The removal of the tracheostomy tube is called decannulation. When the initial medical conditions that required a child to have a tracheostomy have resolved, a microlaryngoscopy and bronchoscopy must be done to make certain that the child's entire airway (from nasopharynx down to lungs) is adequately open and unobstructed. The ENT team looks for two of the more common conditions found in children with long-term tracheostomies:

• Suprastomal granulation tissue or slight anterior tracheal wall collapse is present in many instances. This can partially obstruct the child's airway without the tracheostomy tube in place. A tracheostomal revision at the time of the bronchoscopy would be necessary to remove suprastomal granulation or to lift up any collapse of the trachea with a suture.
• A child with a tracheostomy will sometimes have large tonsils and/or adenoids. This condition can cause airway obstruction during sleep after the tracheostomy tube is removed, so the ENT surgeon will recommend that a tonsillectomy and/or adenoidectomy is performed before decannulation to optimize the child's opportunity for success.

Step 2: Tube downsize and capping trial

If the microlaryngoscopy and bronchoscopy confirm that the child has an adequate airway, the tracheostomy tube is usually downsized (a smaller tube is placed) and the family is given a tracheostomy cap for the child to use when awake.

Capping is an important step in the decannulation process. The surgeon is present the first time the cap is trialed to closely assess the child's tolerance to breathing through the nose and mouth with the tracheostomy tube covered. A capping trial can be done in the hospital or in the ENT office in the Airway Clinic.

The amount of time the child wears the cap on the tracheostomy tube at home is gradually increased. The cap should always be removed if there are any signs of breathing difficulties or if the child is unable to cough and clear secretions. The child's tracheostomy tube should always remain uncapped to sleep at home, because some signs of airway distress may be too subtle to be recognized by family or home care nurses. Unrecognized airway distress can lead to cardiac arrest in children.

Capping during sleep should only be done during ICU observation or in a medically ordered polysomnogram (sleep study). Decannulation can be considered when a child is able to wear the cap for all waking hours without any signs of airway distress or difficulties, and is growing and gaining weight.

Step 3: Removing the tracheostomy tube

Decannulation is a two- to three-day process and is done in the pediatric intensive care unit in the hospital.

• Tube is capped overnight. During the first night, the tracheostomy tube is kept capped while the child sleeps. Heart rate, respiratory rate, and oxygen levels are closely monitored. The ICU team also assesses for restlessness, diaphoresis (excessive sweating associated with medical emergencies) and ability to clear secretions without removing the cap to suction the tracheostomy tube.
• Tube is removed. If the child has no difficulties with the overnight capping trial, then the tracheostomy tube is removed the following day by the ENT team. The stoma is covered with a small occlusive dressing. Observation continues for another 24 to 48 hours to make sure that the child is able to breathe comfortably without the trach tube when awake and asleep, and is able to cough and clear respiratory secretions adequately.

Step 4: Closing the stoma

A child's stoma will start to close without the tracheostomy tube in place. This opening without a tracheostomy tube is called a tracheocutaneous (TC) fistula, which means an open tract between the skin and trachea. The TC fistula should be kept covered with a small bandage until it is fully closed to protect the child's airway from foreign objects or particles in the air. The opening should be carefully cleaned and inspected daily. The bandage should be replaced daily or more frequently if it becomes saturated with secretions.

Some TC fistulas close completely on their own, while some remain open. Until the opening fully closes, it is not safe for the child to go swimming because water can go through the opening into the airway.

If the TC fistula fails to close on its own, surgery can be done to remove the tract. Surgical closure of the TC fistula would be considered if the tract is still open one year after decannulation in a young child. In the older child with a larger airway, surgical closure can be done sooner.

Step 5: Follow-up

The child needs to be seen in the ENT office approximately four to six weeks after decannulation. Home care nursing for tracheostomy management is usually discontinued at this time. Office visits should continue every six months or until the stoma is completely closed.

Sometimes children who have had a tracheostomy have voice difficulties (dysphonia), such as hoarseness, breathiness, voice fatigue or problems with pitch or volume. Children over 3 years old who can verbalize and follow directions, but have persistent dysphonia, can benefit from evaluation and treatment in the Voice Clinic under the guidance of Dr. Karen Zur.