Tracheostomy: Postoperative care, maintenance, and complications in adults

INTRODUCTION — Tracheostomy is a procedure that creates an opening in the anterior wall of the trachea, through which a tracheostomy tube can be placed. Tracheostomy can be performed as a surgical or percutaneous procedure.

An overview of post-tracheostomy care and management of tracheostomy complications are discussed here. Indications and contraindications of tracheostomy and procedural technique are discussed separately. (See "Tracheostomy: Rationale, indications, and contraindications" and "Tracheostomy in adults: Techniques and intraoperative complications".)

POSTOPERATIVE CARE — We advocate for protocolized care following tracheostomy placement (table 1) with the use of skilled multidisciplinary teams [1,2]. (See 'Importance of multidisciplinary teams' below.)

Location — Most patients who undergo this procedure are transferred to the intensive care unit (ICU; surgical tracheostomy) or already reside in the ICU (percutaneous tracheostomy). Occasionally, alert individuals who are able to protect their airway and have no need for aggressive airway clearance or mechanical ventilation may initially be cared for in a monitored non-ICU setting by health care workers knowledgeable in tracheostomy care (eg, high-dependency unit or ear, nose, and throat oncologic unit).

Immediate care — For immediate postoperative care, the following is reasonable:

●We measure vital signs, inquire about postoperative pain, inspect the stoma for bleeding, and examine the neck and torso for subcutaneous air that might suggest pneumomediastinum/pneumothorax. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Pneumothorax/pneumomediastinum from a false tract'.)

●When a complication such as pneumothorax is suspected, we perform a chest radiograph and bedside thoracic ultrasound [3].

●We perform tracheostomy tube suctioning every two to three hours and also as needed, for airway clearance and to monitor for bleeding. (See 'Bleeding' below.)

●If the cuff is inflated, we check cuff pressure to ensure that it is maintained between 20 and 30 cm H₂O, although some experts target 25 to 35 cm H₂O. (See "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients", section on 'Maintain optimal cuff pressure'.)

●If the patient is mechanically ventilated, we resume original ventilator settings once sedation and paralysis medications have worn off (one to four hours, sometimes longer). We inspect ventilator settings and graphics to ensure that volumes and airway pressures are similar to or lower than those obtained prior to tracheostomy placement (table 2); notably, airway resistance, peak inspiratory pressures, and intrinsic positive end-expiratory pressure (ie, auto-PEEP) may decrease after tracheostomy. We do not actively engage patients in ventilator weaning until 24 hours after tracheostomy placement, provided no complications have occurred. An arterial blood gas is not typically obtained. (See "Weaning from mechanical ventilation: Readiness testing" and "Initial weaning strategy in mechanically ventilated adults".)

●We keep an endotracheal tube and "back-up" tracheostomy tubes at the bedside in case of accidental tracheostomy dislodgement. Ideally, one "back-up" tracheostomy tube should have identical dimensions to the one in place and another should be narrower than the one in place.

●For ventilated patients, we also generally remove the inner cannula (if a dual-cannula tracheostomy was placed) and ventilate through a single lumen, unless the inner cannula is needed to connect to the ventilator. For those who do not require mechanical ventilation, the inner cannula may remain in place, provided the patient is comfortably tolerating it. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Tube types'.)

●We do not typically administer antibiotic prophylaxis, unless indicated for another reason (eg, endocarditis prophylaxis).

Subsequent care — Over the subsequent one to two weeks, we routinely perform the following:

●Inspect the stoma and tracheostomy tube for bleeding and signs of infection and cleaned with saline daily. (See 'Bleeding' below and 'Infection' below.)

●Suction on an as-needed basis and check the stoma site for epithelialization.

●Change the dressing two to three times a day, or more if saturated with secretions and/or blood. We prefer a dry dressing, but a wet saline dressing can also be used.

●Provide nursing and respiratory care according to the standard policy set in the institution.

●Perform speech and language pathology evaluation to assist with communication [4,5]. (See 'Speech devices' below.)

●If indicated, begin weaning off the ventilator, which can be initiated as early as 24 hours after placement and assess the potential for decannulation. (See 'Decannulation' below.)

Epithelization of the tract occurs over the first seven days, at which point the tracheostomy tube can be exchanged, although some experts wait for two weeks or longer. (See 'Changing a tracheostomy tube' below.)

Regular maintenance over a longer period (weeks to months) involves daily cleaning of the inner cannula, routine tracheostomy exchanges, stomal care, daily tracheostomy dressings, daily monitoring of cuff pressure (20 to 30 cm H₂0), tracheal suctioning when indicated, and humidification of oxygen. (See 'Changing a tracheostomy tube' below.)

COMPLICATIONS — Minor complications from tracheostomy are frequent (eg, pain, minor bleeding), but serious complications are uncommon. One prospective series found an inpatient complication rate of 47 percent among 1000 tracheostomies performed in a single center over the course of a year [6]. However, the majority of these were minor. In the same series, the complication rate was lower (15 percent) in outpatients than in inpatients who underwent tracheostomy. Although not rigorously studied, the complication rate associated with tracheostomy may be increased in patients with a body mass index ≥35 kg/m² [7].

Tracheostomy is frequently associated with hospital readmission (approximately 33 percent) [6]. However, this is often due to the underlying disease as opposed to complications of the procedure itself.

Postoperative complications occur early or late following tracheostomy. While there is no consensus on how to define early or late, we typically consider complications that occur early as those seen within the first week to 10 days after tracheostomy, while we consider late complications as those that occur after this period.

Intraoperative complications are discussed separately. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Intraoperative complications'.)

Early (within 7 to 10 days) — The most common acute complications of tracheostomy (ie, during the first week to 10 days) include hemorrhage, obstruction, pneumothorax, and infection. Accidental decannulation (ie, dislodgement) is a particularly serious complication when it occurs early, since there is an increased risk of airway loss compared with decannulation after one week when the tracheocutaneous tract is epithelialized.

Bleeding — Minor bleeding from the stoma site is common after tracheostomy and is more commonly encountered in those with a bleeding diathesis (eg, platelet count less than 50 x 10⁹/L and the presence of a coagulopathy) [8].

Bleeding should be monitored by checking the stoma site frequently, observing the quality of secretions on tracheal suctioning, and by recording how often the dressing needs to be changed. In most cases, minor bleeding resolves by itself after a few days.

Although rare, significant bleeding (eg, ongoing saturation of dressings, continued frank bleeding) may require revision of the tracheostomy and search for the source of bleeding after any bleeding diathesis has been addressed.

Bleeding due to the development of a tracheoarterial fistula is a complication that can be catastrophic. While it can occur during the early phase, it is more commonly encountered approximately three to four weeks after the tracheostomy placement. (See 'Tracheoarterial fistula' below.)

