Tracheostomy Management: From Intensive Care to Community

Tracheostomies are widely performed for a variety of reasons in the ICU. This article outlines the process of transitioning from critical care to the community with proactive management by a multidisciplinary team to wean patients from the ventilator and from the tracheostomy.

Introduction

Approximately 10-20% of patients in the intensive care unit (ICU) will have a tracheostomy (McGrath et al. 2020). This procedure, which is performed percutaneously or via a surgical insertion of the tracheostomy tube anteriorly into the trachea, is commonly done as an elective procedure. However, in situations such as impending airway obstruction, tracheostomy insertion is performed emergently. General indications for a tracheostomy include prolonged mechanical ventilation, need for facilitation of pulmonary toilet, airway protection, relief of upper airway obstruction and as part of a surgical procedure. The most common indication is to facilitate weaning from mechanical ventilation in respiratory failure.

Liberation from the ventilator is classified into three types: simple, difficult and prolonged (Boles et al. 2007). Simple weaning occurs in a majority of ICU patients on invasive mechanical ventilation, and ventilation is discontinued after the first successful spontaneous breathing trial. A difficult weaning involves up to three spontaneous breathing trials and less than seven days between the first unsuccessful trial and successful liberation from the ventilator. Prolonged weaning occurs when the patient fails three or more spontaneous breathing trials or requires seven days or more of mechanical ventilation after the first unsuccessful trial.

There is higher ICU mortality in the difficult and prolonged weaning group, and the number of ICU procedures and hospital mortality rates are higher for those mechanically ventilated for more than 21 days (Haas and Laik 2012). Many patients who are likely to require prolonged ventilation will end up having a tracheostomy, and the frequency of tracheostomy creation has increased in part due to wider adoption of percutaneous techniques and during the Coronavirus-19 pandemic (Mehta et al. 2015; QEBH 2020). The benefits of a tracheostomy include less pharyngolaryngeal trauma, reduced sedation requirements, facilitation of speech, easier change of tube and access to oral hygiene, better secretions clearance, improved glottic competence, improved ventilator mechanics and thus potentially an earlier wean from the ventilator. Unfortunately, the prediction of the likelihood of extubation success and duration of ventilation required is imprecise, and the appropriate time for tracheostomy insertion remains controversial.

Transition from Critical Care to Home or Discharge

Weaning from the ventilator and from tracheostomy is part of the rehabilitation process as the patient recovers from critical illness. This is also essential for improving quality of life and reducing healthcare costs and burden. Prolonged mechanical ventilation increases the risk of infections, ventilator-associated lung injury, and respiratory muscle wasting. Therefore, clinicians should aim to minimise the duration of invasive mechanical ventilation. Placement of the artificial tube in the airways poses considerable short- and long-term complications. Early complications include bleeding, aspiration, pneumothorax, subcutaneous emphysema, tube displacement, stomal infection and tracheo-innominate fistula. Late complications include tracheomalacia, tracheal stenosis, tracheoesophageal fistula, and stoma granulation formation. Communication is also compromised unless modifications such as a one-way valve are used, and dysphagia is common due to reasons such as reduced laryngeal elevation, laryngeal structure disuse atrophy, and loss of subglottic air pressure (Skoretz et al. 2020).

As the patient transits out from the critical care setting, healthcare providers should actively assess for suitability to wean from both ventilator and tracheostomy (Figure 1) and expedite this process while monitoring for adverse events.

Weaning of Ventilator Support

Successful weaning of the ventilator involves balancing the respiratory muscle function and the work of breathing. Even brief periods of mechanical ventilation can cause atrophy of the diaphragm muscle fibres and reduce the force-generating capacity of the diaphragm. Factors such as nutritional state, advanced age, sepsis and neuromuscular blocking agents contribute to respiratory muscle dysfunction (Perren and Brochard 2013).

On the other hand, the respiratory load depends on the elastic and resistive properties of the respiratory system. The elastic load increases when the lung or chest wall compliance decreases, e.g. pneumonia, pulmonary oedema, or abdominal distension. The resistive load is increased in bronchoconstriction, dynamic hyperinflation with intrinsic positive end-expiratory pressure, and endotracheal tube resistance from secretions or small internal diameter. Other factors, such as ventilator dysynchrony and higher minute ventilation from pain or anxiety, can contribute to an increased load (Perren and Brochard, 2013). Therefore, the first step in weaning from tracheostomy comprises reconditioning the respiratory pump and reducing the workload imposed during spontaneous breathing. The underlying causes contributing to ventilator dependence should also be addressed and reversed.

