"The anger of health and social care workers is right"

Removal of the temporary tracheostomy can cause anxiety for the patient. Weaning and extubation require careful planning and the support of a multi-disciplinary team

Everitt E (2016) Tracheotomy 2: Manage the weaning of temporary tracheotomy. Nursing time; 112:20, 17-19.

The second article in this four-part series on tracheostomy care describes the patient's disengagement from the tracheostomy, catheter extubation, and postoperative care. Discussed the role of a multidisciplinary team and the importance of psychological care for patients who may be concerned about the ability to breathe without a tube.

Author: Erica Everitt is a tracheotomy specialist at Norfolk and Norwich University Hospitals.

Most tracheostomy procedures are inserted as temporary respiratory support measures. Many patients will remove the catheter in the intensive care unit, a process called extubation; however, weaning planning can be done at the ward level. It is essential that employees have the ability and understanding of the weaning process, risks and weaning accessories (such as speaking valves and extubation caps/plugs).

The tracheostomy multidisciplinary team (MDT) can manage the weaning process of the temporary tracheostomy, ensuring that the plan is safe and easy to manage for patients and ward staff.

Short-term respiratory support requires a temporary tracheotomy, which can be performed surgically or percutaneously. When possible, it is best to meet with the patient before surgery to discuss the insertion of the tracheostomy cannula, the care needs of the tracheostomy cannula, and the weaning/extubation process. Temporary tracheotomy can be performed selectively as part of a planned surgery, for example, after some maxillofacial and ENT surgery. They are also used to protect the airways of patients who cannot swallow and clear their own secretions and who are at risk of aspiration; for example, patients with stroke or brain injury are particularly at risk.

Patients with tracheostomy are more susceptible to respiratory infections due to the inability to filter air through the nose-especially when they use cuffed tracheostomy intubation in situ-the temporary intubation should be regularly checked and removed once it is used It is safe to do it.

The purpose of the weaning plan is to gradually return the airflow to the upper respiratory tract and restore normal physiological functions (National Tracheotomy Safety Project, 2013). The patient needs to stop the tracheostomy, but it is difficult to tell when to start the process (NTSP, 2013). The weaning process varies from person to person and can take days, weeks, or sometimes months to complete. Care providers must agree locally on tracheostomy weaning and extubation guidelines and diagrams, as well as a multidisciplinary approach to provide ongoing support for patients and staff.

When the indications for temporary tracheostomy and intubation are resolved, MDT will evaluate the patient and, if appropriate, will start the weaning plan. The evaluation criteria are listed in Box 1. All actions and differences should be clearly recorded on the tracheostomy weaning chart, which should provide clear guidance for the weaning plan. If possible, informed consent should always be obtained before starting any aspect of the tracheostomy weaning plan.

If the patient’s airway has known difficulties, such as stenosis or vocal cord paralysis, or previous extubation problems, it is recommended that the upper airway be examined endoscopy before starting the weaning plan; once the plan is started, the patient should be closely monitored. Box 2 outlines the contraindications for weaning.

Box 1. Evaluation criteria for weaning

Box 2. Remove contraindications for temporary tracheostomy

Source: St George's Healthcare Trust, 2012

Patients using large tubes, such as 9mm OD (outer diameter) cuffs, need to be downgraded to the next size (8.5/8mm OD cuffs, depending on the manufacturer), and then repeat as needed until it reaches 7.5mm male and female outer diameters The outer diameter is 6.5 mm. The weaning aid used to seal the end of the tube is only suitable for these smaller sizes. The small tube forms a space between the tube and the trachea, allowing air to bypass the tube and pass through the upper respiratory tract when the weaning aid is in place (NTSP, 2013).

Once the appropriate size of the tracheostomy tube is in place, the test cuff can be deflated. It should be noted that after a cuffed tracheostomy tube is placed in place for a period of time, reintroducing airflow into the upper airway when the cuff is deflated can cause irritation, persistent coughing and patient discomfort (NTSP, 2013) . The initial time to deflate the cuff depends on the patient's response.

The synchronized cuff deflation technique should be used every time the cuff is deflated, and two qualified practitioners are required. When using a 10 ml syringe to deflate the cuff, suction through the tracheostomy tube to remove any secretions that enter the trachea from above the cuff. If the patient’s tracheostomy tube has a subglottic port, it should also be aspirated to remove secretions above the cuff before the cuff is deflated. When using a standard cuffed tube, oral suction should be performed before the cuff is deflated (for more information on tube types, see Part 1, Everitt, 2016). Continuous monitoring of oxygen saturation levels is essential, as these levels may drop during the weaning process. The oxygen saturation level should be maintained at the target level determined by MDT. If necessary, oxygen should be given at a prescribed rate.

