see also: Tracheotomy, Tracheostomy & Modifications

and: Tracheotomy - Tracheostomy; Pediatric Tracheostomy Decannulation

Last update: 2017

Definition of decannulation: permanent removal of tracheotomy tube with intent for tracheostomy site to close

PURPOSE

1. To safely remove a tracheostomy tube.
2. Personal note (HTH)
   1. I routinely visualize the airway (oropharyngea/hypopharyngea/laryngeal and sometimes tracheal airway) before decanulating a patient of their tracheotomy
   2. A trial of successful 'corking' or occluding a tracheotomy tube for a specified period of time to ensure safety of removal may be helpful in making the decision to remove the tracheotomy tube, but does not supplant the value in critically assessing the airway visually before removal.

EQUIPMENT

1. Backup equipment to re-establish and airway
   1. Nasal speculum (to place into the tracheostome if necessary to maintain opening
   2. Access to replacement tubes (trach or endotracheal tube) if needed
   3. Decannulation cannula (Shiley fenestrated and cuffless tubes)
   4. 10 cc syringe for tracheostomy cuff deflation
2. Jackson metal tubes:
   1. Half cork (same size as tube)
   2. Full cork (same size as tube)
3. Sterile dressing and tape

PROCEDURE

1. Wash hands thoroughly and don gloves.
2. Explain the procedure to the patient.
3. Always deflate the cuff before the decannulation (see Tracheostomy tube cuff procedure).
4. Assess the patient carefully for signs of respiratory difficulty and continue to observe at frequent intervals. The frequency of monitoring is dictated according to patient tolerance. Remove the tracheostomy tube cork/decannulation cannula with signs of respiratory difficulty and report to the physician.
5. Instruct the patient regarding the location of the tracheostomy tube cork/decannulation cannula and demonstrate how to remove it. A mirror may be helpful to assist in this procedure.
6. When corking the Jackson metal tube, continue to clean the inner cannula (see Tracheostomy site care: tie/dressing change and inner cannula care procedure).
7. If the patient tolerates the full tracheostomy tube cork/decannulation cannula for 1 to 2 days, the entire tube is removed as ordered. Position the patient with the neck flexed, apply an occlusive sterile dressing, and tape securely over the tracheostoma to promote healing. Encourage the patient to cover the tracheostomal dressing when coughing and talking to facilitate site closure.
8. Stoma dressing should be changed as often as necessary to maintain a clean, dry dressing. Cleanse the skin as needed and observe the wound for drainage, infection, and degree of closure.
9. Wash hands thoroughly.

PRECAUTIONS, CONSIDERATIONS, AND OBSERVATIONS

1. The physician may order oximetry during the decannulation process to evaluate the patient's respiratory status.
2. Never cork a tracheostomy tube while the tracheostomy cuff is inflated.
3. The size of the tracheostomy cork should correspond with the size of the Jackson metal tracheostomy tube. Tracheostomy corks should only be used with a Jackson metal tracheostomy tube.
4. If a tracheostomy tube cork is used during the decannulation procedure, secure the strings of the tracheostomy tube cork to the tracheostomy ties.
5. For the patients with a Jackson metal tracheostomy tube, the physician may begin the decannulation procedure with a half cork. If the patient shows no respiratory distress, the physician may order the tracheostomy tube to be full corked.
6. Prior to corking a pediatric tracheostomy tube, it is imperative that the physician decrease the size of the tracheostomy tube to allow air passage around the tracheostomy tube to the oronasal airway.
7. A variation in reestablishing a nasopharyngeal/oropharyngeal airway consists of decreasing the size of the tracheostomy tube daily or every other day until the physician determines that the patient can tolerate complete removal of the tube.
8. Following decannulation, a tracheostomy tube of the appropriate size should be readily available for reinsertion if the patient develops respiratory distress.