Tracheostomy Care and Long-Term Ventilator Weaning

David Ray Velez, MD

Tube Exchange

Inner Cannula

Allows Easy Replacement of the Cannula if it Becomes Obstructed or Filled with Secretions
Change Every 12-24 Hours
Done Routinely to Prevent Secretion Hardening and Obstruction

Outer Cannula

First Postoperative Exchange Done After 7-14 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
Methods:
- The First Exchange is Generally Done Over a Blue Bougie
- Subsequent Exchanges, Once the Tract is Well Defined, are Done by Simple Removal and Replacement with an Obturator

Tracheostomy Obturator (Top), Inner Cannula (Middle), and Outer Cannula (Bottom)

General Approach

Step 1. Still Requiring Airway Protection and Mechanical Ventilation
Step 2. Transition to T-Piece or Trach Collar Once No Longer Requiring Mechanical Ventilation
Step 3. Allow Airflow Around the Tube Once No Longer Requiring Airway Protection
- May Consider Passy-Muir Valve or Capping Once Appropriate
Step 4. Decannulation

T-Piece and Trach Collar

These Weaning Methods Only Provide Supplemental Oxygenation Once the Patient is No Longer Requiring Mechanical Ventilation
T-Piece
- Tubing Attached to the End of the Tracheostomy in a “T” Fashion to Allow Blow-By Oxygen
- Allows Attachment of In-Line Suction for Better Secretion Clearance than a Trach Collar
Trach Collar
- An Oxygen Mask is Placed Over the End of Tracheostomy to Provide Supplemental Oxygen
- More Portable Than T-Piece and Many Consider It to Have a Lower Risk of Accidental Decannulation

Allowing Airflow Around the Tube

Indicated Once No Longer Requiring Airway Protection
Methods:
- Down-Sizing (Decreasing the Size of the Tracheostomy Tube)
  - Often Down to a Size 4.0 Shiley
- 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

Tracheostomy Cuff: Cuffed (Left), Uncuffed (Right)

Tracheostomy Fenestration: Fenestrated (Left), Non-Fenestrated (Right)

Passy-Muir Valve (PMV/Speaking Valve)

A One-Way Valve Placed onto the Hub of the Tracheostomy
Allows Air Inflow but Blocks Expiration
- Redirects Airflow into the Upper Airway on Expiration
- Allows Air Passage Through the Vocal Cords for Speech
Requires Either a Fenestrated Tracheostomy or Cuffless Tube (May Deflate the Cuff Instead)
*NEVER Apply a PMV to a Non-Fenestrated Tube without Deflating the Cuff (No Route for Expiration)
“Finger Occlusion” While Speaking Can Serve the Same Function

Passy-Muir Valve

Capping/“Corking”

A Cap Placed onto the Hub of the Tracheostomy
Completely Blocks Airflow Through the Tube
All Airflow in and Out Must Be Through the Mouth and Around the Tube
Requires Either a Fenestrated Tracheostomy or Cuffless Tube (May Deflate the Cuff Instead)
*NEVER Cap a Non-Fenestrated Tube without Deflating the Cuff (No Source for Inspiration)
Generally Consider a Final Measure in the Weaning Process Before Decannulation

Decannulation Timing