Bleeding rates may be lower in those who undergo percutaneous rather than surgical tracheostomy. One meta-analysis of 17 randomized trials reported lower rates of bleeding in patients who underwent a percutaneous dilatational tracheostomy compared with patients who underwent surgical tracheostomy (odds ratio [OR] 0.29, 95% CI 0.12-0.75 [9]). By contrast, two other meta-analyses reported no difference in major bleeding between the two procedures [10,11].

Management of pharmacologic anticoagulants periprocedurally is discussed separately. (See "Perioperative management of patients receiving anticoagulants" and "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Checklists, medication adjustment, infection control, cuff inflation'.)

Obstruction — Obstruction due to inspissated secretions or blood can occur in the early (or late) postoperative period. To avoid this complication, we promote the use of protocols that advocate for regular tracheal suctioning, humidified oxygen, and scheduled daily cleaning or replacement of the inner cannula.

Tracheostomy tubes can also become partially obstructed by the posterior membranous trachea following initial placement, although symptomatic obstruction is uncommon [12,13]. This complication appears to be related, in part, to the experience of the clinician performing the procedure and can occur even a week after tube placement [13,14].

Rarely, obstruction can occur due to partial displacement of the tracheostomy tube or complete displacement into a false tract. (See 'Tracheostomy tube dislodgement' below.)

The approach to obstruction is similar to that in patients with suspected obstruction of an endotracheal tube (ETT), which is discussed in detail separately (see "Assessment of respiratory distress in the mechanically ventilated patient", section on 'Obstruction'). In brief, when a tracheostomy tube becomes obstructed, obstructing equipment should be removed from the tracheostomy itself including ventilator circuit, a cap, or speaking valves (see 'Techniques' below and 'Speech devices' below). The inner cannula, if present, should also be removed and inspected. A suction catheter should be placed into the tracheostomy tube and passed into the trachea. These maneuvers should relieve most episodes of obstruction. If the obstruction cannot be removed from the tracheostomy tube itself, the tracheostomy tube may need to be removed and replaced or an ETT placed. (See 'Changing a tracheostomy tube' below.)

Subcutaneous emphysema and pneumothorax — The incidence of subcutaneous emphysema and pneumothorax following tracheostomy is 1.4 and 0.8 percent, respectively [15]. This can occur from the creation of a false tract anterior to the trachea during placement or replacement or from accidental perforation of the posterior tracheal wall during percutaneous tracheostomy (eg, from the guiding wire or dilator). Management is discussed separately. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Pneumothorax/pneumomediastinum from a false tract' and "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Esophageal perforation'.)

Infection — Mild cellulitis at the stoma site and tracheitis are the most common infections encountered after tracheostomy placement.

In general, these infections are minor and are treated with good wound care, regular cleaning of the stoma site, tracheal suctioning, and appropriate daily dressing changes. Antibiotics are not generally needed.

Rare infections that require antibiotics include stomal abscess formation, mediastinitis, osteomyelitis, septic arthritis of the sternoclavicular joint, and necrotizing fasciitis [16-18]. (See "Postoperative mediastinitis after cardiac surgery", section on 'Treatment' and "Septic arthritis in adults" and "Nonvertebral osteomyelitis in adults: Treatment" and "Necrotizing soft tissue infections".)

Infection rates may be lower in patients who undergo percutaneous rather than surgical tracheostomy. In two meta-analyses of randomized trials, percutaneous dilatational tracheostomy decreased wound infections compared with surgical tracheostomy (OR 0.28, 95% CI 0.16-0.49) [9,11]. A separate meta-analysis of 29 randomized and nonrandomized studies reported a similar reduction in the rate of wound infection with percutaneous tracheostomy [10]. Although the reason for lower infection rates is unknown, it is thought that the snugly fitting stomal tissue tract around the tracheostomy tube may be less prone to stomal infection.

Tracheostomy tube dislodgement — Accidental decannulation is not uncommon, with reported rates up to 15 percent [19-21]. The tracheostomy tube can be displaced or dislodged during turns, procedures, or transport, and bouts of excessive coughing, or can be removed by the patient.

Some data suggest that this complication may be higher in those who undergo a percutaneous tracheostomy compared with patients who undergo surgical tracheostomy [16].

Risk factors include mental status change, traumatic brain injury, increased secretions, recent tracheostomy changes, and increased neck thickness [19,22].

This complication can be minimized by proper security ties that anchor the flange of the tracheostomy tube to the tracheostomy collar, which encircles the neck. While we do not typically use "stay sutures" to secure the tracheostomy tube to the skin of the neck, this mechanism is used by some experts to avoid dislodgement when staff are poorly experienced in tracheostomy care.

If accidental decannulation occurs within the first 10 days after tracheostomy tube placement and the patient is experiencing respiratory distress, we typically do not replace it with a new tracheostomy tube. We adopt this approach because this maneuver risks generating a false tract anterior to the trachea, since the tract is not considered as mature at this point. The safest approach is to intubate patients orally with an ETT and inflate the cuff distal to the stoma site, provided oral intubation is feasible. A replacement tracheostomy can then be safely attempted by experts skilled at tracheostomy placement; fiberoptic bronchoscopy should be used to confirm proper placement in the airway. In rare circumstances, when an ETT cannot be placed (eg, massive upper airway obstruction) and the tracheostomy tube needs replacement through the original stoma in order to stabilize the airway, we suggest that it be performed under fiberoptic guidance by experts in airway management. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Pneumothorax/pneumomediastinum from a false tract' and "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Tracheostomy techniques'.)

The risk of accidental decannulation has the greatest impact on patients with a difficult airway, since delay in restoring the airway may lead to prolonged hypoxemia. If patients need bag-mask ventilation (BMV), placing two gloved fingers and some gauze over the stoma may help improve the efficiency of BMV. If an upper airway mass is present, BMV over the stoma site may be attempted until an airway is achieved. (See "Approach to the difficult airway in adults for emergency medicine and critical care" and "Management of the difficult airway for general anesthesia in adults".)

Late (≥7 to 10 days) — Late complications of tracheostomy (ie, ≥7 to 10 days) include stenosis of the trachea and stoma, tracheomalacia, and tracheoarterial fistula as well as aspiration and pneumonia, dysphonia and dysphagia, tracheoesophageal fistula (TEF) formation, obstruction, and accidental decannulation. Death is uncommon.

Tracheal and stoma stenosis — Patients who have a tracheostomy for a prolonged period can develop tracheal or stomal obstruction due to the development of granulation tissue.

●Tracheal stenosis – Tracheal stenosis occurs in up to 16 percent of patients with a tracheostomy tube [23-26]. Most stenoses are subglottic and may be more commonly seen with fenestrated tracheostomy tubes [27]. However, stenosis can also develop along the shaft or tip of the tracheostomy tube (eg, due to unusual angulation of the tracheostomy tube), and at the cuff site.

