NTSP Manual 2013: Cuff Management, Vocalisation, and Speaking Valves

Overview

• Tracheostomies may be temporary and should be removed when no longer necessary.
• Decannulation timing can be complex and requires patient progression.
• Early removal of tracheostomy tubes can reduce complications.
• "Weaning" can refer to reducing mechanical ventilation or decannulation process.
• Categories of tracheostomy patients: permanent, long-term (difficult to wean), temporary (weanable).

Multidisciplinary Team (MDT)

• Key members: Ward Nurse, Physiotherapist, Speech & Language Therapist, Specialist Nurse, Respiratory Physician, Head & Neck Surgeon, Anaesthetist or Intensivist.
• Patients and caregivers may contribute valuable knowledge.
• MDT must understand patient condition, reason for tracheostomy, and decannulation indicators.

Patient Assessment for Weaning

• Assess if the reason for tracheostomy is resolved (via endoscopy if needed).
• General patient assessment includes:
  • Airway patency
  • Ability to maintain airway
  • Independence from ventilatory support
  • Haemodynamic stability
  • Absence of infection
  • Alertness and cough strength
  • Swallow competence
  • No impending procedures requiring anaesthesia

Weaning Process

• Numerous decannulation protocols exist; no universal best practice.
• First step: deflate tracheostomy tube cuff to check airway patency and secretion management.
• Hypoxia indicates patient may not be ready for further steps.
• Prolonged cuff deflation should be tolerated before moving forward.
• Occlusion trials assess ability to breathe through upper airways.
• Failure in occlusion trials may suggest upper airway obstruction.

Speaking Valves and Caps

• Speaking valves allow inspiration via tracheostomy, closing on expiration to force air through upper airways.
• Occlusion caps block airflow via tracheostomy tube.
• Never use with a cuffed tube inflated, as it can block exhalation and lead to suffocation.
• Monitor closely as patients may tire quickly, delaying weaning.

Weaning Documentation

• Standardised weaning and decannulation practices should be guided by local, multidisciplinary policies.
• Ensure continuous review, proper documentation, and maintenance of respiratory observations.
• Provide emergency access to expert help with clear guidelines and signs.