T

racheostomy is now considered a common procedure,

1
and so it is important for nurses
to become knowledgeable about tracheostomy progression, beginning immediately
postoperatively and continuing through long-term care. Most tracheostomies placed in
patients in intensive care units (ICUs) are done in order to facilitate weaning from mechanical ventila-
tion. After the patient has been liberated from mechanical ventilation and the need for the tracheostomy
is resolved, there should be a plan to progress toward decannulation. Daily evaluation of the progress
toward decannulation can reduce length of stay, infection rates, and overall health care costs.
2-5
In this
article, we review a systematic method for tracheostomy progression and describe how critical care
nurses can facilitate this process.
The Importance of
Tracheostomy Progression
in the Intensive Care Unit
LINDA L. MORRIS, PhD, APN, CCNS
ERIK McINTOSH, RN, MSN, ACNP-BC
ANDREA WHITMER, RN, MSN, ACNP-BC
Feature
A plan to progress a tracheostomy toward decannulation should be initiated unless the tracheostomy has been
placed for irreversible conditions. In most cases, tracheostomy progression can begin once a patient is free from
ventilator dependence. Progression often begins with cuff deflation, which frequently results in the patients
ability to phonate. A systematic approach to tracheostomy progression involves assessing (1) hemodynamic
stability, (2) whether the patient has been free from ventilator support for at least 24 hours, (3) swallowing,
cough strength, and aspiration risk, (4) management of secretions, and (5) toleration of cuff deflation, followed
by (6) changing to a cuffless tube, (7) capping trials, (8) functional decannulation trials, (9) measuring cough
strength, and (10) decannulation. Critical care nurses can facilitate the process and avoid unnecessary delays
and complications. (Critical Care Nurse. 2014;34[1]:40-50)
This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article,
which tests your knowledge of the following objectives:
1. Discuss a systematic method for tracheostomy progression
2. Describe how critical care nurses can facilitate the process of decannulation
3. List outcomes achieved with a standardized clinical practice guideline for tracheostomy patients
2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2014722
CNE Continuing Nursing Education
40 CriticalCareNurse Vol 34, No. 1, FEBRUARY 2014 www.ccnonline.org
Indications for Tracheostomy
Indications for placing a tracheostomy tube are dis-
cussed in a companion article in a previous issue of Criti-
cal Care Nurse
6
and can be summarized into problems of
ventilation, airway obstruction, airway protection, and
secretion management. Patients can require ventilator
support because of muscle weakness, hypercarbia, or
hypoxia. Patients with airway obstruction include those
with swelling, stricture, paralyzed vocal cords, or unusual
anatomy of the upper airway. A third group includes
patients with an inefficient swallow and/or cough mech-
anism who are unable to protect the airway. This dys-
function is frequently seen in patients after a high spinal
cord injury, cerebrovascular accident, or traumatic brain
injury. Neurological patients with oropharyngeal dyspha-
gia may exhibit slow closure of the laryngeal vestibule
and slow opening of the upper esophageal sphincter, which
can lead to aspiration-related events.
7
Videofluoroscopy
or barium swallow test is the gold standard in the assess-
ment of dysphagia.
8
Finally, patients who cannot manage
their secretions because of their volume, viscosity, or a
poor cough effort may also require a tracheostomy.
Tracheostomy Progression and
Critical Care Nurses
As discussed in a previous article,
6
the critical care nurse
can play an instrumental role in preventing long-term com-
plications such as tube dislodgment, tube obstruction from
mucus buildup, infection, fistulas, and tracheomalacia.
For some patients, a tracheostomy tube is placed as a
short-term solution, for example, to facilitate weaning from
mechanical ventilation. When the issue is resolved, the
tracheostomy tube is no longer needed. For these patients
who have reversible conditions requiring management with
a tracheostomy, the critical care nurse can identify patients
who are ready to progress to the next phase of care.
Decannulation protocols can be quite diverse, vary-
ing from nearly 2 weeks
9
to a rapid 1-step capping
trial.
10
Some of these protocols include bronchoscopic
assessment of the airway, but Rumbak and colleagues
11
reported that routine bronchoscopy was unnecessary.
Zhu and colleagues
12
identified a lack of standardization
in management and surveillance of tracheostomy
patients. They suggested that development of a standard-
ized clinical practice guideline for surveillance and man-
agement of tracheostomy patients could augment and
improve outcomes, improve quality of care, and decrease
costs.
12
Critical care nurses can lead the effort to stan-
dardize care for the patient, which includes tracheostomy
progression.
Ten Steps Toward Decannulation
Tracheostomy progression is a process, usually with
the eventual goal of decannulation. As a patients condi-
tion improves from ventilator dependence to successful
weaning, members of the critical care team may be unsure
how to safely track the pathway to tracheostomy decannu-
lation. This process should begin in the ICU, facilitated
by the critical care nurse and critical care team. The team
includes but is not limited to the intensivists, advanced
practice nurses, respiratory care practitioners, case man-
agers, occupational therapists, physical therapists, and
the speech language pathologist. Tracheostomy progres-
sion should be included as a goal for discussion during
the daily ICU rounds. Tracking of progress to step-down
units and long-term placement facilities should be included
in this plan as well. This process can be done in an
organized fashion by following this 10-step plan for tra-
cheostomy progression.