•Pathogenesis – Most tracheal stenoses are thought to be due to tracheal injury or ischemia from cuff overinflation similar to that seen in patients with tracheal stenosis from endotracheal intubation. However, tracheal stenosis from a tracheostomy tube differs slightly from the stenosis that develops in endotracheally intubated patients; the latter tends to be web like and emerges sooner (eg, six weeks after extubation), while that from tracheostomy tends to be thicker, more circumferential, and occurs later [28-30]. (See "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients", section on 'Laryngotracheal stenosis'.)

•Risk factors – Cited risk factors include cuff overinflation, surgical site infection, obesity, and hypotension [29,31]. It is unknown whether percutaneous or surgical tracheostomy impacts the rate of stenosis. While one meta-analysis of 20 studies reported no difference in the rate of tracheal stenosis or scarring [10], another reported significant reduction on the rate of scarring in patients who underwent a percutaneous tracheostomy [11].

•Clinical features – Most stenoses are less than 50 percent the diameter of the trachea and are asymptomatic. Patients develop symptoms when the degree of stenosis is greater than 50 percent the tracheal diameter [23-26]. Clinical manifestations during ventilator weaning include dysphonia and inability to tolerate speech valves or tracheostomy capping. Alternatively, patients may present with dyspnea and/or wheeze and stridor after decannulation, particularly when they become more mobile.

•Diagnosis – Tracheal stenoses are diagnosed by direct inspection of the upper airway above the tracheostomy tube. We also inspect the rest of the trachea along the shaft and cuff by deflating the cuff and pulling the tracheostomy back into the stomal tract, provided the patient can tolerate partial decannulation for a short period.

•Treatment – Only 3 to 12 percent of patients require intervention [19,31]. As a temporary measure, we place a smaller-diameter tracheostomy tube through the stoma. Definitive therapy involves tracheal dissection and reanastomosis, but many undergo bronchoscopic dilation and/or stent placement for symptomatic alleviation, thereby avoiding the need for major surgery.

Patients with subglottic stenosis may have more favorable outcomes; for example, patients with subglottic stenosis may be more likely to decannulate with bronchoscopic therapies for tracheal stenosis than those with stenosis at the level of the tracheostomy tube cuff or tip [32].

Further details regarding the presentation of cuff-related tracheal stenosis from ETTs are provided separately. (See "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients", section on 'Laryngotracheal stenosis'.)

●Stoma stenosis – Stenosis at the stoma site is not as common as tracheal stenosis. Stomal stenosis is thought to be due trauma from tube insertion, excessive movement at the entry site, or the weight of unsupported tubing causing pressure on the cricoid or tracheal cartilage.

It is generally suspected when resistance is met at the stoma site during a tracheostomy tube exchange. Exchanging for a smaller tube may be required until definitive treatment can be administered.

Treatment includes stomal dilation, cautery with silver nitrate sticks, or rarely surgical revision of the stoma. (See 'Changing a tracheostomy tube' below.)

Tracheomalacia — Focal malacia at the site of the tracheostomy cuff can develop weeks to months after tracheostomy tube insertion.

●Pathogenesis – The pathogenesis is thought to relate to thinning and destruction of cartilaginous tissues due to elevated cuff pressures, especially when cuff pressures are >25 cm H₂O.

●Clinical features – Patients present in a similar fashion to that in patients with tracheomalacia for other reasons. (See "Tracheomalacia in adults: Clinical features and diagnostic evaluation", section on 'Clinical manifestations'.)

●Treatment – As a temporary measure, we place a longer tracheostomy tube or Montgomery tracheal T-tube (ie, a T-shaped tube that enters through the tracheostomy site (figure 1)) that bypasses the segment of malacia. Long-term focal tracheomalacia may need to be addressed before or after decannulation with an airway stent or surgical resection. Further details are provided separately. (See "Airway stents" and "Tracheomalacia in adults: Clinical features and diagnostic evaluation".)

Tracheoarterial fistula — Massive hemorrhage due to a tracheoarterial fistula (most often a tracheoinnominate artery fistula) is the most devastating complication of tracheostomy tube placement, with a reported survival of 14 percent [33].

●Incidence – Tracheoarterial fistula was more common in the past from low-positioned tracheostomy tubes, but is now rarely encountered with several studies reporting an incidence of less than 1 percent for both short- and long-term tracheostomies [34-36].

●Pathogenesis – Tracheoarterial fistulas are due to erosion from the tube tip or cuff into the anterior wall of the trachea resulting in a fistulous communication with an artery as it passes anteriorly across the trachea (typically the innominate artery).

●Risk factors – Risk factors include a high-riding innominate artery, placement of the tracheostomy tube below the third tracheal ring, a tracheostomy tube that is too large or too long, excessive tracheostomy tube movement, tracheostomy infection, and overinflation of the tracheostomy tube cuff.

●Clinical presentation – Up to 50 percent of patients present with an initial small "sentinel" bleed (eg, minor stomal or tracheal bleeding) followed by massive hemorrhage a few hours or days later. It classically occurs within three to four weeks of the initial placement but can occur at any time. Thus, when a sentinel bleed is suspected, it should always be approached with suspicion for a tracheoarterial fistula and assessed using bronchoscopy, computed tomography, and/or angiography.

●Diagnostic evaluation and treatment – Diagnosis is dependent upon a high index of suspicion. When suspected, immediate action should be undertaken to control the airway and stop the bleeding; diagnostic modalities such as angiography or bronchoscopy at this point may lead to delay and death. (See "Evaluation and management of life-threatening hemoptysis".)

The following temporizing maneuvers together with resuscitation may be performed while waiting for definitive therapy, which is surgical repair:

•In an attempt to compress the innominate artery, the tracheostomy cuff should be overinflated (eg, up to 50 mL [37]) and external pressure applied posteriorly on the sternal notch.

•If the above fails or a tracheostomy tube does not have a cuff, an ETT may be placed orally, the tracheostomy removed, and the cuff inflated distal to the stomal site. The cuff of the ETT should also be overinflated.

•If that fails to stop the bleeding, a finger can be placed through the tracheostomy stoma and positioned distally into the trachea ("The little dutch boy maneuver"). The finger is then pulled anteriorly to compress the artery against the sternum (pressure should be sufficient to lift the torso anteriorly). Pressure should be maintained during transport to the operating room and the occluding finger prepared with the surgical field.

•Ventilation and oxygenation need to be preserved with a bag-valve mask via the tracheostomy or ideally, an ETT. Surgical repair involves a median sternotomy with ligation of the innominate artery.

