Page 582 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

402 PART 4: Pulmonary Disorders

Cough Secretions GCS Fi Time since
O 2
tube last
Disposable cu ed changed
tracheostomy
≥ 2 ≤ 25 MP in 24 ≥ 3T ≤ 50% ≥ 48 hours
Cu in
ated hours in SITU
- ≥ 24 hours o positive pressure ventilation
- And low risk of macro -aspiration (absence of:
uncontrolled ongoing vomiting, uncorrected tracheal-esophageal
stula, uncontrolled gastrointestinal bleeding or any clinically
relevant pathology)

Yes? No?

Reassess daily
Disposable cu ed
tracheostomy

De
ate cu
≥ 2 ≤ 25 MP IN 24 ≥ 3T ≤ 50% ≥ 7 days
hours in SITU
- ≥ 24 hours o positive pressure ventilation
- And low risk of macro-aspiration 1
Yes? No?

Change to Reassess daily

Disposable cu ess
fenestrated
tracheostomy
≥ 3 Suctioned ≥ 8T ≤ 50% ≥ 24 hours
≤ every 4 hours in SITU
- ≥ 48 hours o positive pressure ventilation
- And able to expectorate secretions
- And no adventitious sounds with digital occlusion 2

Yes? No?

Reassess daily
Disposable cu ess
fenestrated
tracheostomy

Trial of corking 3 ≥ 3 ≤ Q 4 H ≥ 9 ≤ 50% ≥ 3 days
in SITU
- Corked 48 hours continously
- And able to expectorate secretions
- And strong cough and phonation
- And no further surgery planned
Yes? No?

Decannulation Reassess daily

FIGURE 46-1. Example of an algorithm to guide decisions to deflate the tracheostomy cuff and to proceed toward tracheostomy decannulation. Legend: Cough, score on subjective cough scale
(1 = unable to cough secretions through tracheostomy; 2 = able to cough secretions up to tracheostomy but unable to expectorate beyond tube; 3 = able to expectorate secretions beyond trache-
, fraction of inspired oxygen; GCS, Glasgow Coma Scale from 1 to 15, but scored from 1T to 10T when unable to score verbal component
ostomy tube); Cuff, inflatable cuff on tracheostomy tube; Fi O 2
in patients with tracheostomy; MP, subjective mucopurulence score, calculated by summing the hourly secretion count that is recorded on patient’s flowsheet (range 0 to 3; increasing scores indicate
greater amount of secretions); Time since tube last changed, time since tracheostomy tube first inserted or last changed. Notes: 1. Consideration should be given at this stage to consultation by a speech
and language pathologist to assess safety of swallowing and assist with speech. 2. Patients who have adventitious breath sounds or who are unable to breath during digital occlusion of a dispos-
able cuffless fenestrated tracheostomy tube should be evaluated with laryngoscopy and/or bronchoscopy prior to continuing with the decannulation pathway. 3. We recommend first implementing
intermittent trials of corking of the tracheostomy tube prior to continuous corking of the tube. (This algorithm is adapted with permission from one developed at Sunnybrook Health Sciences Centre
by Ryan Smith RT and Martin Chapman, MD. It is provided for informational purposes only, and site-specific and patient factors should be considered before adapting for use in other settings.)

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