Tracheostomy ready for decannulation

GENERAL APPROACH

Is this tracheostomy patient ready for decannulation?

• Reason for insertion – resolved/treated?
• Airway – cuff down, size, speaking, absence of airway obstruction
• Respiratory assessment – FiO2, cough, sputum load, swallow, infection, WOB, CXR
• Cardiovascular – can patient deal with increase O2 demand
• Neurological – power, cough, awake, alert
• Environmental – time of day, level of staff, MDT involvement

INTRODUCTION

CUBICLE

• long stay
• sputum
• stage of ventilation – mechanical ventilation, T-piece, DTI, cuff down

INFUSIONS

• sedation
• bronchodilators
• antibiotics
• feeding
• anticoagulation

VENTILATOR

• type of support (NIV, IPPV)
• level of support
• level of oxygenation (FiO2, PEEP)
• sputum burden
• cough
• WOB (ability of patient to manage increase in dead space)
• VC breath

MONITOR

• temperature
• tachycardia
• ETCO2 (COPD curve on trace indicating differing type alveolar time constants)
• arterial trace (pressure, swing, pulsus paradoxus)

EQUIPMENT

• tracheostomy (size, type, cuff down, cough, stoma, leak and occlusion test)

QUESTION SPECIFIC EXAMINATION

• hands/arms -> head -> chest -> abdo -> legs/feet -> back

-> airway (tracheostomy, type, size, stoma, bleeding, toleration of cuff down, aspiration risk) -> respiratory (detailed: cough, VC, work of breathing, expansion, active disease signs) -> cardiovascular (murmur, cardiac failure) -> abdominal (distension)

• neurological

-> conscious (including: GCS, cough, gag and other tests of bulbar function; weakness: head up, arms up, grip; reflexes)

General

• cushingoid?
• obese?
• chest wall injury or deformity?
• nutritional state? how are they fed?

Questions

• trends (e.g. fever, fluid balance)
• last sedation or paralysis?
• physiotherapy frequency
• frequency of suctioning
• nautre of tracheal aspirates
• tolerating feeds
• diarrhoea
• SLT assessment
• blue dye test (high false negative rate)

-> direct: on to back of tongue to look for aspiration -> indirect: into N/G feed to look for fistulae

RELEVANT INVESTIGATIONS

• ABG: gas exchange
• FBC: WCC
• microbiology: sputum, blood cultures
• CXR
• video fluoroscopy or fiberoptic endoscopic swallow studies

OPENING STATEMENT

• “This patient is / is NOT ready for decannulation… +/- provided that…”
• Give reasons + evidence from assessment

DISCUSSION

• See the full list of topics on the LITFL CCC Tracheostomy master page
• timing of tracheostomy
• Weaning from Ventilation Hot Case

References and Links

• Foote C, Steel L, Vidhani K, Lister B, MacPartlin M, Blackwell N. Examination Intensive Care Medicine (2nd Edition), Elsevier 2011. [Google Books Preview]