Surgical Critical Care: Tracheostomy – Care & Weaning

Tube Exchange

• Inner Cannula:
  • Change Every 8-12 Hours
  • Done Routinely to Prevent Secretion Hardening & Obstruction
• Outer Cannula:
  • First Postoperative Exchange After 7-10 Days
    • Not Before 3-5 Days (Allow Tract Maturation)
    • Exact Timing Not Well Defined
  • Changing Every 1-2 Weeks Decreases Risk of Infection/Granulation Tissue

Allowing Airflow Around the Tube

• Methods:
  • Down-Sizing (Decreasing Size of Tracheostomy Tube)
  • Cuff Deflation
  • Change to a Cuffless Tube
  • Change to a Fenestrated Tube
• Benefits:
  • Improves Comfort
  • Facilitates Weaning on Spontaneous Breathing Trials with Shortened Weaning Time
  • Allows More Airflow Past the Tube for Improved Speech Function
• Does Not Prevent Aspiration

Passy-Muir Valve (PMV/Speaking Valve)

• Valve Placed onto the Hub of the Tracheostomy
• One-Way Valve: Allows Air Inflow but Blocks on Expiration, Redirecting Airflow into Upper Airway
• Requires Either a Fenestrated Tracheostomy or Cuffless Tube (May Deflate Cuff Instead)
• “Finger Occlusion” While Speaking Can Serve the Same Function

Tracheostomy Weaning/Decannulation

• Indication: Once No Longer Requiring Airway Protection or Mechanical Ventilation
• Weaning Approach:
  • Progressive Down-Sizing – Often Down to a Size 4 Shiley
  • Wean to a Passy-Muir Valve
  • Consider Capping/“Corking” the Tube
• NEVER:
  • Cap a Non-Fenestrated Tube without Deflating the Cuff (No Source for Inspiration)
  • Apply a PMV to a Non-Fenestrated Tube without Deflating the Cuff (No Route for Expiration)
• Decannulation Timing:
  • Institution Dependent with Wide Variations
  • Do Not Remove Before 7-10 Days (Tract Immature)
  • Consider Decannulation Once Capped for ≥ 24-48 Hours
  • Consider Once a Speaking Valve is Tolerated