Aspiration and nosocomial pneumonia

●Aspiration – In tracheostomized patients, aspiration is a result of both pharyngeal pooling of secretions above the airway cuff and delayed triggering of the swallow response [38,39]. The risk of aspiration is directly related to the amount of oropharyngeal secretions.

•Incidence – In patients who have a tracheostomy tube, aspiration occurs in 30 to 50 percent and is clinically silent in 75 to 82 percent of cases [40-42]. The likelihood of aspiration may decrease somewhat after a tracheostomy tube has been present for three weeks [41].

•Risk factors – The tracheostomy itself increases the risk of aspiration. Additional risk factors are similar to those in the general population. (See "Aspiration pneumonia in adults", section on 'Predisposing conditions'.)

Occlusion of the tracheostomy tube with a cap or finger for phonation does not significantly increase the frequency of aspiration [42]. Likewise, keeping the tracheostomy tube cuff inflated does not significantly decrease the risk of aspiration (especially "micro aspiration"). As such, we do not routinely keep the cuff inflated to prevent aspiration, unless required for mechanical ventilation.

It is unclear whether tracheostomy lowers the risk of aspiration pneumonia compared with endotracheal intubation. These data are discussed separately. (See "Tracheostomy: Rationale, indications, and contraindications", section on 'Unclear benefits'.)

•Diagnosis – In patients with a tracheostomy tube, we typically use clinical suspicion (eg, patients with known bulbar disease or stroke) and occasionally direct visualization of the oropharynx and evaluation of the gag reflex to detect increased risk for aspiration. Although several methods have been used to detect aspiration, they are not typically used (eg, methylene blue dye in enteral feeding [42-45], glucose oxidase testing [46]).

•Treatment – Aspiration is only treated with antibiotics when bacterial superinfection occurs. Further details are provided separately. (See "Aspiration pneumonia in adults" and "Aspiration pneumonia in adults", section on 'Bacterial pneumonia'.)

●Nosocomial pneumonia – Several factors may predict nosocomial pneumonia following tracheostomy. In a retrospective study of 137 patients who underwent tracheostomy, early nosocomial pneumonia (occurring within five days of tracheostomy) was associated with significant bacterial colonization (>100,000 CFU/mL), fever on the day of tracheostomy, and the need for sedation beyond 24 hours after tracheostomy [47]. There was a 26 percent incidence of pneumonia in the study population, occurring at a mean of nine days after the tracheostomy.

The timing of tracheostomy (early versus late) does not appear to impact the rate of nosocomial pneumonia following tracheostomy, according to a randomized trial and two observational studies [48-51].

Further details regarding the etiology and treatment of nosocomial pneumonia are provided separately. (See "Epidemiology, pathogenesis, microbiology, and diagnosis of hospital-acquired and ventilator-associated pneumonia in adults" and "Treatment of hospital-acquired and ventilator-associated pneumonia in adults".)

Obstruction — Obstruction due to secretions or a foreign body can occur as a late complication. It is treated in a similar fashion to that encountered in the early postoperative period except, the tracheostomy tube can be more readily exchanged if indicated. (See 'Obstruction' above and "Assessment of respiratory distress in the mechanically ventilated patient", section on 'Obstruction'.)

Tracheoesophageal fistula — TEF occurs in less than 5 percent of patients who undergo tracheostomy, which is less frequent than that encountered in patients with prolonged endotracheal intubation.

TEF is most often due to excessive pressure on the posterior wall of the trachea from an overinflated cuff or posterior orientation of the tracheostomy tube.

In tracheostomized patients, risk factors are similar to intubated patients and include the presence of a nasogastric tube, high cuff pressures, high airway pressures, prolonged presence of a cuffed tube, excessive movement, steroid use, diabetes, poor nutritional status, and gastroesophageal reflux disease [52,53].

The presentation and management of TEF is similar to that in intubated patients. Further details are provided separately. (See "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients", section on 'Tracheoesophageal fistula' and "Tracheo- and broncho-esophageal fistulas in adults".)

Tracheostomy tube dislodgement — When accidental decannulation occurs after the tract has matured (≥7 to 10 days), the tracheostomy tube should be replaced; the risk of tube displacement into the mediastinum is lower than that of tube replacement during the first week. If a suitable sized sterile tracheostomy is not available, an endotracheal tube of similar or lower size than the dislodged tracheostomy may be used to temporarily maintain airway patency. (See 'Tracheostomy tube dislodgement' above and 'Changing a tracheostomy tube' below.)

Reasons for accidental decannulation are similar to those described during the early postoperative period. (See 'Tracheostomy tube dislodgement' above.)

Tracheostomy tube replacement needs to occur relatively quickly, preferably immediately, as the tract begins to undergo spontaneous closure within hours of decannulation and is closed by three to seven days, sometimes earlier if the tract is relatively fresh. A skilled expert may be needed, particularly if the patient has a difficult airway or resistance is met during reinsertion. If skilled personnel are not available to replace the tracheostomy tube, orotracheal intubation should be performed. (See "Direct laryngoscopy and endotracheal intubation in adults".)

Reduced phonation — Following tracheostomy, many patients experience a reduction in or loss of phonation, the duration of which may be prolonged or indefinite, and the effect of which can be devastating to some patients [54].

This complication is noticed when wearing a speech device or following decannulation.

In general, phonation improves spontaneously over time (weeks to months). Rarely, following decannulation, patients with slow-to-resolve symptoms may require laryngoscopic evaluation and specialized speech services. (See 'Decannulation' below and 'Speech devices' below.)

Dysphagia — After decannulation, patients may complain of dysphagia which may be due to oropharyngeal weakness or skin adherent to the trachea. In our facility, we typically perform a formal swallowing evaluation after decannulation and follow recommendations for a specific diet, which changes as swallowing function improves over time.

In most cases, swallowing should slowly return to normal, although a small proportion may have long-term deficits. Dysphagia due to adherent skin may be amenable to surgical correction. (See "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients", section on 'Swallowing and speech impairment'.)

Device-related complications — Occasionally, the device malfunctions, necessitating a tracheostomy exchange. These include fracture of the flange or shaft, poorly fitting inner cannulae, and balloon leak or rupture.

Mortality — Death in association with tracheostomy is rare (<1 percent) and often related to significant underlying cardiopulmonary disease or complications, particularly innominate artery bleeding [55]. In one prospective series of 350 tracheostomies performed in a single center over one year, there was only one tracheostomy-related death [6].

Mortality rates may be lower in patients who undergo percutaneous rather than surgical tracheostomy, although data are conflicting. While one 2006 meta-analysis of 17 trials reported a lower mortality in patients undergoing percutaneous tracheostomy compared with surgical tracheostomy (OR 0.71, 95% CI 0.50-1.0) [9], another 2016 meta-analysis of 20 trials reported no difference in mortality [11].

