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

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]

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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