When the patient can tolerate the deflation of the cuff for 24 hours, the tracheostomy tube may be replaced with a tracheostomy tube without a cuff to allow more air to bypass the tube and enter the larynx. The end of the tracheostomy cannula can then be completely sealed with offline aids such as extubation cap/plug (Figure 1, attachment); if the patient can cope with the cap/plug, the tracheostomy can be removed with the consent of MDT Intubation.

If you decide to continue using the cuffed tube, be sure to check that the cuff is fully deflated before using the cap/plug or other device (such as the speaking valve), otherwise the patient will not be able to breathe and this may result in death.

The inflated cuffed tracheostomy tube will prevent air from entering the larynx and passing through the vocal cords; as a result, the patient cannot speak. Patients can block the tracheostomy tube with their fingers to speak during the deflation of the cuff; this can also help MDT decide whether they can start a weaning plan. If the patient is struggling with a finger bite, they are not ready to start using the speaking valve and may need to recheck their upper airway before deflating the test cuff.

The use of auxiliary equipment, such as a speaking valve, can help the patient to speak (Figure 2, attached). These valves are "one-way" valves that allow air to be inhaled through the tracheostomy tube; when exhaling outward, the valve is closed and the air is exhaled through the upper respiratory tract. Due to the need to force the exhaled air through the trachea, the use of the speaking valve will cause the patient to fatigue easily. This should take into account the gradual increase in the use of the speaking valve in the weaning plan. If there is a decrease in oxygen saturation, respiratory distress, fatigue, and the patient requires valve removal, the speaking valve should be removed (St George's Healthcare Trust, 2012). For more information on the talking valve, see section 3.

When the initial cuff is deflated or an attempt is made to extubate the tube, the weaning plan may fail. Patients may continue to cough after the cuff is deflated, and their oxygen saturation levels will drop and become painful. If this happens, the weaning plan should be stopped immediately and an MDT reassessment should be carried out. This may include repeated endoscopic assessments of the upper airway and further respiratory assessments.

Extubation should only be performed when the patient successfully completes the weaning procedure and MDT confirms that it is safe to remove the tracheostomy tube. Box 3 outlines the key points of de-tubing.

Box 3. Key points of shelling

After the tracheostomy tube is taken out, the stoma site should be cleaned with 0.9% sodium chloride and dried, and a closed dressing should be used in accordance with local policies. If sutures are used to hold the tube in place, it should be removed. The dressing should be changed daily, but may need to be re-used frequently in the initial stage, because the pressure of the dressing exhaled from the stoma opening may cause the dressing to become loose. Observe the area for signs of infection.

The stoma may take 2 to 6 weeks to heal, but occasionally a small tracheal skin fistula may appear after a few weeks, which may require surgical closure. Once the area is completely healed, the patient will be left with a small scar.

When the patient speaks or coughs, the dressing needs to be pressed directly above the stoma to completely occlude the stoma, reduce the exhaled air through the stoma, make the patient’s voice and cough louder, and help the stoma heal.

Reaching the weaning stage is an important stage in the rehabilitation process because for many patients and relatives, the restriction of tracheostomy intubation replaces any other medical problems or diagnoses they encounter. A successful weaning plan means removing social and communication restrictions on patients and their relatives. Griffiths et al. (2005) found that good management of tracheostomy patients in hospitals and communities has a major impact on the quality of life.

Many patients with tracheostomy and intubation know that their body image has changed; this can lead to a sense of social isolation and seclusion. The removal of the tracheostomy tube restored physical and psychological normality. However, after starting the weaning program, patients may become extremely anxious and worried, and they will not be able to breathe without intubation. This is a special problem for patients who have failed extubation attempts. Therefore, it is important for the practitioner to discuss each step of the offline plan and any fears or worries they have with the patient. The MDT meeting helps to update the family and patients of the plan and allows them to ask questions or raise concerns. It is the shared responsibility of all members of MDT to establish a trusting relationship with patients and their relatives/caregivers.

Hashmi et al. (2010) found that preoperative psychological assessment can be used to improve the self-image of patients undergoing elective tracheotomy. The decline in postoperative mental health is attributed to the deterioration of self-esteem. The study also highlighted that patients who underwent an unplanned tracheostomy insertion experienced mental and physical decline after the operation.

A multidisciplinary approach to tracheotomy will ensure that safe and appropriate plans are agreed and put into practice. MDT also provides a routine review of the patient's progress, and changes to the plan as needed. Nurses involved in the weaning and extubation process need to have the appropriate skills to care for patients undergoing tracheotomy and respond to their concerns and changes in clinical conditions. Psychological evaluation should be used as a benchmark in the preoperative evaluation of elective courses.

Log in or register for a new account to join the discussion.

The Nursing Times hosted a free webinar to discuss the role of technology in improving wound assessment and management.

Cornwall Cooperative NHS Foundation Trust

Jersey Department of Health and Social Services