Pre‐procedure

ActionRationale

1. 1.Show
   Discuss decannulation with the multidisciplinary team.
   To ensure the multidisciplinary team agree to the patient being decannulated and are readily available if required. E
2. 2.Show
   This procedure requires the presence of two nurses.
   To ensure patient safety (NTSP [206], C).
3. 3.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [198], C).
4. 4.Show
   Cleanse hands with soap and water or an alcohol‐based handrub.
   To minimize the risk of infection (NHS England and NHSI [179], C).
5. 5.Show
   Help the patient to sit in a semi‐recumbent position with the neck slightly extended.
   To ensure patient comfort. E

   Extending the neck will make removal of the tube easier (NTSP [206], C).
6. 6.Show
   Apply oxygen therapy via either a nasal cannula or a face‐mask (if required).
   To reduce the risk of hypoxia (O'Driscoll et al. [209], C).
7. 7.Show
   Prepare a dressing tray or trolley for the procedure. Open the procedure pack and pour normal saline 0.9% solution into a gallipot. Prepare the dressing to be applied over the tracheostomy stoma.
   To ensure all equipment required is prepared prior to starting the procedure. E

Procedure

1. 8.Show
   Cleanse hands using an alcohol‐based handrub and apply disposable plastic apron, gloves and eye protection.
   To minimize the risk of infection (NHS England and NHSI [179], C).
2. 9.Show
   Encourage the patient to cough and suction any secretions as required.
   To minimize the risk of aspiration (Morris et al. [167], C).
3. 10.Show
   While one nurse holds onto the tracheostomy tube, the second nurse removes the tapes and any sutures present at the flange, and deflate the cuff (if still inflated).
   To ensure the tube is not accidentally dislodged before the right time. E

   To prepare the tube for decannulation. E
4. 11.Show
   Check both practitioners and the patient are happy to proceed prior to removing the tube. Provide reassurance to the patient as required.
   Good communication increases patient safety. E

   To minimize patient anxiety. E
5. 12.Show
   Remove the tube on maximal inspiration.
   To reduce the risk of alveolar collapse (Global Tracheostomy Collaborative [89], C).
6. 13.Show
   Clean the stoma site using normal saline 0.9% soaked gauze then allow it to air dry.
   To clean the skin and minimize the risk of infection (Global Tracheostomy Collaborative [89], C).
7. 14.Show
   Bring together the top and bottom of the stoma to ensure an optimal seal is achieved. Secure with gauze and an occlusive dressing.
   To encourage the stoma to close and ensure all ventilation takes place via the upper airways. E

   Covering the stoma also reduces the risk of infection by ensuring dust and particles are not inhaled directly into the respiratory tract. E
8. 15.Show
   Check that the patient is comfortable and is at ease with their breathing.
   To ensure patient comfort. E

Post‐procedure

1. 16.Show
   Monitor the patient's respiratory status and observations/NEWS. Escalate any concerns or deterioration in condition/NEWS immediately.
   Removal of a tracheostomy tube is a high‐risk procedure. The patient may not be able to maintain their own airway and may require emergency recannulation or intubation. Patients should be monitored closely and the situation escalated immediately if there are any concerns (NTSP [206], C).
2. 17.Show
   Encourage the patient to hold their hand over the stoma dressing when they speak or cough.
   To prevent the occlusive dressing being dislodged and to divert air through the vocal cords, aiding phonation and communication (NTSP [206], C).
3. 18.Show
   Inform the patient that the stoma may take 7–14 days to heal over and close.
   To increase patient understanding and appreciation of how long the stoma will take to heal. E
4. 19.Show
   Document what date and time the patient was decannulated, and any issues or concerns arising during or after the procedure.
   To ensure all members of the multidisciplinary team are aware of when the patient was decannulated and to help plan future care. E
5. 20.Show
   Renew the dressing every 24 hours or more frequently if required. Monitor the size of the stoma daily.
   To minimize infection, promote wound healing and monitor stoma closure (Global Tracheostomy Collaborative [89], C).
6. 21.Show
   Keep the tracheostomy box at the patient's bedside for a further 48 hours post‐decannulation.
   To allow easy access to the emergency equipment if the patient deteriorates and requires emergency recannulation (Global Tracheostomy Collaborative [89], C).