An important point to remember is that for a tra-
cheostomy patient to be considered for progression, it
must be determined that the initial need for the tra-
cheostomy has been resolved. Once it has been determined
that the tracheostomy is no longer needed, the following
systematic steps can be used as a standardized approach
to decannulation.
13
We use a methodical 10-step approach
toward decannulation in order to create a model that can
Linda L. Morris is a clinical nurse specialist in respiratory care at
Northwestern Memorial Hospital, Chicago, Illinois, and an associate
professor of clinical anesthesiology, Feinberg School of Medicine,
Northwestern University, Chicago, Illinois. She is also a member of
the board of directors for the Global Tracheostomy Collaborative, an
international group of specialists dedicated to research and quality
outcomes for patients with trach eosto mies.
Erik McIntosh is a nurse practitioner on an inpatient internal med-
icine unit at Rush University Medical Center.
Andrea Whitmer is the acute care nurse practitioner for the inten-
sivist program in the critical care unit at Elkhart General Hospital,
Elkhart, Indiana.
Corresponding author: Linda L. Morris, PhD, APN, CCNS, FCCM, Northwestern Memorial
Hospital, 251 E. Huron Street, Feinberg Pavilion, Suite 8-330, Chicago, IL 60611
(e-mail: limorris@nmh.org).
To purchase electronic or print reprints, contact the American Association of Critical-
Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)
362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
Authors
www.ccnonline.org CriticalCareNurse Vol 34, No. 1, FEBRUARY 2014 41
Step
1. Ensure the hemodynamic
stability of the patient
2. Assess if the patient been
free from ventilator support
for more than 24 hours
3. Assess whether the patient
is able to protect his/her
airway with a strong cough
and swallow his/her own
secretions
4. Assess if the patient can
mobilize and manage
his/her secretions
5. Deflate cuff
6. Change to cuffless or tight
to shaft (TTS) tube
7. Cap the cuffless or TTS
tracheostomy tube
8. Functional decannulation trial
9. Assess cough strength by
checking vital capacity
and/or peak cough flow
10. Decannulation
Action
If the patient is hemodynamically stable, move to step 2
If not, reassess when patient is stable
If yes, move to step 3
If no, reassess in 24 hours
If yes, move to step 4
If no, reassess and consider:
a. Formal swallowing evaluation
b. Vigorous physical mobility
If yes, move to step 5.
If no, reassess and ensure optimal hydration and
humidification and coughing and deep breathing
exercises
If there are no signs or symptoms of aspiration or
respiratory distress with cuff deflation, leave cuff
deflated for 24 hours and move to step 6
If there are signs and symptoms of aspiration or respi-
ratory distress with cuff deflation, reinflate cuff and
reassess when appropriate
If the patient has tolerated cuff deflation for 24 hours
or more, change to cuffless tube or TTS tube of the
same or smaller size and move to step 7
Evaluate amount and consistency of secretions: those
patients with large amounts of thick secretions may
require a dual-cannula cuffless tube; those with mini-
mal secretions may benefit from a single cannula
cuffless tube
If the patient does not show signs or symptoms of desat-
uration, increased work of breathing and respiratory rate,
stridor, and/or signs of obstruction, leave tube capped
for 24-48 hour hours as tolerated and move to step 8
If the patient does show signs or symptoms of desatu-
ration, increased work of breathing and respiratory
rate, stridor, and/or signs of obstruction, remove cap,
suction vigorously and return to tracheostomy collar
Consider a smaller tube and/or airway evaluation before
progressing to the next step
If the patient is able to tolerate continuous prolonged
capping for 24 hours or greater with no signs or
symptoms or respiratory distress, move to step 9
If the patient is unable to tolerate continuous prolonged
capping, return to step 7
If the vital capacity is at least 15 mL/kg or if the peak
cough flow is at least 160 L/min, move to step 10.
If the vital capacity is not at least 15 mL/kg or if the
peak cough flow is not at least 160 L/min, the patient
will require continued capping trials and a physical
therapy plan before progressing to step 10
Remove tube and cover stoma with gauze dressing;
keep stoma clean
Rationale
Patients who do not have stable vital signs
are not ready for tracheostomy progression
Patients need time to stabilize after being
on ventilator support
A bedside assessment of cough and
swallow help determine aspiration risk
Patients who have adequate cough and
swallow mechanisms are a lower risk for
aspiration
Patients who can manage their own secre-
tions (cough, swallow) are a lower risk for
aspiration
Patients who can manage their own secre-
tions often require less suctioning
Cuff deflation minimizes long-term compli-
cations of an inflated cuff, such as tracheal
stenosis or tracheomalacia
Patients who do not tolerate cuff deflation
may exhibit signs of continued coughing,
desaturation, increased respiratory distress,
etc
Patients who can tolerate prolonged cuff
deflation are usually candidates for a cuff-
less tracheostomy tube
Patients who continue to require intermit-
tent positive pressure ventilation or
bronchial hygiene maneuvers can benefit
from a TTS tube (single cannula)
Assessing volume and consistency of secre-
tions will help determine the optimal tube
to place (dual cannula vs single cannula)
After the tube is changed to cuffless or TTS
tube, it can be capped; DO NOT cap a
standard low-pressure, high-volume tra-
cheostomy tube; even with the cuff fully
deflated, the bulk of the deflated cuff cre-
ates a risk of airway obstruction
Prolonged capping is a method to assess
the patients ability to function without the
tube, ie, functional decannulation
After the patient has tolerated a period of
continuous capping, he or she can be
evaluated for decannulation
Patients who do not tolerate prolonged cap-
ping are not ready for decannulation and
may require additional capping trials
and/or physical therapy
Peak cough flow and vital capacity are
measures to estimate the patients cough
strength (there will be a leak around a
cuffless tube)
Stoma will heal itself over the next 1 day to
2 weeks
Table 1 Ten steps of tracheostomy progression to decannulation
begin in the ICU (Table 1). Last, evaluating the patients
overall strength to assess readiness for rehabilitation is
necessary. This plan should include exercise training, nutri-
tional intervention, and psychosocial support.
