk.
• Progressively ↑ duration of trials and ↓ of support until the patient is consistently stable and comfortable on a non-CPAP mode of support
• Consider decannulation once above preconditions met

Considerations for cuff down periods:

• ↑ Aspiration risk whilst cuff is down
  Positive pressure ventilation partially mitigates this by providing continual flow of air out via the larynx
• Aspirate secretions above the cuff prior to deflation
• Suction via the tracheostomy during deflation to catch dislodged cuff secretions

Failure to Wean

If progress is not being made, consider:

• Replacing with a fenestrated tracheostomy
  • ↑ Respiratory work
  • Permits vocalisation with cuff up
• Downsize tracheostomy
  ↓ Size by 1 (e.g. 8.0 to 7.0) to ↓ degree of native airway obstruction produced by tracheostomy.
  • ↑ Ease of cuff-down periods
  • ↑ Resistance of breathing via tracheostomy
  • Cuff may be non-occlusive if under-sized, limiting positive pressure ventilation
• Refer to ENT team
  Other airway pathology that is impeding wean, e.g.
  • Paradoxical vocal cord movement
  • Granulation tissue
  • Stenosis

Decannulation

A tracheostomy can be removed safely if a patient:

Effects of decannulation

Benefits	Drawbacks
↑ Secretion clearance	↑ Work of Breathing
↓ Secretion burden	↑ Anatomical dead space
Facilitate speech
Improved swallowing
Better humidification
Pursed lip breathing - provides auto-PEEP
↓ Nursing/carer burden
↓ Tracheostomy risks (bleeding, infection)

• Has a patent upper airway
  • Indication for tracheostomy
  • Known difficulties with airway management
• Has a protected upper airway
  • Adequate conscious state
  • Airway reflexes intact
    Cough and gag present.
  • Low gastric aspirates
    Avoid commencing weaning in patients with gastric aspirates >250mL due to the risk of aspiration.
• Can clear their secretion load
  Cough adequate for the volume of secretions. Consider met if:
  • <4 suction episodes in previous 24 hours
  • No suppurative lung disease
  • Adequate analgesia and strength
• Does not require mechanical ventilation
  • >24 hours free from assisted ventilation
  • Minimal additional oxygenation
    
  • No upcoming requirement for mechanical ventilation
  • Adequate strength

Approach

If preconditions are met:

• Perform a cuff-down trial
  Deflate the tracheostomy cuff.
• Ensure 48-72 hours without need for mechanical ventilation
• Remove tracheostomy tube and apply occlusive dressing
  It should heal over in 7-10 days. If there is late failure, an existing tract can be reopened with serial dilators, or a smaller tracheostomy tube can be placed.

One traditional approach to weaning was a capping trial, which:

• Involves occluding (capping) the tracheostomy
• Evaluates the patients ability to breathe via the native airway with with an upper airway obstruction provided by the blocked trache
• The patient should be 1:1 monitored during the first 15 minutes of capping
• Duration of capping depends on where the tracheostomy wean is being conducted
  In a ward/lower-skilled environment, the cap should be tolerated for least 24 hours prior to removal. This can be expedited in an ICU setting.
• Is probably an unnecessary burden in the overwhelming majority of patients

Failure to Decannulate

If weaning is unsuccessful, consider:

• Long-term tracheostomy
• Vocal cord surgery
  For paralysis or dysfunction.
• NIV with capped tracheostomy
• Airway stenting
  For tracheomalacia.

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References

1. De Leyn, Paul, Lieven Bedert, Marion Delcroix, Pieter Depuydt, Geert Lauwers, Youri Sokolov, Alain Van Meerhaeghe, Paul Van Schil, and Belgian Association of Pneumology and Belgian Association of Cardiothoracic Surgery. “Tracheotomy: Clinical Review and Guidelines.” European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-Thoracic Surgery 32, no. 3 (September 2007): 412–21.
2. O’Connor, Heidi H., and Alexander C. White. Tracheostomy Decannulation. Respiratory Care 55, no. 8 (August 1, 2010): 1076–81.