Todd Fraser on 16-06-2013
One of the great areas of "black magic" in ICU surrounds the best method for removing a tracheostomy.
While a decision on whether or not the patient requires ongoing ventilation is relatively easy to answer, questions often linger as to whether or not the patient has sufficient airway control to prevent aspiration following decannulation. The problem is, how do they prove it, particularly when they have a trachy in, which by its very nature, completely mucks up this important protective mechanism?
Cuff up? Cuff down? How long, and how often? Fenestrated tube? Down sized tube? Speaking valve trials? Video fluoroscopy? Swallow assessments? Blue dye test?
Who better to ask than a speach pathologist...
But for some clinicians, the mere mention of our swallow-obsessed friends is enough to make veins bulge from their neck. "Just pull the damn thing out..." is a common refrain.
So how do you do this where you work?
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Gemma from Canada wrote 06-18-2013 08:48:14 am
Well, I must say I just pull it out when the patient doesn't need ventilation any more.
Lets say a patient has a cerebral event and is recovering but has poor airway reflexes and hasn't required intubation. I wouldn't put a trachy in, I'd just keep them not eating and put in a feeding tube.
So why would I keep a trachy in someone who's improving and has the same issues? Just pull it out, let their airway recover, if you absolutely must then get a swallow assessment, then let them go for it.
Mucking around with cuff deflations and all that rubbish just leads to prolonged cannulation times and potential for further complications.
Gordon West from United Kingdom wrote 06-18-2013 01:18:49 pm
While I understand Gemma's points, I think that there is a role for cuff deflations, given one of the more common reasons for reinsertion / reventilation is inadequate handling of secretions.
Letting the cuff down appears to improve cord function and airway reflexes by exposing the larynx to airflow before decannulation. This might play a role in improving airway reflexes and preventing silent aspiration.
As for downsizing the tube, I'll do this if the patient struggles with the cuff down and the trachy occluded, but otherwise respiratory function is okay. Speaking valves - useful during deflations to force the air up.
Deepak bhonagiri from Sydney wrote 06-19-2013 11:53:52 am
I tend to review the reasons the trache was put in in the first place before deciding how to pull it out. If it was put in for respiratory failure which is no longer an issue and my patient is awake, coughing etc, I'd just pull the trache out when its no longer needed based on the presumption that the airway reflexes and swallow were not primarily affected. In the neuro subgroup, those with midbrain and brainstem involvement need specific assessment such as cuff down and swallow assessments before pulling the trache out.
Its always a clinical and clinician's decision and every patient is different.
Todd Fraser from Australia wrote 06-22-2013 12:32:20 pm
All good comments.
I'm curious about the concept of "airway exercise" though. There seems to be a tendency to let the cuff down for short periods with "rest" in between. This is supposed to toughen the larynx up and get it ready for decannulation. However, I've struggled to find any evidence to support this.
Is there any basis for this type of practice? Is there a protocol available for this? Or does everyone just make it up as they go along?