Prior to decannulation, the patient should have been appropriately weaned and be able to tolerate having the cuff down with either a speaking valve or a heat and moisture exchanger on permanently. It may also be appropriate to trial an occlusion or decannulation plug for 12–24 hours (NTSP [206]). This is a small plastic plug or cap that fits onto the outer tube of either a fenestrated or a non‐fenestrated tracheostomy tube (Figure 12.53). It completely blocks off the tracheostomy tube and diverts air around the tube and into the patient's nose and mouth instead. Patients may find this stage difficult as airway resistance is high, and so it may not be well tolerated. As with all care pathways related to tracheostomies, a multidisciplinary approach is required and all members should be involved in the decision to decannulate (Bonvento et al. [28]).

The process should be undertaken or supervised by a practitioner who is competent in recannulation and airway management. The procedure should be well planned and performed at an appropriate time of the day when experienced staff are present (Dawson [58], ICS [116]).

Undiagnosed damage to the trachea – including stenosis, tracheomalacia and granuloma – may result in a failed decannulation (Cipriano et al. [47], ICS [116]). It is important, therefore, that the patient is closely monitored for a period of time after decannulation, to ensure they remain stable and are able to maintain their own airway.

The patient will be able to maintain their own airway once the tracheostomy tube has been removed and will show no signs of clinical deterioration, in particular respiratory distress or tiring.

A tracheostomy box, with a new tracheostomy tube and all emergency equipment (oxygen, suction and a fibreoptic scope), should be available at the bedside and in working order. A resuscitation and advanced airway trolley should be easily accessible if required.

The procedure should always be explained to the patient and verbal consent gained. If required, the patient should be repositioned to ensure their comfort and allow easy access to the tracheostomy tube.

The patient should be nil by mouth for at least 6 hours after eating solids and 2 hours after consuming fluids (NTSP [206]). This is to minimize the risk of vomiting and aspiration.