Synopsis
Separate liberation from ventilatory support from airway safety, use a structured weaning pathway, and respond safely to secretion burden or tracheostomy emergencies.
- Weaning succeeds when respiratory capacity can meet load after reversible problems, sedation, fluid excess, metabolic disturbance and excessive support have been addressed.
- A spontaneous breathing trial tests ventilatory independence, but successful extubation also requires airway protection, cough, manageable secretions and a credible reintubation plan.
- Repeated weaning failure should trigger a diagnosis-focused review rather than progressively exhausting trials; cardiac dysfunction, diaphragm weakness, delirium and critical-illness weakness are common contributors.
- Every clinician approaching a neck stoma must distinguish a tracheostomy from a total laryngectomy because a laryngectomy patient cannot be oxygenated through the mouth or nose.
- In tracheostomy deterioration, call for expert help, apply oxygen to face and stoma when anatomy is uncertain, remove any speaking valve or cap, check the inner cannula and assess catheter passage.
- Humidification, hydration, mobilisation, positioning, physiotherapy, suction when indicated and treatment of the cause are a coordinated secretion plan; routine saline instillation is not a substitute.
- Cuff deflation, speaking-valve trials, oral intake and decannulation require coordinated respiratory, airway and swallowing assessment, not a calendar date alone.
- A specialised weaning service can improve continuity for prolonged dependence and should be considered early enough to preserve rehabilitation momentum and discharge planning.
Key red flags
Acute distress with a tracheostomy, absent airflow or inability to pass a suction catheter is an airway emergency: call for expert help and follow the bedside emergency algorithm immediately.
Sentinel bleeding from a tracheostomy can precede catastrophic haemorrhage; escalate urgently rather than attributing fresh blood to routine suction trauma.
A total laryngectomy patient has no connection between lungs and upper airway, so face-mask ventilation alone cannot oxygenate them.
Post-extubation stridor, exhaustion, worsening hypercapnia or impaired consciousness requires immediate senior airway review and should not be managed by delaying reintubation with repeated nebulisers.
Rapidly rising suction requirement, recurrent mucus plugging or lobar collapse signals failure of the airway-clearance plan and may precede respiratory arrest.
Investigation priorities
Identify when a spontaneous breathing trial is safe and potentially informative.
Management branches
The acute illness is improving and the patient is initiating breaths with acceptable physiological stability.
- Perform a daily readiness review covering illness trajectory, oxygenation, haemodynamics, consciousness, sedation, fluid balance, electrolytes, pain and neuromuscular function.
- Conduct a supervised spontaneous breathing trial using the unit protocol, stopping safely if distress, gas exchange or haemodynamic instability develops.
- After a successful trial, assess airway patency, cough, secretion frequency, bulbar function and reintubation difficulty before making the extubation decision.
- Plan post-extubation oxygen, physiotherapy and, for an evidence-based high-risk phenotype, non-invasive or high-flow support with close observation and a rescue threshold.