CHANGING A TRACHEOSTOMY TUBE

Indications — Tracheostomy tubes are mostly exchanged electively as part of long-term maintenance, but exchange may also be required in emergency circumstances (eg, accidental decannulation or obstruction) or for other reasons (eg, patient discomfort, malposition).

Based upon our experience, the following are generally accepted indications:

●Routine changes – Tracheostomy tubes are routinely changed as an infection prevention measure. The timing of routine changes is discussed below. (See 'Timing of routine change' below.)

●Patient discomfort – Patient discomfort due to an ill-fitting or malpositioned tracheostomy tube (eg, a tube that is too large or long, a tube that places pressure against the posterior wall of the trachea) may respond to a change in tracheostomy tube dimensions or components. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Tube types'.)

●Tracheal stenosis or tracheomalacia – Tracheal or stomal stenosis may initially be temporarily treated with a smaller tracheostomy tube, while tracheomalacia may require a longer tracheostomy tube or a Montgomery tracheal T-tube (figure 1). (See 'Tracheal and stoma stenosis' above and 'Tracheomalacia' above.)

●Patient-ventilator asynchrony – Patient-ventilator asynchrony that is related to the tracheostomy tube (eg, malpositioning) may respond to changing the tube.

●Cuff leak – A cuff leak may be due to malposition of the tracheostomy tube, focal tracheomalacia (eg, due to an overinflated cuff), or device malfunction; in most cases it responds to changing the tube (eg, longer shaft, if malposition is suspected).

●Fracture – Fracture of the tracheostomy tube or flange, which may be suspected on chest radiograph as a foreign body, is rare and is an indication for a new tracheostomy tube.

●Type change – Changing a tracheostomy tube from one type to another may be indicated by the clinical or manufacturer issues; as an example, a cuffless tracheostomy tube in a spontaneously breathing patient may need to be changed to a cuffed tube if mechanical ventilation becomes necessary. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Tube types'.)

●Bronchoscopy – Flexible bronchoscopy generally requires a tracheostomy tube with an inner diameter of at least 7.5 mm; thus, the tracheostomy tube may need to be changed to one with a larger inner diameter to facilitate bronchoscopy. Alternatively, a bronchoscope of smaller diameter can be used, understanding that its therapeutic capacity may be limited (eg, poorer suctioning capacity, inability to take a biopsy). (See "Flexible bronchoscopy in adults: Preparation, procedural technique, and complications", section on 'Procedural technique'.)

Timing of routine change — Tracheostomy tubes are routinely changed 7 to 30 days after initial insertion and then every 30 to 90 days.

However, practice varies. For example, one consensus statement suggested that if tracheostomy tubes that were inserted operatively, initial exchange can occur at 3 to 7 days, but if placed percutaneously, 10 to 14 days was appropriate [56]. Timing for the first exchange may also be determined by administrative issues since many ventilator weaning facilities will not accept patients unless they have undergone their first tracheostomy tube change.

Changing a tracheostomy tube during the first week after initial placement is risky since the tract is not mature and the exchange risks anterior displacement resulting in pneumomediastinum, pneumothorax, and airway loss. However, once the tracheocutaneous tract is mature (generally between one and six weeks), the risk of displacement is significantly lower. (See 'Tracheostomy tube dislodgement' above and 'Tracheostomy tube dislodgement' above.)

Observational data suggest that changing the tracheostomy tube before seven days may be associated with earlier use of a speaking valve and earlier ability to tolerate oral intake [57]. However, there was no difference in the time to decannulation. Despite these data, given the risk, we do not promote exchange before seven days after initial placement.

Equipment — For tracheostomy tube exchange, we typically prepare the following:

●Tracheostomy tray – A prepared tracheostomy tray should have a sterile tracheostomy tube, tracheostomy dressing, gauze, gown, and gloves; 10 mL syringe; mask; soft tracheal collar with ties (or other holder); and water-based lubricant. Additional personal protective equipment is necessary if airborne precautions are needed since a tracheostomy change is an aerosolizing procedure. The procedure does not have to be sterile but should be clean.

A tracheostomy tube of the same size and model is generally used unless the patient requires a different size or style (eg, downsizing with goal of decannulation). We also make sure to have a tracheostomy tube of a smaller diameter (one size down) in the event that stomal or tracheal obstruction is encountered and an urgent airway is needed. (See "Tracheostomy in adults: Techniques and intraoperative complications", section on 'Tube types'.)

For early tracheostomy changes, we also ensure that a similar-sized endotracheal tube (ETT) is also available in the event that orotracheal intubation or intubation via the tracheostomy tract is required.

●Cuff manometer – A cuff manometer is used for measuring cuff pressure after inflation.

●Monitoring equipment – Depending upon the stability of the patient and risk of displacement, we may monitor the exchange with oximetry, telemetry, and waveform capnography or carbon dioxide detector. This practice is more prudent in high-acuity patients in the intensive care unit undergoing an emergency exchange, while stable outpatients or nursing home residents who undergo frequent exchanges may not require aggressive monitoring.

●Sterile 0.9% sodium chloride and cotton tips for cleaning.

●Suction equipment.

●Additional items that may be needed, particularly in higher-risk or early exchanges, include the following:

•An oxygen mask and bag ventilation equipment, suture removal kit, and flashlight.

•Ready access to a fiberoptic laryngoscope or bronchoscope, although this is not always feasible or necessary for exchanges in the outpatient department, home, or chronic nursing home setting.

•In some cases, a microbial swab when infection is suspected and silver nitrate sticks for superficial cauterization when granulation tissue is encountered.

•We sometimes additionally require tracheal dilators (if stomal stenosis is encountered), an intubation kit with a selection of oral airway devices, and an airway exchange device or catheter.

Personnel and location — We encourage institutions to develop their own protocols for tracheostomy changes.

Typically, one person exchanges the tube, and an assistant is needed to facilitate with suctioning and securing the tracheostomy in place.

In general, for the first tracheostomy change, we have either the inserting surgeon or other expert skilled with tracheostomy insertion perform the first tracheostomy change.

Thereafter, exchanges may be performed by other skilled staff including a respiratory therapist, intensivist, pulmonologist, anesthesiologist, nurse, nurse practitioner, physician assistant, and speech and language therapist, provided they are educated and skilled in the procedure. However, if any problem is anticipated during the exchange or the patient is known to have a "difficult airway," then the exchange should be performed by an airway expert.

Due to the higher risk of displacement and airway loss, the first tracheostomy change is generally performed in an inpatient and monitored setting compared with subsequent tracheostomy changes. Less monitored settings may be appropriate for additional changes, including the home.