14
Many
ICU patients are physically deconditioned over time and
will benefit from these programs. Including these programs
in tandem with tracheostomy progression will increase
the patients chances of successful decannulation.
Step 1: Determine Hemodynamic Stability
Tracheostomy progression begins with an assessment
of hemodynamic stability. Patients who have unstable
vital signs are not ready to progress and need time to
stabilize. Thorough assessment of the patient including
vital signs is necessary to determine stability.
Step 2: Ventilator Independence for
More Than 24 Hours
Patients need time to stabilize after they have been
liberated from ventilator support and should not progress
to the next step until they have been stable on a tra-
cheostomy collar or t-piece for at least 24 hours.
13
How-
ever, some patients continue to require part-time ventilator
supportmost commonly, nocturnal ventilator support.
Those patients may be progressed in a different way that
is discussed later in this article.
Step 3: Assess Swallow, Cough Strength, and
Aspiration Risk
Assessment of the adequacy of the cough strength and
ability to swallow secretions is necessary because these
are the 2 primary mechanisms responsible for airway
protection. If the cough is very weak and secretions can-
not be mobilized, or the patient is unable to swallow,
the risk for aspiration is increased. A speech language
pathologist can do a formal evaluation of swallowing to
determine the exact nature of the problem and recommend
strategies for improvement. Failure to pass a swallowing
evaluation does not prevent tracheostomy progression,
but can be used as part of the overall assessment of tra-
cheostomy patients.
13
During this time, the ICU nurse can
also encourage the patient to practice swallowing his or
her saliva rather than relying on oral suctioning.
Step 4: Assess Management of Secretions
Secretions and the patients ability to manage them
should be assessed by recognizing thickness, color, and
suctioning requirements. Ideally, secretions should be
thin so that they are more easily mobilized by coughing
or suctioning. Adequate hydration plays a key role in
thickness of secretions. Patients with poor cough strength
or poor cough reflex usually require more suctioning
than do patients with a strong cough.
Step 5: Assess Toleration of Cuff Deflation
Step 5 is cuff deflation and is recommended as soon
as the patient has been liberated from ventilator support.
15
A common myth is that an inflated cuff decreases the
risk of aspiration, but an inflated cuff can actually
increase the risk of aspiration.
16,17
It has been demon-
strated that the inflated cuff anchors the trachea to the
anterior part of the neck and results in reduced move-
ment of the larynx and obstruction of the esophagus.
17-20
Suiter et al
21
demonstrated that deflation of the cuff
reduced risk of aspiration of liquids and improved laryn-
geal excursion. Amathieu and colleagues
17
demonstrated
that the swallowing reflex was progressively more diffi-
cult to elicit with increasing cuff pressure. Therefore,
patients should not be fed orally with the cuff inflated.
16
Deep oropharyngeal, or subglottic, suctioning should
be performed before cuff deflation because of the large
amounts of secretions that collect above the inflated cuff.
These secretions usually accumulate regardless of the
effectiveness of the
swallow. Deep sub-
glottic suctioning is
best done with a soft
suction catheter
because this type of
suctioning often elicits the gag reflex, and caution
should be used to minimize trauma to the tissues that
may occur with a rigid suctioning device.
Some patients can react strongly to cuff deflation,
not because of respiratory distress or aspiration, but
because of movement of air in their oropharynx, a feel-
ing that may be unfamiliar after long-term cuff inflation.
13
In these patients, slow cuff deflation over several minutes,
combined with an explanation of what they are feeling,
may help to minimize this reaction.
Once the cuff is deflated, patients should be assessed
for desaturation of less than 92% and any signs of respi-
ratory distress, such as increased respiratory rate, con-
tinued coughing, increased work of breathing, anxiety,
or stridor, muscle retraction, or nasal flaring. If the patient
www.ccnonline.org CriticalCareNurse Vol 34, No. 1, FEBRUARY 2014 43
A common myth is that an inflated cuff
decreases the risk of aspiration, but an
inflated cuff can actually increase the
risk of aspiration.
exhibits any signs of distress, the cuff should be reinflated
and the patient assessed to ensure that the symptoms
are relieved.
Step 6: Change to Cuffless Tube
After a period of prolonged cuff deflation (24 hours
or longer), the patient is ready for step 6, when the tube
is changed to a cuffless one, which will allow safe cap-
ping trials. In order to determine the proper size of the
cuffless tube, it may be helpful to assess the patients
ability to breathe around the tube and the deflated cuff.
The tube can be occluded with a gloved finger (never
with the cuff inflated) for a few breaths and the patient
should be assessed for signs of respiratory distress, as
described earlier.
