Protocol for Weaning from Chronic Ventilation through Tracheostomy

Preliminary Assessment of Readiness for Weaning

The American Academy of Otolaryngology-Head and Neck Surgery recommends daily assessment of readiness for weaning from the ventilator using standardized protocols 1, 2
The primary diagnostic test for determining the possibility of weaning is a spontaneous breathing trial (SBT) 3, 2
Criteria for successful passage of the SBT include a respiratory rate of 10-30 breaths/minute, SpO2 > 92%, absence of signs of exhaustion, agitation, hypertension, and tachycardia 3

The American Academy of Otolaryngology-Head and Neck Surgery suggests that the initial SBT should be performed with a small amount of pressure support (5-8 cm H₂O) 2
Most failures of the SBT occur within the first 30 minutes of the test 2
For patients with a high risk of extubation failure, T-tube trials may be more specific for identifying patients who are truly ready for extubation 2

The cuff of the tracheostomy tube should be deflated when the patient is breathing spontaneously 1, 4, 5
The pressure in the cuff should be maintained between 20-30 cm H₂O for air-filled cuffs to avoid loss of tidal volume and prevent tracheal damage 6, 7

The American Academy of Otolaryngology-Head and Neck Surgery recommends a pressure support mode with a deflated cuff as preferable to SBT using a T-tube 6, 7
After successful weaning from the ventilator, a heat and moisture exchanger with a viral filter should be established 6, 7
When the patient is considered to have a low risk of requiring mechanical ventilation again, the tracheostomy tube can be replaced with a cuffless tube 6, 7

Pharyngeal examination should be performed during or after decannulation 1, 5, 8
Assessment of swallowing should include a consistent evaluation of saliva pooling and quiet inhalation, spontaneous swallowing, and laryngeal sensitivity 1, 5, 8
For patients with a low risk of dysphagia, alternative swallowing assessments may include a blue dye test instead of flexible endoscopic evaluation of swallowing (FEES) 6, 7

Patients are candidates for decannulation when the reason for the tracheostomy has been resolved, ventilatory support is not required, coughing/swallowing is adequate, and aspiration is minimal 6, 7
The use of a one-way speaking valve or tracheostomy tube plug requires tolerance of a deflated cuff or cuffless tube to ensure airflow through the vocal cords for phonation 6, 7

Patients with prolonged mechanical ventilation have a higher frequency of swallowing dysfunction 1, 5, 8
Longer intensive care unit stays and increased risk of aspiration and pharyngolaryngeal injuries are associated with prolonged tracheostomy or delayed decannulation 1, 5, 8

A multidisciplinary decannulation protocol should be available in intensive care units 1, 4, 5
A multidisciplinary approach to respiratory rehabilitation can modify the care process for patients who are difficult to wean from ventilation 1, 4, 5