Decannulation of Tracheostomy Tube (TT) in Stroke Patients

Why Stroke Patients Are Challenging

• Impaired level of consciousness
• Dysphagia and silent aspiration from bulbar involvement
• Weak or absent voluntary cough
• Excess/thick secretions
• Infratentorial (brainstem) lesions affecting airway reflexes more severely

Pre-Decannulation Criteria (Must ALL Be Met)

The Decannulation Process - Step by Step

Step 1: Multidisciplinary Assessment

• Intensivist / Neurologist - overall readiness
• Respiratory Therapist - ventilation and secretion status
• Speech-Language Pathologist (SLP) - swallowing and cough assessment
• Physiotherapist - respiratory physiotherapy, secretion clearance
• Nurse - day-to-day monitoring

Step 2: Cuff Deflation Trial

• Deflate the tracheostomy tube cuff gradually
• Assess the patient's ability to breathe around the tube (not just through it)
• Monitor for signs of aspiration, desaturation, or distress
• This re-introduces airflow through the upper airway and larynx
• Use a Passy-Muir Valve (speaking valve) once cuff is deflated - improves secretion management, swallowing, and voice; also helps restore subglottic sensation

Step 3: Tube Downsizing

• Replace with a smaller diameter tube (inner diameter ≤ 6 mm)
• This increases the resistance of breathing through the tube, encouraging more airflow through the upper airway
• Re-assess tolerance and secretion management at the smaller size
• In many protocols, a fenestrated tube is used at this stage (cuff deflated)

Step 4: Swallowing and Airway Evaluation

• Fiberoptic Endoscopic Evaluation of Swallowing (FEES) or video fluoroscopic swallowing study
• Flexible laryngoscopy to confirm:
  • Airway patency to the subglottis
  • At least one mobile vocal cord
  • Absence of significant subglottic stenosis or granulation tissue
• Tracheoscopy through the stoma to assess the trachea above and below (retrograde and antegrade views)

Step 5: Capping / Corking Trial

• The tracheostomy tube opening is plugged/capped (with cuff deflated)
• The patient must breathe entirely through the upper airway
• Monitor continuously for:
  • Respiratory distress or stridor
  • Desaturation (SpO2 drop)
  • Tachycardia
  • Noisy breathing
  • Aspiration signs during swallowing
• The patient must tolerate capping for a minimum of 48-72 hours without distress before proceeding
• Some protocols use 24-hour gradual capping (initially a few hours, then extended)

Step 6: Decannulation (Tube Removal)

1. Explain the procedure to the patient (consent, reduce anxiety)
2. Position patient upright/sitting
3. Initiate continuous SpO2 monitoring
4. Suction the trachea and oropharynx thoroughly
5. Deflate the cuff completely (if not already deflated)
6. Cut any retaining sutures
7. Remove the tube on expiration (ask patient to take a deep breath and then breathe out; remove during exhalation)
8. Apply a clean occlusive dressing (e.g., gauze with tape) over the stoma site
   • This allows the tracheocutaneous fistula to close spontaneously over a few days
   • The patient should be taught to press the dressing when coughing or speaking to facilitate closure

Step 7: Post-Decannulation Monitoring (Strapping Phase)

• Monitor continuously for at least 24-48 hours in-patient
• Watch for:
  • Stridor or airway obstruction
  • Desaturation
  • Tachycardia
  • Breathing difficulty while swallowing
  • Surgical emphysema
• Keep tracheostomy emergency equipment at bedside for 48 hours post-decannulation
• Stoma site care: protect from water entry; dressing changed regularly

Six Key Criteria (6-Point Decannulation Protocol - Brain Injury/Stroke)

1. Level of consciousness - adequate responsiveness
2. Respiration - stable, no ventilatory support needed
3. Tracheal secretions - manageable quantity and consistency (small/clear secretions preferred)
4. Phonation - ability to phonate (indicates laryngeal function)
5. Swallowing - functional, minimal-to-no aspiration
6. Coughing - effective voluntary and reflex cough

Predictive Factors for Successful Decannulation in Stroke (Key Research Finding)

• Higher neurological/consciousness status
• Effective swallowing
• Effective cough
• Absence of pulmonary infections
• Younger age
• Supratentorial (rather than brainstem) lesion

• Early tracheostomy placement
• Absence of critical illness polyneuropathy/myopathy
• Absence of tracheal lesions

Special Considerations in Stroke Patients

• Silent aspiration is common - a normal cough reflex does NOT rule out aspiration; always perform objective swallowing evaluation (FEES/VFSS)
• Bulbar stroke patients may have severely impaired laryngopharyngeal function and may never achieve decannulation
• Brainstem strokes are associated with poorer decannulation outcomes than cortical strokes
• A Passy-Muir speaking valve trial before full decannulation is particularly valuable in stroke patients to restore subglottic pressure and improve swallowing mechanics
• Communication throughout the process is key - use communication aids as needed

Summary Flow

Stroke + Tracheostomy
        ↓
Meet pre-decannulation criteria?
        ↓
Cuff Deflation Trial → Speaking Valve Trial
        ↓
Tube Downsizing (fenestrated tube)
        ↓
Swallowing Assessment (FEES/Laryngoscopy)
        ↓
Capping Trial (48-72 hours)
        ↓
Tube Removal (on expiration, upright position)
        ↓
Stoma Dressing + 48hr Monitoring
        ↓
Stoma Closure (spontaneous, days-weeks)