A tracheostomy tube decreases dead space and work of breathing and allows gradual weaning of ventilator support until the patient is able to maintain unassisted breathing (Epstein 2005). The optimal method of weaning of respiratory support is not evident and may depend on the indications for tracheostomy and other patient factors. A randomised controlled trial showed that using a once-daily tracheostomy mask trial with progressive extension based on tolerance led to greater weaning success and shorter weaning times compared to pressure support ventilation (Jubran et al. 2013). Interestingly, 37% of patients were excluded upon screening for trial inclusion as they were successfully liberated from the ventilator during the screening process, which consisted of unassisted breathing with humidified oxygen through a tracheostomy collar for five days. This demonstrates the need for a regular assessment of weaning and extubation readiness.

Patients should be screened daily for readiness for a spontaneous breathing trial – if they fulfil criteria such as stability of haemodynamic and metabolic parameters, adequate gas exchange, an unassisted breathing via tracheostomy mask (TM) trial should be performed as soon as possible. An initial TM trial may be 1-2 hours long in the daytime, with the duration of unassisted breathing via TM increased gradually during wake hours with nocturnal ventilatory support until the patient no longer requires assisted ventilation.

Weaning of Tracheostomy

After successful weaning from mechanical ventilation, the next logical step is to evaluate the patient for tracheostomy weaning. However, timing and methods for decannulation remain controversial, lacking robust evidence-based guidelines (Singh et al. 2017). This has resulted in variability across institutions and countries, with decisions often left to individual physician preferences, potentially leading to suboptimal care.

Weaning the tracheostomy is often delayed, overshadowed by other medical issues the patient may have. While the process of weaning from endotracheal tubes is well-documented with established criteria, tracheostomy weaning lacks uniformity. In our institution, the process has been primarily based on physician judgment rather than on structured, patient-centred protocols. To address this, we propose a more systematic approach.

The first step in the weaning process involves cuff deflation trials. This should be done as soon as the patient is off mechanical ventilation and the aspiration risk is managed. Cuff deflation allows assessment of airway patency and respiratory effort. Like spontaneous breathing trials for ventilated patients, cuff deflation trials should be performed daily. Once the patient tolerates 24 hours of cuff deflation, subsequent steps to spigotting and decannulation can happen.

These steps focused on the assessment of the patient's airway patency, respiratory effort and ability to protect the airway, which includes management of secretion. There are many variations in how these functions are assessed. The most cited steps were swallowing assessment, occlusion training, evaluation of air permeability, ability to manipulate secretion, exchange of cannula, cuff deflation, cough training and use of speech valve (Medeiros et al. 2019).

In our institution, a typical weaning process is as follows (Figure 2):

However, in our clinical experience, these processes are not sequential and are often tailored to the patient's trajectory of recovery. We propose that weaning should occur alongside managing the patient's other medical and functional issues, restoring the functions lost due to tracheostomy, and preventing complications like infection and airway stenosis.

Additionally, we prioritise functional airway testing by observing the patient’s ability to tolerate bedside challenge tests to use natural airway rather than relying solely on instrumental measures like endoscopy or peak cough flow (PCF). These tests serve as diagnostic adjuncts when the patient struggles to meet milestones in the weaning process.

The final step in tracheostomy weaning is decannulation. There are no universally accepted criteria for tracheostomy decannulation, but they can be extrapolated from ventilator liberation. A recent systematic review looked at predictive factors for successful decannulation in brain-injured patients, and some of these factors are the criteria for decannulation we considered in our institution (Gallice et al. 2024a). Another study in acquired brain injured patients suggested that the best clinical prediction rule for decannulation is a combination of the following assessments: (1) tracheostomy tube capping, (2) endoscopic assessment of patency of airways, (3) swallowing instrumental assessment, and (4) blue dye test (Enrichi et al. 2017).

In our institution, we use a combination of clinical features and bedside challenge tests to assess patients’ suitability for decannulation (Figure 3).