Procedure — The patient does not generally need to be sedated. We typically perform the following:

●Double-check the tracheostomy dimensions on the flange of the indwelling tracheostomy and ensure that the replacement tracheostomy tubes are of equivalent or smaller size. Ensure that the new tracheostomy tube has been removed from its packaging, and that the cuff has been inflated, tested for air leaks by placing it in sterile water, and deflated. The inner trocar (also known as the obturator) should be inserted and the tip of the device covered in lubricant.

●The neck is gently extended to expose the stoma site typically with the patient placed in the semi-recumbent position. We typically use a shoulder roll or pillow for positioning.

●The patient should be preoxygenated, if oxygen is needed at baseline or the exchange is high risk.

●Suction the patient via the tracheostomy (and subglottic port if one is present).

●Loosen and remove the tracheostomy ties from the flange. We use the thumb and forefinger to hold the tracheostomy tube steady and in place at the level of the ventilator connector.

●Clean around the stoma site with some saline followed by dry gauze.

●Deflate the cuff completely (until resistance is met); this may induce coughing with expectoration of secretions through the tracheostomy tube that may need to be suctioned again.

●For patients who remain ventilator dependent, we typically do not disconnect the ventilator circuitry from the tracheostomy until we are ready to remove the tube.

●Remove the tracheostomy (with attached circuitry) swiftly and smoothly using "an out-then-down" semi-circular maneuver, similar to the shape of the tracheostomy tube itself. If significant resistance is met, this may suggest tracheal or stomal stenosis; we do not proceed with removal, we replace the tube and we consult with an airway expert so these issues can be addressed before removal is attempted again. (See 'Tracheal and stoma stenosis' above.)

●Once the tracheostomy tube is removed, we quickly inspect the stoma for ulceration, bleeding, and granulation tissue, and clean it again, if necessary.

●Insert the new device with its main axis, initially in a horizontal position (ie, at right angles to the long axis of the neck) and use a 45-degree caudal (ie, distal) rotational maneuver during insertion until the stoma is snug with the hub and the tracheostomy shaft is parallel with the trachea. The 45-degree caudal turn should not be premature since this can increase the risk of misplacement anteriorly and the creation of a false tract. We advise not forcing this maneuver. Alternatively, it can be inserted using a path that is parallel to the long axis of the neck.

●If resistance is met during insertion, we do not advance the tracheostomy tube further. In such cases, we reinspect the stoma, and attempt recannulation using either the same tracheostomy tube or a smaller-diameter tracheostomy tube. Alternatively, an analogous-sized ETT may be inserted through the stoma and temporarily secured using stay sutures until an appropriate-sized tracheostomy can be found.

●Once in place, remove the trocar immediately, inflate the cuff, and secure the flange to the neck with clean tracheostomy ties (one finger should fit between the neck and tracheostomy collar). Once secured, the patient can be suctioned, the inner cannula placed (or removed), and the ventilator circuitry attached (if indicated).

●Place new tracheostomy gauze around the tracheostomy tube and palpate for subcutaneous air in the chest and neck.

●Confirm intraluminal airway placement. For first tracheostomy exchanges, we typically perform capnography and/or direct visualization using bronchoscopy via the newly placed tracheostomy tube. For additional changes, we typically listen for good air entry and watch the chest rise bilaterally and only perform capnography and/or direct visualization if intraluminal placement is uncertain.

Some experts examine the stoma, upper airway, glottis, and trachea with a bronchoscope following each tracheostomy change to look for tracheal stenosis that may be problematic during decannulation, although this is not universal. (See 'Decannulation' below and 'Tracheal and stoma stenosis' above.)

DECANNULATION — Decannulation is the process by which a tracheostomy tube is removed. Data suggest that the multidisciplinary involvement of nursing, speech and language pathology, and clinicians can improve patient safety during decannulation [58]. While most decannulations are performed in long term care facilities, it is feasible to do under appropriate supervision at home [59].

Criteria — Appropriate candidates for tracheal decannulation include patients who fulfill all of the following criteria [60]:

●Mechanical ventilation is no longer required – During weaning, once a patient has tolerated a tracheostomy mask for 24 hours or longer, mechanical ventilation is no longer needed and decannulation should be considered, provided all other criteria are in place. Weaning from mechanical ventilation is discussed separately. (See "Initial weaning strategy in mechanically ventilated adults" and "Management of the difficult-to-wean adult patient in the intensive care unit" and "Management and prognosis of patients requiring prolonged mechanical ventilation", section on 'Weaning'.)

●No upper airway obstruction – We assess the upper airway for patency (ie, glottis, vocal cords, and subglottic space). Patients who cannot protect their upper airway should not be decannulated, while those who can protect their upper airway are considered good candidates for decannulation.

There is no formal approach to this assessment. We deflate the cuff and occlude the tracheostomy tube with a gloved finger and ask the patient to phonate by saying one or two words or a full sentence.

•If the patient is comfortable, can phonate, and has no labored breathing or stridor, they should tolerate decannulation.

•If the patient is unable to phonate, has stridor or labored breathing, or manifests respiratory distress, we suggest endoscopic examination of the upper airway, including the vocal cords, subglottic space, and trachea to the level of the carina.

-If airway patency is compromised by stenosis, granulation tissue, or abnormal vocal cord movement, we consult experts with a view to treatment before decannulation.

-If no pathology is found on endoscopy, we down-size the tracheostomy tube, with the cuff fully deflated to enhance air flow around the tracheostomy tube. We retest the patient for upper airway patency at a later date (eg, one to two weeks later).

Some experts routinely inspect the upper airway endoscopically prior to decannulation or with every tracheostomy change to look for tracheal stenosis [61]. However, it still needs to be determined whether the patient can clinically tolerate decannulation since the majority of stenoses are not symptomatic until at least 50 percent or more of the airway diameter is compromised. In our opinion, the initial tolerance to finger occlusion indicates the likelihood of subsequent success and decreases the need for airway inspection.

●The presence of an effective cough – Typically, we use gestalt assessment to evaluate the ability of the patient to cough and clear their own secretions.

However, some clinicians use peak cough flow (using a tracheostomy adapter), particularly in patients with respiratory failure due to respiratory muscle weakness (eg, patients with neuromuscular disease). In such patients, a peak cough flow greater than 160 L/minute generally predicts successful decannulation [62]. The value of this measurement in patients without neuromuscular disease is unknown. (See "Respiratory muscle weakness due to neuromuscular disease: Management", section on 'Discontinuing invasive mechanical ventilation' and "Respiratory muscle weakness due to neuromuscular disease: Clinical manifestations and evaluation", section on 'Assessing cough strength' and "Extubation management in the adult intensive care unit", section on 'Cough strength and secretion clearance'.)

●Minimal secretions – Even with a good cough, thick and copious secretions represent a challenge for decannulation. We prefer to decannulate when patients have thin and minimal secretions (eg, require suctioning of think secretions every two hours or more).

