This guideline relates to children and young people undergoing tracheostomy decannulation at Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH).
The ‘Tracheostomy Decannulation Information Booklet’ is a useful resource which can be used to supplement the information contained within this guideline.
This information is used to support the Integrated Care Pathway (ICP) (see appendix 1) for tracheostomy decannulation and should be utilised, alongside standardised Trust documentation, and CEWS charts, nervecentre or carevue. Paediatric decannulation can be achieved in two ways:
- surgically under a general anaesthetic
- on the ward
Surgical decannulation is carried out under a general anaesthetic and usually involves reconstruction of the upper airway or stomal area. The tracheostomy is removed at the time of surgery and the stomal opening surgically closed, the child will be routinely intubated on the intensive care unit for up to seven days with an elective Microlaryngoscopy (MLB) and Bronchoscopy, downsize and elective extubation (Rationale 1).
Trial of ward decannulation is the most common method to remove the tracheostomy tube. It is non-invasive and does not require intubation and or admission to a paediatric intensive care unit.
Endoscopic evaluation of the airway is required to confirm the patency at all levels and to exclude (and treat) peri-stomal complications such as granulation or collapse. The decannulation trial itself must take place within six weeks of the assessment (Rationale 2).
If the decannulation is carried out straight after the MLB (this would be unusual) then the patient must have a ‘rest day’ to allow any potential oedema to settle, before the trial period begins.
The child/young person remains in hospital during the most critical stage of the programme (Rationale 3).
The guideline gives direction to enhance the safety of the child/young person during this critical time.
Ward decannulation usually required a five-day admission but this will vary according to the age of the child/young person and the type of tracheostomy tube they have in situ.
The child/young person and family should be informed of the following (Rationale 4):
- That a decannulation trial is appropriate and why.
- What the trial entails.
- Likely duration of the procedure (Rationale 4).
- Inform/involve psychologist/play staff/family members (as required) (Rationale 5).
The child/young person’s locker top (or a trolley) should be prepared as per the tracheostomy guidelines, and dedicated to tracheostomy care and equipment only. As the tracheostomy tube is downsized the tube in the emergency tray must be ‘downsized’ accordingly (Rationale 6).
Principles of decannulation
Decannulation is an extremely worrying time for parents and the child, therefore we stage the process to give the child confidence that they can breathe without the tube.
If an older child/young person has a tracheostomy tube with an internal diameter (ID) greater than 3.0mm, smaller tracheostomy tubes should be inserted until a tube size of 3.0mm is reached (Rationale 7). For example if the child is admitted with a 5.0mm ID tube it may take two days to get to the 3.0mm ID tube, by reducing one whole size each day.
Older children/young people who have been using larger tubes (all relative to the airway diameter) or tubes with cuffs or inner cannulas, will need to be discussed and the procedure planned on an individual basis with the Tracheostomy Nurse Practitioner (NP) or medical team.
For small infants /children, weighing less than 12 kg, where a tracheostomy tube with a 3.0mm ID will occupy much of their airway, the decannulation process will be different. This will include downsizing the tracheostomy tube to a 2.5 ID rather than the 3.0 ID or removing the tracheostomy tube without going through the process of downsizing or capping (Rationale 8). This will only be done after discussion with the child’s consultant/tracheostomy NP.
When a size 3.0mm (or 2.5mm) internal diameter (ID) tracheostomy tube size is reached this is recorded as 'Day One' of the decannulation programme.
Downsize the tracheostomy tube to a 3.0 internal diameter tube has been achieved
The child must have in place a tracheostomy tube with a 15 mm standard termination to allow fitting of the decannulation cap.
Observe and record for any signs of increased respiratory effort.
- skin colour change (cyanosis, pale)
- irritability/anxious (associated with breathing)
- restlessness, particularly when asleep
- loss of appetite
- tracheal tug/nasal flaring
- lethargy when normally active/ breathlessness on exertion
- sternal/intercostal/subcostal recession
- change in general observations (increased heart/respiratory rate)
- increased respiratory effort
Should complications arise, as outlined above, indicative of deterioration, follow Trust Observation and CEWS Policy to ensure effective urgent response is achieved. The Ear Nose Throat (ENT) medical team/tracheostomy NP should also be called, but DO NOT delay following the appropriate CEWS escalation processes. Should the child experience any difficulties consideration should be given to stopping the trial by upsizing the tracheostomy tube (Rationale 9).