1. Stable medical condition: The patient's medical condition should be stable or improving. All surgical procedures should be completed, and conditions like pneumonia and delirium optimised.
2. Cardiorespiratory stability: Preferably, the patient’s vital signs—such as blood pressure, heart rate, respiratory rate, and oxygen saturation—should be within normal ranges to indicate physiological stability. However, this may not always be the case. We emphasise monitoring trends and addressing abnormal values to rule out reversible causes. This individualised approach helps tailor criteria for discontinuing spigotting without being overly cautious, ensuring patients aren’t unnecessarily delayed in their decannulation process.
3. Cough strength and secretion clearance: While PCF can be measured, we rely more on clinical assessment of the patient's ability to clear secretions to the hypopharynx for oral suctioning. If suctioning is required less frequently than every four hours without desaturation or increased work of breathing, it is typically considered manageable for home care.
4. Consciousness: Airway protection and consciousness are often assessed together, though recent evidence suggests that a Glasgow Coma Scale (GCS) of less than 8 is not always indicative of impaired gag or cough reflex (Orso et al. 2020; Hatchimonji et al. 2021). We do not use a strict GCS cut-off for weaning or decannulation decisions.
5. Successful cuff deflation: The ability to tolerate cuff deflation is crucial and is a common step in weaning in most protocols.
6. Speaking valve use: Tolerance to speaking valve, while not mandatory, provides an indication of airway patency, secretion management, and the patient's ability to handle increased airflow. We recommend at least four hours of tolerance before capping trials.
7. Spigotting trials: Spigotting trials are also a common step described in most spigotting protocols. However, this protocol varies across institutions, and the duration of capping (Devaraja et al. 2024; Gallice et al. 2024b) remains a topic of debate. In most studies, there is a minimum of 24 hours of capping. In our institution, we have adopted a 2-day spigotting protocol since 2018, with no reported failures of decannulation. We believe that stratifying patients for shorter spigotting durations is feasible, particularly for those with good speaking valve tolerance and secretion management. However, there is currently limited evidence to guide patient stratification for shorter spigotting trials.
8. Direct visualisation of airway patency: Nasoendoscopy is not routinely used to decide on decannulation unless there are concerns about altered anatomy. In most cases, we assess airway function through secretion management, tolerance to the speaking valve, and capping trials. Nevertheless, we have moved to using fibreoptic endoscopic evaluation of swallowing (FEES) in such patients earlier than later, which at the same time will give an inclination of airway patency and vocal cord integrity.

The decannulation process itself is usually straightforward once the patient successfully passes spigotting trials. Post-decannulation care, including stoma care and teaching the patient techniques for digital occlusion to generate forceful coughs, is crucial to avoid stoma infections and aspiration.

By adopting a structured protocol for tracheostomy weaning, we can ensure more standardised, patient-centred care, minimising variability and improving patient outcomes. Further research is needed to establish evidence-based guidelines to optimise the weaning process across different clinical settings.

Weaning in the Chronic Ventilated Patient

A subset of patients who may have comorbidities such as chronic obstructive pulmonary disease, neuromuscular disease, advanced age, and markers of severity of acute illness that predict prolonged weaning may not be able to wean off the ventilator. In patients who are likely to require chronic ventilation, non-invasive ventilation (NIV) can be used to facilitate the transition to removal of mechanical ventilation partially or completely and aid in decannulation. 

Physiological benefits of NIV that favour its use include reduced inspiratory effort, unloading ventilator muscles to facilitate recovery, improved gas exchange, reduced intrinsic PEEP and better dynamic lung compliance (Kallet and Diaz 2009; MacIntyre 2019). NIV can also be initiated in patients with tracheostomy in situ and continued during and after tracheostomy decannulation. Patients with neuromuscular disease who are on NIV due to chronic respiratory failure may eventually progress to requiring ventilator support 24 hours a day. It is common practice to recommend invasive mechanical ventilation at this stage, although this increases institutional care (Sahni and Wolfe 2018). Continuous NIV with a mouthpiece in the daytime and a mask at night has been shown to be a safe alternative approach in select patients, thus obviating the need for a tracheostomy (McKim et al. 2013; Khan et al. 2023).

For effective NIV use, there should be a patent upper airway, adequate bulbar function and adequate cognitive state. Airway protection parameters such as cough strength (maximum expiratory pressure, PCF greater than 160L/min) (Bach and Saporito 1996), ability to manage secretions, quality and quantity of secretions, swallowing function have been found to be predictive factors for successful decannulation (Medeiros et al. 2019; Santus et al. 2014). In thoracic wall restrictions, neuromuscular disease and spinal cord injury, PCFs and thus central airway clearance are reduced due to inadequate vital capacity, expiratory abdominal muscle weakness, and impaired glottic closure. Other conditions resulting in upper airway obstruction or bronchoconstriction also reduce PCF. Adjunctive techniques to improve cough function and proximal airway secretion clearance will benefit such patients.

Lung volume recruitment provides increased end-inspiratory volume to increase expiratory airflow at the expulsive phase of cough. The patient serially inhales a volume of gas without exhalation until maximum insufflation capacity, either via the ventilator or manually with a self-inflating resuscitation bag adapted with a one-way valve. Periodic full inflations improve lung and chest wall compliance and reduce the work of breathing, cough capacity, and airway clearance (Mckim 2008; Spinou 2020).

