Spinal unit protocol for progression to uncuffed tracheostomy and subsequent decannulation.

This process is explained to improve understanding of the rationale. Each patient should be individually assessed and their treatment plan devised with the consultant and the respiratory clinical specialist physiotherapist.

Action / Rationale
1. First step is often to down size the cuffed tracheostomy tube one or half a size smaller. / To enable the patient to have their cuff deflated in order to be able to talk.
Decreasing size in very large steps could cause problems with increased airway resistance and increase work of breathing.
2. The cuff is deflated to allow speech.
This is done for gradually increasing periods of time over several days. / This enhances communication and psychological well being.
Times are gradually increased to avoid problems with potential deterioration in lung compliance, and drying of airways due to lessening of humidification with deflated cuff.
3. When the patient is able to tolerate having their tracheostomy cuff deflated for 24 hours or more then the tracheostomy tube is changed for an uncuffed tube. / To ensure the patient is ready to have an uncuffed tube.
4. Once the patient is able to breathe without added oxygen they can have a ‘swedish nose’ or HME fitted over their tracheostomy for increasing periods of time. / An HME allows the patient to breathe through their tracheostomy and their nose and mouth, if the cuff is deflated. This does not increase their work of breathing.
5. A speaking valve or ‘Orator’ valve is used for gradually increasing periods of time with deflated cuff only.
Humidification using a tracheostomy mask is sometimes needed. / These valves direct all exhaled air up around the tube and out of the patients nose and mouth enabling them to vocalise more easily.
The cuff must be deflated to use a speaking valve otherwise the patient will not be able to breathe at all.
This can lead to drying out of the airways as the patient is inhaling air from the room directly through their tracheostomy bypassing their upper respiratory tract.
6. . The speaking valve may cause respiratory distress so the patient should be closely monitored for signs of respiratory distress. / If the cuff is not fully deflated or there is insufficient space around the tube for the patient to breathe then they will become distressed quickly. The speaking valve should be immediately removed.
7. When the patient is able to tolerate the speaking valve with good voice for several hours per day they are progressed onto the red bung or ‘decannulation cap’ over their tracheostomy.
8. Red bung use is gradually progressed over several days until the patient is able to breathe comfortably with:
¨  no deterioration in vital capacity
¨  not requiring tracheal suctioning to clear secretions. / It should be gradually progressed because the patient has to work harder to breathe around the tube.
They must have an effective assisted cough and be able to clear secretions to their mouth to expectorate. If they can’t then the tube may need to be reinserted as an emergency.
9. The red bung is the most difficult stage in breathing progression and the patient should be closely monitored for signs of respiratory distress. / If respiratory distress occurs the red bung should be immediately removed.
A smaller size tracheostomy tube may need to be inserted to use the red bung.
10. When the patient has had the red bung on their tracheostomy for a minimum of 24 hours with no problems they can have their tracheostomy removed. / 24 hours is needed to fully assess the patient prior to removal of the tube.