The child/young person may be allowed off the ward with a carer who is tracheostomy competent and can recognise and manage the signs of respiratory distress as described above.
Record the downsizing of the tracheostomy tube in the child’s health care record.
Record half hourly observations of pulse and respiratory rate, whilst asleep and undertake routine observations in line with the child’s general condition whilst awake (Rationale 10). Document observations in the Integrated Care Pathway (ICP) and record on the CEWS chart, nervecentre or carevue.
Should complications arise, as outlined above, indicative of deterioration, follow Trust Observation and CEWS Policy.
Occlude the tracheostomy tube
The child/young person’s progress will be assessed and reviewed by the ENT team/tracheostomy NP who will advise on the next stage. If the child/young person has been stable during the past 24 hours the tracheostomy tube will be covered with a red 'occlusion cap'. This cap can be easily seen and easily removed in case of any difficulty.
The child/young person should be able to cough around the tube (Rationale 11). Removing the cap during coughing or suctioning the tube is classed as a failed attempt, so this should not be done. The child/young person must learn to clear secretions on their own. If they are finding this difficult ask the tracheostomy NP for advice on exercises to support the child/young person develop this skill.
If the child becomes overly distressed remove the cap immediately and inform the ENT team/tracheostomy NP. Should complications arise, indicative of deterioration, follow Trust Observations and CEWS Policy. Monitor and record the child/young person’s pulse and respiratory rate every half hour when asleep (Rationale 10). This is recorded on the CEWS chart, nervecentre or carevue AND in the ICP. Routine observations as condition depicts whilst awake.
Whilst the patient is allowed off the ward, to walk around hospital/attend school, there must be staff/carer present that is ‘tracheostomy competent’.
Record the child’s progress in their health care records.
Remove the tracheostomy tube
The child/young person is re-assessed by the ENT team/tracheostomy NP. If the capping stage has been uneventful for 24hrs:
Remove the tracheostomy tube.
Cover the stoma with clean gauze secured with a waterproof, airtight dressing such as Duoderm or P3 Tracheseal®. Both will provide an airtight occlusion around the opening, preventing the child from breathing through it.
Practitioners should ensure that the dressing remains airtight (Rationale 12). If the stoma is particularly large it may be sensible to leave the stoma exposed until it closes down a little, otherwise the dressing will blow outwards and come away from the skin.
Record the decannulation in the health care record.
Change the tracheostomy swivel connection to a face mask on re-breathe circuit - but keep the swivel connector in the emergency box. Keep the tracheostomy box by the bedside with a size 3.0mm ID tube in it; this is only to be re-inserted by the ENT team or Tracheostomy NP.
The child/young person must not leave the ward for the next 24 hours (Rationale 13). Involve the play therapist/parents to keep the child occupied.
Monitor and record the child/young person’s pulse and respiratory rate every half hour when asleep. This is recorded on the CEWS chart/nervecentre/carevue AND in the ICP. Routine observations as condition depicts whilst awake.
Should complications arise, indicative of deterioration, follow Trust Observation and CEWS Policy. Include Ear Nose Throat (ENT) medical team/tracheostomy NP but DO NOT delay calling the emergency team on ext. 2222 as necessary. Consideration should be given to reinserting the tube, but this must only be done by the ENT team/tracheostomy NP (Rationale 14).
In an emergency do not attempt to replace the tracheostomy tube into the stoma until ENT/tracheostomy NP/emergency team are present but manage the airway in the conventional manner. Call 'emergency team' if child appears to be in difficulty (ext. 2222).
After the assessment and it is deemed that the trial has failed the ENT /Tracheostomy NP will reinsert the tracheostomy tube. However if the stoma has closed it may need to be dilated with smaller tubes until the original size is reached or the child may be taken back to theatre for the stoma to be dilated. The child is then discharged with a follow-up plan.
