Trach Progression

B.F. asks, "What is the usual progression of trachs?  My mom got her trach after being in the ICU on a ventilator.  Now she is off the ventilator...so what happens next?"

Answer: The usual progression for tracheostomies depends upon the reason why it was initally placed.  For patients who received their trach because they had difficulty weaning from the ventilator, once they become free from ventilator support, they can begin what we call "trach progression". 

Trach progression is the process of gradually allowing the patient to do more breathing around the tube, rather than through the tube.  Frequently, this requires a tube with a smaller outer diameter--or usually, one without a cuff.  The eventual goal of trach progression is usually removal of the tube.

The first step in trach progression involves deflating the cuff of the tube and assessing the patient to ensure that cuff deflation is tolerated well.  Some patients do not tolerate cuff deflation because they cannot manage their secretions, or because they don't have an effective cough or swallow.  

When the patient is able to tolerate cuff deflation, the tube is usually changed to a cuffless tube and then capping trials can begin.  Capping has many benefits, including voice restoration, smell, taste, improving cough and swallow, etc.

When the patient is able to tolerate capping for 24-48 hours, he or she is evaluated for decannulation--that is, the ability to function safely without the trach.  This involves measuring cough strength to ensure that the patient can cough up all their secretions.  When cough strength is strong enough and the patient can manage their secretions, the tube can be removed.  After decannulation, the stoma usually closes up completely within a few days.

When people have been on the ventilator in the ICU for a prolonged period of time, they are usually quite weak and  frequently trach progression must take place over a prolonged period of time.  Sometimes, it takes a long period of time in rehab before the patient has gained enough strength for the trach to be safely decannulated.