The tracheostomy entry into the trachea is assessed, with the tracheostomy tube both in place and withdrawn. Special attention is given to whether suprastomal granulation tissue exists and whether the anterior tracheal wall is collapsed posteriorly by the tracheostomy tube. Granulation tissue, if present, is removed. The process of decannulation can be performed in two ways. Most commonly, the tube is removed and the track is allowed to close down and heal.
Some practitioners prefer to excise the track and allow it to heal by first intention.
However in both the methods, safety of decannulation must be ensured by a prior decannulation trial. If the child has been sent home then the child should be readmitted. The basic principle of the trial is to carry out progressive blockage of the tube lumen. The child is watched carefully for any signs of respiratory distress as he carries out normal physical activities. Willis et al. prefer to fenestrate the tracheostomy tube under direct visualisation in the operating room.