Record the progress of the child in their health care records.
If the 24 hours after tube removal has been uneventful, remove the airtight dressing to enable ENT team/ NP Tracheostomies to review stoma site.
Renew dressing as before using an aseptic non touch technique.
Monitor and record the child/young person’s pulse and respiratory rate every half hour when asleep. This is recorded on the CEWS chart, nervecentre or carevue AND in the ICP. Routine observations as condition depicts whilst awake.
The child will be allowed off the ward but only after a review of mouth to mouth resuscitation technique - this is completed by one of the trust BLS instructors. The Tracheostomy NP or ENT nurses will discuss the general care of the stoma, equipment, emergency procedures, schooling, and care of the stomal opening, with the parents/carer and ensure they are confident to manage these aspects of care once discharged. This must be documented in the ICP.
Record the progress in their health care records.
Review by the ENT team/ Tracheostomy NP in the morning.
If the decannulation process has been without complication the child will be discharged home.
If the stoma remains large/with excessive exudate replace the dressing as necessary and give parents a stock of dressings.
Explain to parents that the stoma may/may not close by itself. If it hasn’t closed after six to nine months then it will be surgically closed.
Contact Community team and GP to inform them of the outcome of the decannulation process and to arrange for replacement dressings to be ordered.
Arrange an ENT Outpatient appointment for six/eight weeks.
Ensure the parents have a contact number for the ward in case of any concerns.
Record the outcome of decannulation in the health records.
Rationale 1: To protect the airway in case of post-surgical oedema and for the tube to support any reconstructive surgery.
Rationale 2: To ensure there are no airway changes eg formation of a granulation from where the tube has irritated the tracheal lining.
Rationale 3: To allow appropriate airway monitoring as well as intervention including halting the procedure and replacing the tracheostomy tube if indicated.
Rationale 4: Information giving and management of expectations and assessing the families understanding and cooperation with the process.
Rationale 5: To utilise other professionals to assist in addressing any fear/distress.
Rationale 6: Appropriate sized equipment readily available to achieve and maintain patent airway.
Rationale 7: The tube size should only be downsized one whole size at a time, this will allow the stoma to shrink and the child to adjust to breathing through the nose and mouth,
Rationale 8: The 3.0 ID tube can occlude a significant amount of the baby’s airway, going down to a 2.5 ID (or removing the tube- albeit rare) will give the child space to breathe around it.
Rationale 9: Return the child to the appropriate tube before discharge.
Rationale 10: Children tend to deteriorate whilst sleeping when the airway is relaxed, therefore careful observations every half hour is essential in maintaining their safety during the process.
Rationale 11: Downsizing to a 3.0/2.5 ID should allow enough space for the child to breathe around the tube and to expel secretions.
Rationale 12: The decannulation process is to see if the upper airway can support breathing, therefore the stoma must be covered completely to prevent air from entering or leaving the stoma.
Rationale 13: The first 24 hours after the tube has been removed is the most crucial and dangerous for the child/young person. If the process fails and the tube needs to be re-inserted it will be within this period. Easy access to emergency equipment and personnel is essential.
Rationale 14: Forcing a tracheostomy tube into a tight/closed stoma with cause pain and distress to the child, oedema/trauma at the site and prevent further efforts to replace the tube.
Waddell, A, Appleford, R, Dunning, C, Papsin, BC, Bailey, CM (1997) The Great Ormond Street Protocol for ward decannulation of children with tracheostomy; increasing safety and decreasing cost. Int J Pediatric Otorhinolaryngology 39(2): 111-118
Kubba, H,Cooke, J, Hartley, B (2004) Can we develop a protocol for the safe decannulation of tracheostomies in children less than 18 months old? Int J Pediatric Otorhinolaryngology 68(7): 935-937
Possimi, V, Cooke, J, Jephson, C (2015-Pending) Great Ormond Street Hospital; Safe Approach to Paediatric Tracheostomy Decannulation. Int J Pediatric Otorhinolaryngology (pending - due for publication summer 2015)