Assisted expiration techniques include manually assisted cough and mechanical insufflation-exsufflation therapy. The aim is to support the expiratory muscles to generate sufficient intrathoracic and intra-abdominal pressure and/or to increase expiratory flow during the cough manoeuvre. Manually assisted cough provides increased air compression in the lungs and comprises an abdominal thrust and/or lateral costal compression timed to glottic opening. Mechanical insufflation-exsufflation (MIE) therapy involves the delivery of positive pressure insufflation, allowing the lungs to passively and deeply expand, followed by rapid negative pressure exsufflation (Gipsman et al. 2023). This produces a high expiratory flow velocity that simulates a cough, which shears secretions from the walls of the central airways and moves them proximally where they can be expectorated or suctioned. It can be performed non-invasively via a mask or through the tracheostomy tube with cuff up.

The process of weaning of the tracheostomy in the chronic ventilated patient is similar to that in the patient with unassisted breathing with the following points to note:

Our preference is to equally prioritise periods of ventilator-free breathing to work towards ventilator liberation in patients who potentially can be weaned AND restoring speech and swallowing if possible. While alternative and augmentative communication options such as communication boards are available, the ability to vocalise is valued more highly by patients than other communication options (Newman et al. 2022) and enhances the quality of life.

Cuff deflation of the tracheostomy may be performed as soon as there is ability to control upper airway secretions, clinical stability and no new or worsening lung infection (Pryor et al. 2016). With the tracheostomy cuff deflated, there will be more leak around the tracheostomy tube, and the delivered volume or pressure by the ventilator should be increased to ensure adequate minute ventilation and improve patient comfort.

Excessive secretions are not uncommon, resulting in signs of poor tolerance, including frequent coughing, patient distress and discomfort, and are associated with aspiration pneumonia and delayed weaning. Oral secretions can be managed by upright positioning, regular suctioning, subglottic suctioning and pharmacotherapy such as sublingual atropine, glycopyrrolate, amitriptyline and intrasalivary gland botulinum injections (Gipsman et al. 2023). Tracheostomy cuff deflation may be delayed until secretions are more manageable.

In our practice, downsizing of tracheostomy is only done if patients have significant ventilator-free time and are considered for decannulation, as it leads to greater leak at the stoma and prevents generation of adequate pressure for lung volume recruitment.

During the process of weaning, the tracheostomy tube is spigotted and NIV is initiated during patient’s usual ventilation hours. Formal assessment of upper airway patency is done via nasoendoscopy or functional endoscopic evaluation of swallowing (FEES) if there are suggestions of reduced airway patency, even after the downsizing of a tracheostomy tube. Monitoring of the pCO₂ while on NIV with the tracheostomy tube capped allows for titration of NIV settings if required and assesses the patient's tolerance for decannulation. Upon decannulation, an occlusive dressing is placed over the tracheostoma, and cough augmentation techniques and ventilation will be continued non-invasively.

Evidence for Multidisciplinary Team Effort

Tracheostomy insertion has implications on communication, airway management, feeding and nursing care (Paul 2010). Thus, these patients often have complex care needs. Optimal delivery of care and facilitation of weaning and discharge planning require expertise from multiple providers, giving support to a coordinated multidisciplinary approach (Bonvento et al. 2017). Key members who should be involved include physiotherapists who manage secretions and physical rehabilitation, speech therapists who manage swallowing and communication difficulties, and outreach nurses who coordinate ward nursing support for the care of tracheostomy patients (Martin et al. 2014). Physicians oversee the clinical aspects and often retain the overall responsibility of tracheostomy management in the patient, and patients who require ventilation are assessed by respiratory therapists to facilitate weaning.

There is growing evidence for interprofessional collaboration and team-based care regarding tracheostomy management (Speed and Harding 2013). A recent systematic review reported that implementation of multidisciplinary tracheostomy teams was associated with a significant increase in one-way speaking valve use and swallowing rates, allowing speech more rapidly, fewer adverse events and a positive trend towards reduced time to decannulation, reduced hospital length of stay (Ninan et al. 2023). Additionally, observational studies indicate that tracheostomy care bundles and a weaning and decannulation protocol can reduce the time to decannulation in the acute care setting (Musssa et al. 2021). Effective communication within the team is essential to ensure coordination of care and that appropriate therapies are considered and initiated in a timely fashion.

Conclusion

Patients with tracheostomies have complex care needs and will benefit from consistency of care through their journey of recovery from the intensive care unit into the community. Given the heterogeneity of this patient population, it is crucial to develop a structured and individualised approach through collaboration with the multidisciplinary team, patient and family.

Conflict of Interest

None