Weaning from the tracheostomy tube
After a severe illness with the necessity of a tra-cheo- stomy and sometimes a long treatment period, possibly with ventilation, there is a clearly defined objective for many patients and their relatives: weaning off the tracheostomy tube. After all, the altered airway brings with it many changes and functional limitations. Understanda-bly, the desire to live without this aid in the long term, and if possible, without a tracheostoma, is therefore profound.
Achieving this goal depends on several factors. Decisive factors include the indication for the tracheostomy, i.e. the underlying disease, the progress made during the necessary therapy and the anatomical conditions.
To achieve the goal of permanent decannulation, it is important that physicians and therapists, but also the aid supplier, the nursing staff as well as the patient and relatives work closely together. Intensive speech therapy is particularly important in this context.
Intensive speech therapy is particularly important in this context. Speech therapy is conducted step by step to re-store physiological swallowing, breathing and coughing functions. There are various approaches to therapy, which in principle depend on the respective underlying disease and the patient‘s resources.
How is decannulation performed in practice?
In most cases the tracheostomy tube or phonation cannula is generally unblocked first, i.e. the sealing of the trachea with the cuff is dispensed with. In addition, the affected person is provided with a speaking valve. By using the speaking valve, exhalation is again directed through the larynx, mouth and nose. On the one hand, this makes it possible for the person affected to speak, and on the other hand, the frequency of swallowing is increased. Normally, a person swallows 2000 times a day on average. People who are perman-ently provided with a tracheostomy tube swallow significantly less often. The reason being that the lack of airflow in the mouth and throat means that important perceptual impulses are missing, which are necessary to trigger the swallowing reflex. By using the speaking valve, the nerves in the mouth and throat receive increased stimulation again, which can lead to an increase in the frequency of swallowing.
In addition, it is useful to stimulate the swallowing reflex through special logopaedic exercises. In addition to the exercises for swallowing, which concern both the frequency of swallowing and strengthening of the muscles involved in swallo-wing, coughing is also trained. Coughing is a pro-tective reflex which is triggered involuntarily when you choke. In patients who have been wearing a tracheostomy tube for a long period of time, the force of coughing is mostly not strong enough as the supporting respiratory muscles have often atrophied. These muscles can be strengthened and developed again in the long term through specific exercises. Among other things, efficient breathing exercises are performed in logopaedic therapy as part of the weaning process.
Therapeutic measures
ll therapeutic measures are intended to prepare the patient for leaving the tracheostomy tube unblocked for increasingly longer periods of time.
It also makes sense to gradually reduce the dia-meter of the tracheostomy tube during this phase. A combination of specially selected medical aids and regularly performed exercises should lead to a continuous improvement of physiological func-tions such as swallowing, coughing and speaking. In this context, the reduction of secretions also constitutes an important part of therapy, which can be achieved through targeted measures, such as the continuous use of HMEs. With all therapeutic exercises, it is important to make sure that the patient is able to tolerate the individual measures well, so that the patient can noticeably benefit from therapy.
If therapy progresses appropriately, the next step can be to replace the blockable tracheostomy tube with a tracheostomy tube without CUFF or a placeholder/button. Subsequently, a cap is then placed instead of the speaking valve. This largely restores an almost physiological anatomy of the airways. In this constellation, breathing no longer takes place via the tracheostoma but again exclusively via the mouth, nose and throat, the basic prerequisite for permanent decannulation and possible subsequent closure of the tracheosto-ma. The final decision as to whether decannulation is possible is ultimately made by the attending physician after reviewing all the necessary medical criteria.
The weaning process is constantly monitored by the responsible physician and accompanied by regular endoscopic examinations of the airways to determine which therapeutic measures can be performed and at which point in time. Both the time needed and the decision on whether decannulation is ultimately possible must be made very individually for each patient. Decannulation itself is by necessity performed under inpatient conditions. There, the first step is to examine whet-her the permanent cessation of cannulation can in fact be medically advised.
How is decannulation actually performed?
Under permanent monitoring, the tracheostomy tube is removed and the tracheostoma is initially closed with a bandage/patch system. In some cases, as is usually the case with dilated punctu-re tracheostoma, the stoma closes by itself after a short period of time.
However, if a tracheos-toma has been created surgically, then it often has to be closed again surgically. In general, it is advisable to initially allow the tracheostoma to shrink for 10 to 14 days to enable a possible spontaneous closure. Even if this is not the case, the tracheostoma has usually shrunk so much during this time that the necessary subsequent surgical closure only leaves a small scar.
Decannulation is usually not possible in patients with progressive degenerative diseases or also in patients who need to be ventilated 24 hours a day. Nevertheless, intensive logopaedic therapy is strongly recommended especially for these pa-tients to maintain existing bodily functions as best possible and maybe even improve them.
The indication-appropriate attempt to wean the patient from the tracheostomy tube is an ele-mentary part of patient-oriented, professionally planned and accompanied tracheostoma care in the interdisciplinary team consisting of medicine, nursing, therapy and aid suppliers.
FAHL® Decannulation Tape
The FAHL® DECANNULATION TAPE may only be used for tracheostomised patients and is contraindicated for laryngectomised patients.
References:
1 Dodds, Stewart & Logemann (1990). Physiology and Radiology of the Normal Oral and Pharyngeal Phases of Swallowing. American Journal of Roentgenology,154(5), 953–963. Doi: 10.2214/ajr.154.5.2108569.
2 Seidl, R. O., Nusser-Müller-Busch, R. & Ernst, A. (2002). Der Einfluss von Trachealkanülen auf die Schluckfrequenz bei neurogenen Schluckstörungen. Neurol Rehabil 8(6), 302–305.
