10. Accidental decannulation
Decannulation refers to the unintentional or voluntary removal of the tracheostomy cannula from its proper position. In the context of patients on home mechanical ventilation, involuntary decannulation is a critical and life-threatening respiratory problem. Decannulation is the most frequent (6%) late complication of tracheostomy in a Canadian cohort with 30 years of follow-up 21. The incidence of accidental decannulation, as a late complication of tracheostomy, was found in a Korean (2.7%) and a Brazilian study (5.7%)22,23.
There are some studies about various methods for maturing an infant’s tracheostomy stoma to prevent accidental decannulation and complications, such as creating a permanent fenestration in the trachea, using flaps to suture the tracheal opening, and employing the ‘starplasty technique’. The ‘starplasty technique’ appears to be the most effective in reducing major complications but may result in a tracheocutaneous fistula after decannulation, necessitating reconstruction. These procedures are generally reserved for long-term tracheostomy cases or when there’s a concern for accidental decannulation 6.
The latest ATS statement on caring for a child with a tracheostomy at home recommends that two adult caregivers be trained in the care and replacement of a tracheostomy tube 1. A study by Tolomeo et al. examined caregivers of infants discharged from the hospital with a tracheostomy. Seventy percent of caregivers reported that the second caregiver attended the child’s medical care frequently or very often, and 50% of those surveyed believed they could not take adequate care of the patient at home without another trained caregiver (24). In making this recommendation, ATS places high value on patient safety and caregiver quality of life, while placing low value on the increased use of resources required for training multiple caregivers. The following pieces of equipment must be available for home use when caring for a patient in home mechanical ventilation: ventilator, spare ventilator, batteries, aspiration equipment (portable), a self-inflating bag and mask, heated humidifier, supplemental oxygen for emergency use, pulse oximeter and nebulizer 1.
When a tracheostomy cannula becomes dislodged or removed accidentally at home, it can lead to immediate airway obstruction, compromising the patient’s ability to breathe. This situation requires urgent intervention and can be life-threatening if not addressed promptly. Patients on home mechanical ventilation are at a higher risk of involuntary decannulation due to their need for prolonged respiratory support and the presence of a tracheostomy tube.
Hypoxemia can lead to serious complications and even death if not promptly addressed. Therefore, in cases of accidental decannulation or any other event that obstructs the airway, it is essential to act quickly and appropriately. Caregivers, family members, and anyone responsible for the patient’s care at home should be trained to recognize the signs of airway obstruction and know how to respond appropriately. For patients with tracheostomy tubes, reinsertion of the cannula by trained individuals should be attempted, if possible. However, if unsure or unable to reinsert the cannula safely, it is essential not to force it, as this could worsen the situation. Instead, focus on maintaining a clear airway until professional medical help arrives.
Regular monitoring, education, and having a well-prepared emergency plan are essential components of managing patients on home mechanical ventilation to mitigate the risks of airway obstruction and ensure a prompt response to any respiratory emergencies 25.