●The ability to remove the cap and/or call for help if needed – If patients cannot perform these activities. we prefer one-on-one observation in the room during breathing trials.

Techniques — Several techniques for weaning patients from tracheostomy tubes have been described, and practice varies among institutions and clinicians. There are no guidelines that suggest one particular method is superior to another. In our facility, we typically use capping trials. A consensus statement advocates that patients should undergo a successful capping trial with the cuff deflated prior to decannulation; however, tracheostomy downsizing should be considered when a large tracheostomy tube is in place (eg, size 8 tracheostomy) [56].

●Progressive capping trials until tolerated for 12, 24, or 48 hours – This approach is relatively common, particularly in long-term weaning facilities. It involves deflating the cuff and placing a cap over the tracheostomy tube and observing the patient for tolerance. Supplemental oxygen may be needed via nasal cannulae. Trials of capping initially last two to four hours, sometimes longer, and are progressively increased to 48 hours over one to two weeks.

A successful trial is one where the patients tolerate a prolonged period of capping without respiratory distress, stridor, or secretion retention (eg, 24 to 48 hours). Difficulty or symptoms should prompt an upper airway assessment with bronchoscopy for tracheomalacia or stenosis.

In one uncontrolled series, 16 percent of patients did not tolerate an initial 30-minute trial of capping. At bronchoscopy, these patients were found to have >50 percent tracheal obstruction. All the patients that tolerated their initial capping trial went on to successful decannulation without requiring bronchoscopy [63].

●Progressive decrease in the size of the tracheostomy tube – In this approach, the tracheostomy tube size is reduced slowly every one to two days (sometimes longer) until spontaneous breathing is documented with the smallest tube in place (eg, size 4).

If a small tube is tolerated for a few days, then the patient can be decannulated. This slows the closure rate of the tracheocutaneous fistula over time and allows the patient to build up tolerance and strength for breathing through the vocal cords.

This approach was shown to have a success rate of nearly 80 percent in a prospective, observational cohort study of over 100 patients with chronic respiratory failure [64].

●Immediate decannulation – This approach entails an abbreviated capping trial (eg, 12 hours) and no down-sizing of the tracheostomy tube in patients whose airways have been visually inspected [65]. A successful trial is one where the patient tolerates capping without respiratory distress, stridor, or secretion retention. This approach only applies to a highly selected minority of patients. As examples:

•Patients who are off ventilation and without need for respiratory support

•Patients who have a normal fiberoptic examination of the upper airway

•Patients who have a leak around the cuff

•Patients who have no dyspnea

•Patients who have stable arterial blood gases

•Patients who have stable hemodynamic status

•Patients who have no active infection

Patients require telemetry and oximetry monitoring for the first 24 hours after immediate decannulation; for those undergoing decannulation at home, a brief hospital admission may be necessary.

●Use of heated-humidified high-flow oxygen and low frequency of suctioning – This involves a 24-hour spontaneous breathing trial while heated-humidified high-flow oxygen is provided through the tracheostomy tube with the cuff deflated. However, the efficacy of such an approach needs replication. In addition, doubt remains over the applicability to patients who wean in long-term acute care facilities, and questions remain regarding the confounding impact of high-flow oxygen on the outcome (since it delivers a small amount of positive pressure). (See "Heated and humidified high-flow nasal oxygen in adults: Practical considerations and potential applications".)

Only one study has described this method. One randomized trial of 330 patients who demonstrated an ability to breathe spontaneously through their tracheostomy tube for 24 hours compared a 24-hour trial of capping with a spontaneous breathing trial that used heated-humidified high-flow oxygen delivered through the tracheostomy for 24 hours [66]. Patients underwent decannulation if they passed a 24-hour trial of capping (control group) or required suctioning no more than twice in an eight-hour period over 24 hours (high-flow oxygen intervention group). The time to decannulation was shorter in the intervention group by seven days and the incidence of pneumonia and tracheobronchitis was lower. Regardless of the method used, both groups had a similar success rate of decannulation, with less than 5 percent requiring a replacement tracheostomy tube.

Tracheostomy plug — A tracheostomy plug (also known as a tracheal retainer) is a small device (figure 2) that is placed through the stoma after decannulation. It spans the length of the stoma but does not extend into the trachea; thus, it helps keep the proximal end of the tracheocutaneous tract open to the level of the trachea.

A tracheostomy plug may be particularly useful in patients who have borderline clearance of secretions and require maintenance of the stoma during a prolonged observation period, especially in patients who have recently undergone percutaneous dilational tracheostomy as the stoma closes rapidly in these patients [67,68].

Tracheal plugs come in a variety of sizes such that a plug of similar size to the original tracheostomy tube is an appropriately-sized initial plug.

Delayed tracheocutaneous closure — Most tracheocutaneous tracts begin to close within the first 48 hours following decannulation, and by seven days they should be completely or almost completely closed.

A small proportion take a little longer. If they persist after three to six months, a tracheocutaneous fistula is diagnosed.

Cited risk factors include prolonged tracheostomy, corticosteroid use, advanced age, and malnutrition [16,19].

Symptoms include skin irritation, infection, weak cough and phonation, recurrent aspiration and pneumonia, submersion intolerance, and poor cosmetic appearance.

Treatment includes cauterization, excision, or in rare and refractory cases, surgical closure of the fistula.

Failed decannulation — For patients who fail decannulation and in whom the stoma has not yet fully closed, a mini-tracheostomy may be placed for suctioning and short-term ventilation; the tract may subsequently be reopened using serial dilators. The reason for failure should be assessed and treated before reattempting decannulation. However, for those in whom the stoma is closed, orotracheal intubation is generally needed. (See "Direct laryngoscopy and endotracheal intubation in adults".)

Factors that determine success are poorly defined. One study reported that among 134 patients who were weaned but still had a tracheostomy tube in place at discharge, subsequent successful decannulation was associated with the absence of hypertension, the ability to walk in the hospital hallway, and the ability to eat without tube feedings prior to discharge [69].

Outcomes in patients with difficulty weaning are discussed separately. (See "Management and prognosis of patients requiring prolonged mechanical ventilation", section on 'Outcomes'.)

SPEECH DEVICES — For patients in whom a tracheostomy has been performed and the cuff inflated, speech is not feasible. However, patient communication via speech can be achieved with the following phonation techniques:

●Capping – Capping trials allow the patient to phonate while the cap is applied, and the cuff deflated. Air is inspired through the mouth and nose, creating a tidal volume of sufficient quantity and flow to allow speech during expiration. Nasal oxygen can be provided for oxygen supplementation. (See 'Techniques' above.)

