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http://www.nhsggc.org.

uk/about-us/professional-support-sites/shock-team/guidelines-for-care-of-
patients-with-a-tracheostomy-tube/tracheostomy-emergencies/accidental-decannulation/

Action rational for Tube Change / Accidental Decannulation Explained


ACTION RATIONALE
Unplanned decannulation is defined as any patient in
whom a tracheostomy is removed either accidentally
Unplanned decannulation? or when during a planned tube change the new
tracheostomy tube is unable to be inserted

Expert can be defined as any competent healthcare


practitioner. This can be any member of the
Seek Expert Help multidisciplinary team who has experience in caring
for the patient with a tracheostomy.

Assess Stoma The stoma should be assessed by performing a head


Head tilt & chin lift tilt and chin lift to open the airway and help visualise
Optimise patient position the tracheostomy site.
Look

at the opening of the stoma to identify any


possible obstruction and remove.
for chest movement. Remember that if the
stoma is completelyobstructed there may
paradoxical breathing but no air movement.

Listen

at the opening of the stoma for movement of


air.

Feel

at the opening of the stoma with your cheek

At all times when managing tube change failure or


AT ANY TIME IF accidental decannulation the patient is at risk of
CLINICALLY INDICATED hypoxia that if unresolved will result in cardiac arrest.
CALL 2222 Therefore at any time, if clinically indicated, the
cardiac arrest team must be called.
PATENT If the patient is still breathing increase/commence
100% O2. If airflow is present optimising
100% oxygen via stoma or oxygenation may prevent the patient developing a
patent airway cardiac arrest.

If following a look, listen, feel there are doubts


regarding the patency of the stoma/airway or no air
OCCLUDED movement is detected, re-establishing a patent airway
is the priority

Remove visible occlusion If there is any visible occlusion this must be relieved
Consider utilising; either by asking the patient to cough and expectorate
Ask patient to cough or by applying suction via the stoma. Tracheal dilators
Tracheal dilators can be utilized to aid visualisation of the stoma and to
Suction maintain a patent stoma/airway.

Perform another look, listen, feel to identify if a patent


Reassess airway has been achieved.

If the airway remains occluded call the cardiac


Call 2222 arrest team and continue to attempt to relieve the
occlusion.
Recannulation When attempting to insert a new tracheostomy tube
Attempts should take no longer than 30
seconds Ensure oxygenation is being maintained
STOP AND REOXYGENATE WITH attempt to pre-oxygenate the patient with
100% OXYGEN VIA STOMA OR 100% xygen
PATENT AIRWAY If not already monitor SaO2
Check the tube prior to insertion to ensure the
cuff is intact
Lubricate the tube
Visualise the stoma
Insert the new tracheostomy tube in a
downwards backwards motion
Remove obturator if used
Check position of tube by listening to air entry
Re-oxygenate
Secure tube

Any attempt at recannulation should take no longer


than 30 seconds to prevent hypoxia.
STOP AND REOXYGENATE WITH 100%
OXYGEN VIA THE STOMA OR PATENT
AIRWAY
Failed Recannulation ? If after a failed attempt at recannulation priority must
Consider be given to
Tracheal dilators maintaining oxygenation.
Exchange device
Cannualtion with a a smaller
tracheostomy tube Monitor the patients SaO2 and optimise
Avoid unnecesary trauma oxygenation.
If after repeated attempts if the patient Tracheal dilators
remains decannulated o Allows good visualisation of the stoma
o Maintains a patent stoma in patients
CONSIDER THE NEED FOR ORAL
Exchange device
INTUBATION
o Bougie/Cooks airway exchange
catheter/guidewire/introducer
o When inserted via the stoma into the
trachea will guide the tracheostomy
tube into the correct position.
Cannulation with a smaller tracheostomy tube
o Following a failed attempt to reinsert a
tracheostomy tube of the same size, a
tracheostomy tube one size smaller
may be easier to insert. It should be
remembered that this will result in a
narrowed airway and the patient should
be monitored accordingly. Repeated
attempts at recannulation may cause
trauma to the stoma and trachea.
Haemorrhage and oedema may further
compromise the airway making further
attempts at cannulation more difficult.
Care must be taken to avoid
unnecessary trauma.

Successful recannulation OR If attempts at recannulation are unsuccessful, oral


Decision made not to recannulate intubation may be required to secure a patent airway
immediately. and maintain oxygenation.
(This decision will only be made by a
competent healthcare practitioner) Following successful recannulation ensure the
Maintain oxygenation tracheostomy tube is in the correct position by
Remain with patient until stable listening to the patients air entry and securing the
Review frequency of observations tracheostomy tube. Monitoring SaO2, respiratory rate
and optimising oxygenation may prevent hypoxic
cardiac arrest and will give an early indication that the
patient is developing respiratory failure.
It must be assumed that all patients will require
recannulation. There is a small number of patients
who may not require recannulation. The decision not
to recannulate the patient must be made by a
competent healthcare practitioner.