The patient should be prepared for a change to a cuff-
less tube. Determining the size of the tube to place can
be confusing to many clinicians, so tube sizing deserves
some discussion. The 2 largest US manufacturers of tra-
cheostomy tubes (Shiley and Portex) use different sizing
systems; therefore, it is important to consider 3 pri-
mary measurements when considering size needs: inner
diameter, outer diameter, and length. When a patient is
breathing through the tube with the cuff inflated, the largest
inner diameter is appropriate. However, when breathing
around the tube, as in capping, using the narrowest feasi-
ble outer diameter is optimal. But this must be weighed
against the volume and thickness of secretions that are
suctioned. For example, in most adults, a size 4 cuffless
tube should be used only when secretions are minimal
and only when the tube is capped, because the size 4 tube
may be too small to effectively pass a suction catheter
that is large enough to remove thick secretions.
When evaluating the type of tube to place, an assessment
of the amount and consistency of secretions is necessary.
Patients with thick secretions can often benefit from a dual
cannula tube, with either a disposable or a reusable inner
cannula. The purpose of an inner cannula is for ease of
cleaning or replacing in the event of respiratory distress;
patients with thin secretions may not need an inner cannula.
Step 7: Capping Trials
With a cuffless tracheostomy tube (Figure 1), capping
trials can begin (step 7). The goal of capping is to prevent
air from entering and exiting through the tracheostomy
tube itself, allowing airflow to be redirected around the tube
and through the upper airway. Capping a tracheostomy
tube has many benefits, including restoring speech,
restoring glottis function, including taste, smell, Valsalva
movement (bearing down), improving cough and swal-
low, and decreasing the volume of secretions.
22
Figure 2 illustrates a cuffless tube that is capped,
where the patient breathes around the tube on both inspi-
ration and expiration. Initiation of capping trials can
induce respiratory distress, especially when there is insuf-
ficient space to move air around the tube, so it is important
to assess the patient properly for appropriateness of and
tolerance to capping. The most serious complication of
Figure 1 Cuffless tracheostomy tube.
Photo courtesy of Smiths Medical.
Figure 2 Airflow with capped tracheostomy tube. Note
that air flows around the tube on both inspiration and
expiration.
From Morris,
22
Tracheostomies: The Complete Guide, Linda L. Morris and
M. Sherif Afifi, Eds. Adapted with the permission of Springer Publishing
Company, LLC, New York, NY 10036.
Vocal
cords
Cap
Vocal
cords
Expiration Inspiration
44 CriticalCareNurse Vol 34, No. 1, FEBRUARY 2014 www.ccnonline.org
capping is airway obstruction due to either the bulk of
the tube preventing effective airflow around it or mucus
buildup within or around the tube.
Two authors suggest that it may be safe to cap a cuffed
tube with the cuff deflated
23,24
; however, we cannot rec-
ommend this practice. Because of the danger of airway
obstruction, a standard low-pressure cuffed tube should
never be capped, even when the cuff is completely
deflated.
13
The bulk of the deflated cuff creates a great
deal of resistance when breathing around it and renders
the cuff prone to mucus buildup, which increases the
potential for occlusion of the airway.
22
Figure 3 shows the
bulk of a deflated cuff and the resistance to airflow
around it, compared with airflow around a cuffless tube.
The cuffless tube should be capped and the patient
assessed for respiratory distress as discussed earlier:
desaturation, increased work of breathing and respira-
tory rate, stridor, and/or signs of obstruction. Capping
trials force the patient to breathe around the tracheostomy
tube, instead of through it, so oxygen should be provided
by nasal cannula. If any signs of respiratory distress are
present, the cap should be immediately removed and
the patient suctioned.
If the patient cannot tolerate capping of an appropri-
ately sized tube, a speaking valve can be used as an interim
step to capping. A speaking valve allows inspiration
through the tube, but the valve closes on exhalation, forc-
ing air through the upper airway. Therefore, supplemental
oxygen should be provided by a humidified tracheostomy
collar. Like capping, speaking valves also have benefits
in addition to phonation, including fewer secretions,
improved swallow, cough, Valsalva maneuver, and restora-
tion of intrinsic positive end-expiratory pressure.
25
Patients who do not tolerate capping may require a
smaller tube, or they may have some other obstruction
within the airway such as paralyzed vocal cords. These
patients may require further bronchoscopic evaluation
to determine the cause of the obstruction.
When the immediate capping trial is successful, it is
necessary to assess the respiratory status several times
during the next few hours, ensuring that the capping
trial continues to be well tolerated. If there are no diffi-
culties, the patient can often have the tube capped as
long as tolerated.
Step 8: Functional Decannulation
After the patient has tolerated prolonged capping for
24 to 48 hours, he or she can be evaluated for decannula-
tion (step 8).
13
This period of prolonged capping is an
assessment of functional decannulation and is done to
evaluate a patients ability to function without the tube.
Secretions tend to diminish over time when the tube is
capped. If respiratory distress should develop, the cap
should be immediately removed and the patient suctioned
and returned to a humidified tracheostomy collar.
During the time of functional decannulation, the
patient must be free from respiratory distress and able
to clear secretions. Once these steps have been satisfied
and the patients condition remains stable, the patient
may continue to the next step.
Step 9: Cough Strength
Step 9 is an objective measurement of cough strength
such as vital capacity or peak cough flow. Cough strength
must be adequate to enable patients to expectorate all
their secretions.
