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.