Sample Tracheostomy Weaning Protocol
TRACHEOSTOMY WEANING PROTOCOL
This protocol outlines the process for the safe and effective weaning of a patient from a tracheostomy tube in order to facilitate decannulation.
People Involved: Interdisciplinary: with Respiratory Care Services, Speech Pathology, and Nursing, in conjunction with physician participation and a protocol guided order set.
PREREQUISITE: Physician order to initiate Tracheostomy Wean Protocol
CONTRAINDICATIONS: severe aspiration risk (per speech therapy evaluation), severe upper airway obstruction, medical instability, foam-cuffed tracheostomy tube.
II. SUPPORTIVE INFORMATION
A. To implement this guideline, the patient must be medically stable and meet the minimum criteria:
- Five to seven days postoperative, to ensure a mature stoma, following a temporary tracheostomy.
- Patient must be awake/alert
- No acute respiratory problems (such as pneumonia, shortness of breath, respiratory insufficiency)
- Not a significant aspiration risk- (handling secretions)- per SLP
- Oxygen saturations in range ordered by MD
- Not on mechanical ventilation- (may begin at a minimum of 4 hours off mechanical ventilation)
- No anatomical upper airway obstruction or limitation
- Tolerating a minimum of 1 hour of speaking valve use with general supervision
B. Patient population:
Postoperative temporary tracheostomy patients may be candidates for this protocol. Permanent tracheostomy (e.g. total laryngectomy) patients are not probable candidates for this protocol.
C. Protocol limitation;
Patients meeting the above criteria can be initiated into the protocol with a physician order for the “Tracheostomy Weaning Protocol”. Patients will already have been trialed with cuff deflation and able to tolerate the Passy Muir Speaking Valve for at least one hour with general supervision. Please see protocol for Passy-Muir Speaking valve placement for more information. Patients will also be, at the minimum, on 4 hours of spontaneous breathing trials.
III. PASSY MUIR SPEAKING VALVE AND CAPPING
Patient will wear the speaking valve in increments of time:
Step 1. 1 hour
Step 2. 2 hours
Step 3. 4 hours
Step 4. 6 hours
Step 5. 10 hours
Step 6. 12 hours
Daily goals can be skipped if a patient is tolerating the speaking valve well.
After 12 hours of use, a capping trial will begin for all waking hours. A separate order will be required for capping the patient for 24 hours (to avoid problems if a patient has sleep apnea).
Options to consider with extended speaking valve use include (MD order required):
-Cuffless tracheostomy tube
-Downsized tracheostomy tube
-Fenestrated tracheostomy tube
-Removal of the inner cannula
-O2 by Nasal Cannula
RCP will remove the speaking valve during treatments and when the patient returns to mechanical ventilation (unless there is an order for “PMV in-line with ventilator). RCP may continue with the speaking valve as tolerated to all waking hours if indicated.
“Stop Criteria”: Remove the speaking valve if:
HR increases by 20BMP
RR is greater than 35
SpO2 is less than 90%
FiO2 is required to be greater than 60% to maintain adequate saturations
Patient reports difficulty breathing greater than 6 (on a scale of 1-10)
For patients who effectively mobilize secretions without the need for suctioning for 24 hours, and successful completion of trach capping for 24-48 hours, the RCP/SLP may recommend a bronchoscopy and button. An order from the MD must be obtained prior to the procedure.
Documentation will take place in Meditech under each discipline for individual patient progress within the protocol pathway.
RCP will document each step under “PMV tracking.” RCP will document that the patient has been buttoned and/or decannulated under “Care Plan” on the same day that the procedure occurs.
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