It is recom-
mended that
in order to be
successfully
decannulated,
peak cough flow should be at least 160 L/min
26
or vital
capacity should be at least 15 mL/kg, or 1 L for most
adults.
27
If cough strength does not meet the minimum
acceptable range, the patient will need a vigorous physi-
cal therapy program before decannulation.
Figure 3 Deflated cuff of standard low-pressure, high-
volume tracheostomy tube (left), compared with cuffless
tube (right). On the left, note the bulk of the deflated cuff
and the resistance to airflow around it, compared with
laminar airflow around a cuffless tube.
From Morris,
13
Tracheostomies: The Complete Guide, Linda L. Morris and
M. Sherif Afifi, Eds. Reproduced with the permission of Springer Publishing
Company, LLC, New York, NY 10036.
www.ccnonline.org CriticalCareNurse Vol 34, No. 1, FEBRUARY 2014 45
Because of the danger of airway obstruction,
a standard low-pressure cuffed tube should
never be capped, even when the cuff is
completely deflated.
Step 10: Decannulation
When the patient has met the minimum requirements
for cough strength and has tolerated a period of pro-
longed capping, he or she is ready for step 10: decannu-
lation. The tracheostomy tube is simply removed and
the stoma covered with sterile gauze. The stoma will
heal by secondary intention, and rate of stomal healing
varies, ranging from 1 day to 2 weeks.
28
After the tube
has been removed, the voice may be quite soft and airy.
This altered voice can be remedied by using several
gauze pads to provide a thick cushion over the stoma.
The patient can also be taught to use digital pressure
over the gauze to increase the strength of the voice until
the stoma heals completely.
In certain populations of patients who may require
repeated tracheostomies, such as those with myasthenia
gravis, spinal cord injuries, or sleep apnea, a tracheostomy
button (Figure 4) may be placed instead of decannulation.
A tracheostomy button may also be useful to patients
who are in active rehabilitation whose secretions are
minimal but whose cough strength is not quite strong
enough for decannulation. A tracheostomy button is a
device that can be used to stent open the stoma; such
devices are used more often in a rehabilitation setting
than in an acute care hospital. The purpose of the button
is to keep the stoma open for a prescribed period, after
which it can be removed. The primary benefit of the tra-
cheostomy button is that it removes the airway resistance
created by the occupied space of a capped tracheostomy
tube (Figure 5). This factor may be significant in some
patients with limited airway reserve. If patients require
frequent suctioning, the button should be removed and
replaced with a tracheostomy tube.
Patients Who Require
Intermittent Ventilation
Some patients are unable to be fully weaned from
ventilator support and may require intermittent support,
most commonly, nocturnal ventilation. These patients
require positive pressure ventilation during the night,
but may be free from the ventilator during the day. These
patients can benefit from use of the Bivona TTS, or tight
to shaft, tube (Figure 6), which has a low-volume, high-
pressure cuff. The cuff seals the airway when inflated,
Figure 4 Tracheostomy button within the stoma.
Image courtesy of Natus Medical Incorporated.
Figure 5 Comparison of tracheostomy button within the
airway (left), compared with capped tracheostomy tube (right).
From Parson and Morris,
29
Tracheostomies: The Complete Guide, Linda L.
Morris and M. Sherif Afifi, Eds. Reproduced with the permission of Springer
Publishing Company, LLC, New York, NY 10036.
Figure 6 Bivona TTS (tight to shaft) tracheostomy tube.
Photo courtesy of Smiths Medical.
46 CriticalCareNurse Vol 34, No. 1, FEBRUARY 2014 www.ccnonline.org
but has no bulk when deflated. The tube can be safely
capped when deflated, as long as the space around the
outside of the tube is sufficient for airflow. Capping the
tube while off the ventilator can sometimes be used as
an adjunct in weaning patients from ventilator support.
Figure 7 illustrates the inflation and deflation charac-
teristics of the high-pressure, low-volume tubes compared
with standard low-pressure, high-volume cuffs.
29
Note
that the standard low-pressure cuff is quite bulky even
when fully deflated. This compares to the high-pressure
TTS cuff, which essentially disappears on deflation.
Upon inflation, however, the cuff of the standard low-
pressure tracheostomy tube diffuses pressure across a
wider surface area, while the high-pressure cuff focuses
pressure in a small area. This focused pressure creates
the need for added precautions with inflation of the high-
pressure cuff. When a patient is returning to mechanical
ventilator support, the TTS cuff should be inflated with
sterile water, not saline or air. Sterile water will help to
distribute pressure evenly and prevent the loss of cuff
volume that occurs when inflated with air as it diffuses
out of the cuff. Saline should not be used because it
damages the cuff over time.
30
It is important to use a minimal leak technique when
inflating the cuff of the TTS tube because its high-pressure
cuff will create elevated direct cuff pressure measure-
ments.
30
Table 2 discusses the procedure for minimal
leak technique.
31
Bivona TTS tracheostomy tubes are
single-cannula tubes, so large amounts of thick secretions
may increase the risk for obstruction. Regular assessment
of tube patency as well as pulmonary hygiene, suctioning,
and efforts to mobilize secretions are very important. If
difficulty passing a suction catheter or mucus plugging
occurs with the TTS tube, the tube should be changed,
perhaps to a tube with an inner cannula.
