Tracheostomy discontinuance / Post Trach:
For some people, the tracheostomy tube may be removed in hospital after a few days or weeks when they are able to breathe, protect their airway, and clear pulmonary secretions unaided. For others, it may be permanent or needed for a longer time. Some hospitals and facilities will not begin to consider removal until once the trach can be capped or plugged for 48 hours or more, although this varies and is institution-dependent. (15)
If the tube is temporary, the opening in the neck will be covered with a wound dressing when it’s removed. This opening will usually begin to close in a day or so and take a few weeks to heal completely, and later there may be a small scar where the opening was.
If a patient needs a tracheostomy for the long term, he or she may be able to be discharged from the hospital with the tube in place.
Tracheostomy placement can be a short term solution to a more comfortable and secure airway, but it can also be a life sentence for a patient to require this form of assistance, becoming dependent upon the trach.
Trach usage on an ongoing basis can have many risks, including:
- Infections and complications from the procedure and wound site at the stoma or intra-tracheally
- Loss of voice over time
- Psychological distress
- Speech and language complications, especially in youth development
- Higher risk of aspiration, along with impaired swallowing capabilities
- Loss of smell and taste
- Compromised nutritional health
- Secretion issues
- Loss of physiological PEEP (positive end expiratory pressure that normally develops as you exhale through the nose) and poor oxygenation
Hospital patients will typically receive a tracheostomy during an acute episode that lasts more than a week, stabilize, then be moved to another facility for vent weaning or rehab with their trach in place. But are all options considered prior to placing the trach? The trach may ultimately be left in due to continued need to connect to the invasive vent. Trachs can be discontinued once the reason they were required is resolved. A care plan can be established with a goal of tracheal decannulation (trach removal). If the patient can be supported non-invasively, discontinuation of the trach can be considered.
Trach removal is usually a trial process in most cases. The tube has been in place usually for a significant length of time and the swallowing and airway tone maintenance reflexes and muscles of the upper airway may not be ready to resume full function and need to be conditioned with gradually increasing lengths of time with a speaking valve initially then with the trach plugged or capped.
Once fully established that the patient can tolerate the trach being capped most of the time, trach removal (decannulation) may be considered.
Decannulation is the process of removing a trach tube once the patient no longer requires it. This can be achieved when the initial indication for a tracheostomy no longer exists.
A patient is considered a candidate for decannulation once the following conditions are met.
- Patient should be independent of a ventilator for breathing assistance, and able to spontaneously breathe under their own power.
- The airway has been assessed as patent (open).
- Patient should be able to manage their oral secretions without a risk of aspiration.
- Patient’s mental status should be alert and responsive to commands
- Patient should not require frequent suctioning
- Patient should be able to cough productively.
- The patient should be able to tolerate a downsize their trach tube and breathe with the smaller sizing
- The smaller size tube should be capped or plugged (with a trach plug/ cork) for twelve hours during the day (with close monitoring by staff) without breathing difficulty or requiring of suctioning of the trach tube.
- Once the patient can tolerate the twelve hour plug, trach should be plugged for twenty four hours (under monitoring for difficulty breathing or suction requirement).
Once the patient is able to complete the required steps, decannulation can be attempted. This is typically done in a professional setting with qualified medical personnel to assist.
In cases where there is concern for decannulation failure or the patient marginally meets criteria, a trach button may be placed as an interim step. The button holds the stoma open and allows emergency access to the trachea for suctioning if needed and is usually a very short term bridge to full decannulation.
When coughing or speaking after decannulation, the patient should cover the dressed wound with their finger or hand with slight pressure, so that air does not leak. The less air the leaks the more quickly the stoma will usually close. The gauze and the tape should be changed at least once a day (or more often if required) until the trach stoma heals itself closed. This may typically take a few days to a few weeks, depending upon the patient. In a minority of patients (<10 %), the opening wound has to be surgically closed.
Assistance with Decannulation
Many patients have found assistance with decannulation by using Biphasic Cuirass Ventilation (a non-invasive ventilator which uses positive and negative pressures applied to the torso) to help manage secretions, strengthen respiratory muscles, and decrease dependency on mechanical ventilation or positive airway pressure (PAP) devices.