CHESTGuidelines & Topic CollectionsLong-Term Tracheostomy Management

Long-Term Tracheostomy Management

In this infographic from the CHEST Critical Care Network, learn about long-term tracheostomy management, including oxygenation and ventilation management, nonrespiratory management, and decannulation (removal) readiness assessment.

Last updated April 28, 2026

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Oxygenation and ventilation management

  • Signs of weaning readiness: Resolving etiology requiring mechanical ventilation, hemodynamic stability, and ability to undergo spontaneous breathing
  • Predictors of successful weaning:
    • Adequate gas exchange
    • Ability to protect airways
    • Maximal inspiratory pressure
    • Rapid shallow breathing index
    • Vital capacity
  • Options for weaning/liberation: Pressure support via ventilator, humidified high-flow nasal cannula, and oxygen via tracheostomy collar
  • Strategies for successful weaning:
    • Protocolized weaning can reduce duration and improve outcomes
    • Early mobilization and rehabilitation
    • Identify and reverse causes for weaning failure

Nonrespiratory management

  • Downsizing or transitioning to cuffless tubes to be considered after postoperative day #7 or track maturation—discuss with proceduralist
    • Improved airflow in upper airways
    • Phonation options:
      • Finger occlusion
      • One-way speaking valve (eg, Passy Muir Valve)
      • In-line speaking valves if ventilator-dependent
      • Speaking tracheostomies (cuff remains inflated)
    • Dysphagia assessment:
      • Formal respiratory therapist (RT) and speech-language pathologist (SLP) evaluation once able to perform dry swallowing without difficulty
  • Tracheostomy occlusion/capping: Capping/spigotting to test ability to breathe through upper airway
  • It takes a village! Physicians, nurses, RTs, SLPs, physical therapists, and occupational therapists

Decannulation (removal) readiness assessment

  • Hemodynamic stability
  • Minimal supplemental oxygen needs
  • Ability to tolerate facial interface for PAP if indicated for chronic indications
  • Reduced secretion suction needs (no more than two times every 8 hours)
  • Strong, consistent cough
  • Improved swallow
  • Tolerance of capping for at least 24 hours
  • Evidence highlight: Using suction frequency for assessment + continuous high-flow oxygen achieved shorter time to decannulation in the REDECAP trial

Resources
Engels. PMID: 19865580
Singh. PMID: 28649385
Bonvento. PMID: 29066907
Whitmore. PMID: 32723731
REDECAP. PMID: 32905673