1
Nursing Implications
The critical care nurse can act as a facilitator to execute
a planned and systematic approach to downsizing and
decannulation. Table 3 identifies a simple tracheostomy
progression checklist that can be used during daily
rounds. When each question can be answered with yes,
the patient is ready for decannulation. It is necessary to
use the nursing process to develop a plan of care and
coordinate the various disciplines to set goals toward
timely decannulation. Executing policies and procedures
within the scope of tracheostomy progression along with
facilitating these steps of tracheostomy progression can
lead to a successful plan of decannulation.
Conclusion
Tracheostomy progression is an important consider-
ation in daily assessment and planning. Nurses can moti-
vate and encourage progress toward decannulation. Unless
a tracheostomy is placed for an irreversible condition,
Figure 7 Inflation and deflation characteristics of low-
pressure, high-volume tracheostomy tubes (left), com-
pared with low-volume, high-pressure tubes (right).
From Parson and Morris,
29
Tracheostomies: The Complete Guide, Linda
L. Morris and M. Sherif Afifi, Eds. Reproduced with the permission of
Springer Publishing Company, LLC, New York, NY 10036.
Low-pressure
high-volume cuffs
Low-volume
high-pressure cuffs
Cuff inflation
Cuff deflation B
A
Table 2 Minimal leak technique
1. With fully deflated cuff, place stethoscope over trachea and
listen for air leak
May use manual resuscitation bag for patients off the
ventilator
Patients may be able to phonate with the cuff deflated
2. Inflate cuff slowly and listen for disappearance of air leak;
this point is termed minimal occlusive volume or just seal
If patients can phonate, this is the point at which their
voice disappears
3. Remove 0.5 mL of air from cuff
www.ccnonline.org CriticalCareNurse Vol 34, No. 1, FEBRUARY 2014 47
there should be a plan for a systematic approach to tra-
cheostomy progression. Following such a plan will lead
to timely decannulation and avoid unnecessary delays
and complications. CCN
Financial Disclosures
Dr Morris is a coeditor/author of the 2010 edition of Tracheostomies: The Com-
plete Guide. She has been a consultant for Covidien and was the recipient of
research funding for a study of outcome evaluation of a structured program of
deep breathing and arm exercises for patients with new tracheostomies,
funded by an Eleanor Wood-Prince Grant: A Project of the Womans Board
of Northwestern Memorial Hospital.
References
1. Garner JM, Shoemaker-Moyle M, Franzese CB. Adult outpatient tra-
cheostomy care: Practices and perspectives. Otolaryngol Head Neck Surg.
2007;136(2):301-306.
2. Cameron T, McKinstry A, Burt S, et al. Outcomes of patients with
spinal cord injury before and after the introduction of an interdiscipli-
nary tracheostomy team. Crit Care Resusc. 2009;11(1):14-19.
3. Parker V, Giles M, Shylan G, et al. Tracheostomy management in acute
care facilities: a matter of teamwork. J Clin Nurs. 2010;19:1275-1283.
4. De Mestral C, Iqbal S, Fong N, et al. Impact of a specialized multidisci-
plinary tracheostomy team on tracheostomy care in critically ill patients.
Can J Surg. 2011;54(3):167-172.
5. Pandian V, Miller CR, Mirski MA, et al. Multidisciplinary team approach
in the management of tracheostomy patients. Otolaryngol Head Neck Surg.
2012;147(4):684-691.
6. Morris LL, Whitmer A, McIntosh E. Tracheostomy care and complications
in the intensive care unit. Crit Care Nurs. 2013;33(5):18-22,24-31.
7. Clave P, de Kraa M, Arreola V, et al. The effect of bolus viscosity on swal-
lowing function in neurogenic dysphagia. Aliment Pharmacol Ther. 2006;
24:1385-1394.
8. American College of Radiology (2010). ACR appropriateness criteria:
dysphagia. http://www.acr.org/Quality-Safety/Appropriateness-Criteria.
Accessed October 30, 2013.
9. Waddell, A, Appleford, R, Dunning, C, Papsin, BC, Bailey, CM. The Great
Ormond Street protocol for ward decannulation of children with tra-
cheostomy: increasing safety and decreasing cost. Int J Ped Otorhino-
laryngol. 1997; 39(2):111-118.
10. Lewarski JS. Long-term care of the patient with a tracheostomy. Respir
Care. 2005;50(4):534-537.
11. Rumbak MJ, Graves AE, Scott MP, et al. Tracheostomy occlusion proto-
col predicts significant obstruction to air flow in patients requiring pro-
longed mechanical ventilation. Crit Care Med. 1997;25(3):413-417.
12. Zhu H, Das P, Brereton J, Roberson D, Shah RK. Surveillance and man-
agement practices in tracheotomy patients. Laryngoscope. 2012;122:46-50.
13. Morris LL. Downsizing and decannulation. In Morris LL, Afifi MS, eds.
Tracheostomies: The Complete Guide. New York, NY: Springer Publishing
Company; 2010:303-322.
14. Nici L, Donner C, Woulters E, et al. ATS/ERS Pulmonary Rehabilitation
Writing Committee. American Thoracic Society/European Respiratory
Society statement on pulmonary rehabilitation. Am J Respir Crit Care
Med. 2006;173(12):1390-1413.
15. Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement:
tracheostomy care. Otolaryngol Head Neck Surg. 2013;148(1):6-20. doi:
10.1177/0194599812460376. http://oto.sagepub.com/content/early
/2012/09/18/0194599812460376.full.pdf+html. Accessed October 30,
2013.