●One-way speech valve – Passy-Muir speech valves can be used as an alternative to capping prior to decannulation and may be more easily tolerated by the patient due to lower airway resistance. A Passy-Muir speech valve is attached to the tracheostomy tube (figure 3). It is a one-way valve that permits inspiration through the valve, but expiration is prohibited by the valve. Thus, air must circulate around the tracheostomy tube and through the vocal cords for phonation. Importantly the cuff must be fully deflated for this to be safe. A tracheostomy mask can be placed around the valve to supplement the delivery of oxygen.

While one-way valves may be more comfortable for the patient and are commonly used, the time to decannulation does not differ from traditional capping trials [70].

When used repeatedly, we inspect the valve daily before use since they can become blocked with secretions and impair valve function and cause respiratory distress.

In general, one-way valves are less suitable for patients with neuromuscular disorders, since we prefer that the patient be able to remove the device by themselves in the event of respiratory distress; an alternative is that they are observed continuously during trials so that urgent removal can be assisted, if needed.

●Talking tracheostomy tube – Some commercial appliances utilize an additional small-diameter tube that expels gas above the cuff of the tracheostomy tube when the proximal end has been manually occluded (figure 4). These are infrequently used. Limitations include the requirement for manual occlusion and the frequent inability to speak in complete sentences.

Preliminary data suggest that early phonation is feasible and may be beneficial when instituted during mechanical ventilation in tracheostomized patients [71-76]. As an example, one randomized trial of 30 ventilated tracheostomized patients reported that early intervention with cuff deflation plus an in-line speaking valve during mechanical ventilation shortened the time to phonation by 11 days, when compared with late intervention using the standard approach [71]. Further research is needed before performing early phonation can become routine for this population.

IMPORTANCE OF MULTIDISCIPLINARY TEAMS — Although there are few guidelines, we advocate a multidisciplinary approach to tracheostomy care [77-79]. One systematic review reported that a dedicated interdisciplinary team approach to tracheostomy care led to a reduction in adverse events, time to decannulation, and length of stay [77].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Weaning from mechanical ventilation" and "Society guideline links: Airway management in adults".)

SUMMARY AND RECOMMENDATIONS

●Postoperative care – Tracheostomy is a procedure that creates an opening in the anterior wall of the trachea, through which a tracheostomy tube can be placed. In the early postoperative phase, we advocate for protocolized care following tracheostomy placement; an example is shown in the table (table 1). Care focuses on monitoring and treating complications, particularly bleeding and infection, as well as stoma, tracheostomy tube, and cuff care. (See 'Postoperative care' above.)

●Complications – Tracheostomy complications are frequent but serious complications are uncommon. Death is rare.

•The most common acute complications of tracheostomy (ie, <10 days) are hemorrhage, obstruction, pneumothorax, infection, and accidental decannulation. (See 'Early (within 7 to 10 days)' above.)

•Late complications of tracheostomy (ie, ≥10 days) are stenosis of the trachea and stoma, tracheomalacia, tracheoarterial fistula as well as aspiration and pneumonia, tracheoesophageal fistula formation, dysphonia and dysphagia, obstruction, and accidental decannulation. (See 'Late (≥7 to 10 days)' above.)

•In patients with accidental decannulation, the approach depends upon tract maturity but the time when this is established is controversial. We define it at 7 to 10 days, although other experts have varying definitions. When decannulation occurs before the tract is mature (eg, during the first week), oral intubation with cuff placement beyond the stoma is appropriate. This approach is based upon avoiding airway loss and reducing risk of creating a false tract. For those with a mature tract, reinserting the tracheostomy is reasonable.

•Massive hemorrhage due to a tracheoarterial fistula (typically tracheoinnominate artery) is a life-threatening emergency. It may be preceded by a sentinel bleed. When a sentinel bleed is suspected, it should be assessed using bronchoscopy, computed tomography, and/or angiography. When a fistula is suspected, we perform innominate artery compression with cuff overinflation (eg, up to 50 mL) and apply external pressure posteriorly on the sternal notch. If that fails, we perform oral intubation with cuff overinflation distal to the stoma, removal of tracheostomy tube, and the placement of pressure on the bleeding artery using a finger through the tracheostomy stoma. Surgical repair is the only definitive treatment. (See 'Late (≥7 to 10 days)' above.)

●Tracheostomy change – Tracheostomy tubes are mostly exchanged electively as part of long-term maintenance, but exchange may also be required in emergency circumstances (eg, accidental decannulation or obstruction) or for other reasons (eg, patient discomfort, malposition, cuff leak, ventilator asynchrony, device-related complications, and bronchoscopy). (See 'Changing a tracheostomy tube' above and 'Indications' above.)

•We typically change tracheostomy tubes 7 to 30 days after initial insertion and then every 30 to 90 days, although practice varies. (See 'Timing of routine change' above.)

•We typically perform most exchanges as an inpatient and less commonly as an outpatient. Most patients do not require sedation. Generally, two individuals are needed. (See 'Equipment' above and 'Personnel and location' above.)

•We remove the tracheostomy tube using an "out-then-down" semicircular maneuver and insert the new device with either a 45-degree caudal (ie, distal) rotational maneuver or a linear maneuver that parallels the long axis of the neck. A tracheostomy of smaller diameter and endotracheal tube should be prepared as a back-up in the event that the insertion meets resistance, and the airway is lost. During the exchange we take the opportunity to examine the stoma site for bleeding, secretions, ulceration, and granulation tissue. We confirm intraluminal placement with clinical examination, visual inspection, and/or capnography. (See 'Procedure' above.)

●Decannulation – Decannulation is the process by which a tracheostomy tube is removed. Decannulation can be performed when all of the following are present: mechanical ventilation is no longer required, upper airway obstruction is absent, the cough is adequate, and secretions are well controlled. (See 'Decannulation' above and 'Criteria' above.)

•We assess readiness for decannulation by capping the tracheostomy tube (with the cuff deflated) for progressively longer periods of time or by progressively decreasing the size of the tracheostomy tube. Immediate decannulation is uncommonly performed in a select group of individuals. (See 'Techniques' above.)

•Most tracheocutaneous tracts begin to close within the first 48 hours following decannulation and by seven days they should be completely or almost completely closed. A tracheocutaneous fistula is considered persistent if it remains open at three to six months following decannulation. Treatment includes cauterization, excision, or rarely, surgical closure. If a patient fails decannulation and the stoma remains open, a mini-tracheostomy tube may be placed for suctioning and short-term ventilation and the stoma serially dilated; if the stoma is closed, then orotracheal intubation is required. (See 'Delayed tracheocutaneous closure' above and 'Failed decannulation' above.)

●Speech devices – Patient communication can be greatly enhanced following tracheostomy by use of capping (with the cuff deflated) or one-way speech valves (figure 3); talking tracheostomy tubes (figure 4) are infrequently used. (See 'Speech devices' above.)