16. Ding R, Logemann JA. Swallow physiology in patients with trach cuff
inflated or deflated: a retrospective study. Head Neck. 2005;27:809-813.
17. Amathieu R, Sauvat S, Reynaud P, et al. Influence of the cuff pressure on
the swallowing reflex in tracheostomized intensive care unit patients.
Br J Anaesthesia. 2012;109(4):578-583.
18. Bonnano PC. Swallowing dysfunction after tracheostomy. Ann Surg. 1971;
174:129-133.
19. Logemann J. Evaluation and Treatment of Swallowing Disorders. San Diego,
CA: College-Hill Press; 1983.
20. Nash M. Swallowing problems in the tracheostomized patient. Otolaryn-
gol Clin North Am. 1988;21:701-709.
21. Suiter DM, McCullough GH, Powell P. Effects of cuff deflation and one-
way tracheostomy speaking valve placement on swallow physiology.
Dysphagia. 2003;18:284-292.
22. Morris LL. Phonation with a tracheostomy. In Morris LL, Afifi MS, eds.
Tracheostomies: The Complete Guide. New York, NY: Springer Publishing
Company, 2010:181-209.
23. Christopher KL. Tracheostomy decannulation. Respir Care. 2005;50(4):
538-541.
24. Grossbach I. Capping a cuffed tracheostomy tube [author reply to letter
to the editor]. Crit Care Nurs. 2012;32:12-13.
25. Lichtman SW, Birnbaum IL, Sanfilippo MR, Pellicone JT, Damon WJ,
King ML. Effect of a tracheostomy speaking valve on secretions, arterial
oxygenation, and olfaction: a quantitative evaluation. J Speech Hear Res.
1995;38(3):549-555.
26. Bach JR. Saporito LR. Criteria for extubation and tracheostomy tube
removal for patients with ventilatory failure: a different approach to
weaning, Chest. 1996;110:1566-1571.
27. Shapiro BA, Kacmarek RM, Cane RD, Peruzzi WT, Hauptman D. Clinical
Application of Respiratory Care. 4th ed. St Louis, MO: Mosby Year Book;
1991.
28. OConnor HH, White AC. Tracheostomy decannulation. Respir Care.
2010;55(8):1076-1081.
29. Parson J, Morris LL. Rehabilitation and recovery. In Morris LL, Afifi MS,
eds. Tracheostomies: The Complete Guide. New York, NY: Springer Publishing
Company; 2010:323-349.
30. Smiths Medical Product Literature, Bivona TTS Adult Tracheostomy
Tube. Gary, IN: Smiths Medical Product; 2010.
31. Skillings KN, Curtis BL. Tracheal tube cuff care. In Wiegand DL, ed.
AACN Procedure Manual for Critical Care. 6th ed. Philadelphia, PA:
Sanders; 2011:88-95.
Table 3 Tracheostomy progression checklist
Questions
1. Is the patient free from ventila-
tor support?
2. Can the cuff be deflated?
3. Can the tracheostomy be
changed to cuffless or TTS?
4. Does the patient tolerate pro-
longed capping of the cuffless
(or TTS) tracheostomy?
5. Is the vital capacity at least 1 L?
6. Can the patient manage his/her
own secretions?
7. Has the initial need for the tra-
cheostomy been resolved,
with no further need for the
tracheostomy?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Date
completed
Circle a
response
No
No
No
No
No
No
No
Abbreviation: TTS, tight to shaft.
Now that youve read the article, create or contribute to an online discussion
about this topic using eLetters. Just visit www.ccnonline.org and select the article
you want to comment on. In the full-text or PDF view of the article, click Responses
in the middle column and then Submit a response.
To learn more about tracheostomy care, read Tracheostomy Care
and Complications in the Intensive Care Unit by Morris et al in
Critical Care Nurse, October 2013;33(5):18-30. Available at
www.ccnonline.org.
48 CriticalCareNurse Vol 34, No. 1, FEBRUARY 2014 www.ccnonline.org
CCN Fast Facts
The Importance of Tracheostomy
Progression in the Intensive Care Unit
CriticalCareNurse
The journal for high acuity, progressive, and critical care nursing
patients condition improves from ventilator depend-
ence to successful weaning, members of the critical
care team may be unsure how to safely track the path-
way to tracheostomy decannulation. This process
should begin in the intensive care unit, facilitated by
the critical care nurse and critical care team. Tra-
cheostomy progression should be included as a goal for
discussion during the daily intensive care unit rounds.
An important point to remember is that for a tra-
cheostomy patient to be considered for progression,
it must be determined that the initial need for the tra-
cheostomy has been resolved.
A systematic approach to tracheostomy progession
involves assessing (1) hemodynamic stability, (2)
whether the patient has been free from ventilator
support for at least 24 hours, (3) swallowing, cough
strength, and aspiration risk, (4) management of secre-
tions, and (5) toleration of cuff deflation, followed by
(6) changing to a cuffless tube, (7) capping trials, (8)
functional decannulation trials, (9) measuring cough
strength, and (10) decannulation.
Critical care nurses can act as facilitators to execute a
planned and systematic approach to downsizing and
decannulation. The Table identifies a simple tra-
cheostomy progression checklist that can be used dur-
ing daily rounds. When each question can be answered
with yes, the patient is ready for decannulation. It is
necessary to use the nursing process to develop a plan
of care and coordinate the various disciplines to set
goals toward timely decannulation.
Tracheostomy progression is an important considera-
tion in daily assessment and planning. Nurses can
motivate and encourage progress toward decannula-
tion. Unless a tracheostomy is placed for an irreversible
condition, there should be a plan for a systematic
approach to tracheostomy progression. Following
such a plan will lead to timely decannulation and
avoid unnecessary delays and complications. CCN
Facts
Indications for placing a tracheostomy tube can
be summarized into problems of ventilation, air-
way obstruction, airway protection, and secretion
management.
Critical care nurses can play an instrumental role
in preventing long-term complications such as
tube dislodgment, tube obstruction from mucus
buildup, infection, fistulas, and tracheomalacia.
For some patients, a tracheostomy tube is placed
as a short-term solution. For these patients who
have reversible conditions requiring management
with a tracheostomy, the critical care nurse can
identify patients who are ready to progress to the
next phase of care.
Tracheostomy progression is a process, usually
with the eventual goal of decannulation. As a
Morris LL, McIntosh E, Whitmer A. The Importance of Tracheostomy Progression in the Intensive Care Unit. Critical Care Nurse. 2014;34(1):40-50.
Table Tracheostomy progression checklist
Questions
1. Is the patient free from ventila-
tor support?
2. Can the cuff be deflated?
3. Can the tracheostomy be
changed to cuffless or TTS?
4. Does the patient tolerate pro-
longed capping of the cuffless
(or TTS) tracheostomy?
5. Is the vital capacity at least 1 L?
6. Can the patient manage his/her
own secretions?
7. Has the initial need for the tra-
cheostomy been resolved,
with no further need for the
tracheostomy?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Date
completed
Circle a
response
No
No
No
No
No
No
No
Abbreviation: TTS, tight to shaft.
www.ccnonline.org CriticalCareNurse Vol 34, No. 1, FEBRUARY 2014 49
CNE Test Test ID C1412: The Importance of Tracheostomy Progression in the Intensive Care Unit
Learning objectives: 1. Discuss a systematic method for tracheostomy progression 2. Describe how critical care nurses can facilitate the process of decannulation
3. List outcomes achieved with a standardized clinical practice guideline for tracheostomy patients
Program evaluation
Yes No
Objective 1 was met q q
Objective 2 was met q q
Objective 3 was met q q
Content was relevant to my
nursing practice q q
My expectations were met q q
This method of CNE is effective
for this content q q
The level of difficulty of this test was:
qeasy qmedium qdifficult
To complete this program,
it took me hours/minutes.
1. A systematic approach to tracheostomy progression begins by
assessing which of the following?
a. Cuff deflation has been tolerated for 24 hours
b. Peak cough flow is at least 150 L/min
c. Ventilator support has been off for at least 48 hours
d. Vital capacity is at least 10 mL/kg
2. Which of the following is not influenced by daily evaluation of the
progress toward decannulation?
a. Infection rate
b. Overall cost
c. Reduced length of stay
d. Patient/family satisfaction
3. Which of the following statements is true regarding the cuff?
a. An inflated cuff decreases the risk of aspiration.
b. Cuffs should not be deflated until ventilator support is ceased.
c. Patients should not be fed orally with the cuff inflated.
d. Secretions can be eliminated with an effective swallow.
4. Which of the following should be considered when changing to a
cuffless tube?
a. A reusable inner cannula for patients with thin secretions
b. The smallest inner diameter when breathing with an inflated cuff
c. The narrowest feasible outer diameter if the tube will be capped
d. Size 4 cuffless tube for thick, copious secretions
5. Which of the following is not a benefit of capping a tracheostomy
tube?
a. Decreased volume of secretions
b. Improved cough and swallow
c. Promotion of comfort
d. Restoration of speech
6. If a patient develops signs of respiratory distress during a capping
trial, the first intervention should be which of the following?
a. Apply supplemental oxygen
b. Provide ventilator support
c. Remove the cap
d. Suction the patient
7. Which of the following is not a benefit provided by a speaking valve?
a. Decreased pressure
b. Improved swallow
c. Minimized secretions
d. Restored positive end-expiratory pressure
8. Which of the following is the recommended peak cough flow for
successful decannulation?
a. 100 L/min
b. 120 L/min
c. 140 L/min
d. 160 L/min
9. Which of the following is the recommended vital capacity for success-
ful decannulation?
a. 10 mL/kg
b. 15 mL/kg
c. 20 mL/kg
d. 25 mL/kg
10. Which of the following is the primary benefit of a tracheostomy button?
a. Allows phonation
b. Creates less secretions
c. Is more comfortable
d. Removes airway resistance
11. Which of the following statements is true about tight to shaft (TTS)
tracheostomy tubes?
a. Air should be injected when the TTS cuff deflates.
b. A TTS tube decreases the risk of obstruction for thick secretions.
c. Sterile saline should be used to inflate the TTS cuff.
d. When inflated, the TTS cuff diffuses pressure across a small area.
12. If there is difficulty with mucus plugging with a TTS tube, which of
the following interventions should the nurse do first?
a. Ensure the tracheostomy tube is changed promptly
b. Increase the humidification
c. Suction more frequently
d. Provide pulmonary hygiene
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