Decannulation and assessment of deglutition in the tracheostomized patient in non-neurocritical intensive care

Guidelines for Tracheostomy From the Korean Bronchoesophagological Society

The Korean Bronchoesophagological Society appointed a task force to develop a clinical practice guideline for tracheostomy. The task force conducted a systematic search of the Embase, Medline, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to key questions. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. An external expert review and a Delphi questionnaire were conducted to reach a consensus regarding the recommendations. Accordingly, the committee developed 18 evidence-based recommendations, which are grouped into seven categories. These recommendations are intended to assist clinicians in performing tracheostomy and in the management of tracheostomized patients.

Expiratory airflow obstruction due to tracheostomy tube: A spirometric study in 50 patients

OBJECTIVES

Tracheostomy is commonly used in intensive care units and in head and neck departments. Airway obstruction due to occluded cuffless tracheostomy tubes themselves remains unknown, although capping trials are commonly used before decannulation. The aim of this study was to evaluate the extent to which airway obstruction can be caused by occluded cuffless tubes in patients who underwent head and neck surgery.

DESIGN

Prospective Research Outcome.

SETTINGS

University teaching hospital.

PARTICIPANTS

Fifty patients requiring transient tracheostomy after head and neck surgery.

MAIN OUTCOME MEASURES

A flow-volume loop (FVL) through the mouth using a portable spirometer, with the occluded fenestrated cuffless tube, was measured before and immediately after decannulation, by obstructing the orifice of tracheostomy tube. The measurement of FVL recorded the forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁ ), peak expiratory flow (PEF), forced expiratory flow at 50% of FVC, peak inspiratory flow (PIF) and forced inspiratory flow at 50% of FVC.

RESULTS

A statistically significant difference between all spirometric parameters was found. Mean PEF and PIF, respectively, increased from 2.8 to 4.5 L/s (P < .0001) and 2.3 to 2.7 L/s (P < .01) before and after decannulation, with a strong positive correlation (r = 0.7; P < .05). A mean expiratory (34%) and inspiratory (9%) airflow reduction was observed due to cannula.

CONCLUSIONS

Occluded cuffless tracheostomy tubes cause a dramatic airflow obstruction, mainly in the expiratory phase of FVL. This should be taken into account during capping trials.

Selective rehabilitative approach to neurological dysfunctions of the oro-pharyngo-laryngeal trivium

CONCLUSION

A dedicated team proved to provide the optimal approach for the rehabilitation of patients with neurological oro-pharyngo-laryngeal dysfunctions.

OBJECTIVES

To assess the effectiveness of a dedicated and specialist team (otolaryngologist, phoniatrician, speech therapist) in the management of patients with severe neurological impairments of the upper airways and digestive routes.

METHODS

Fifty-one subjects with neurological impairment of the upper airways and digestive tract due to either central or peripheral causes, who underwent tracheotomy if needed, were recruited at a tertiary university hospital. Two different rehabilitative approaches were used: the classic approach (CA), where a specialist ENT consultation was requested by the professionals if needed; and a selective approach (SA) where a specialist team directly followed and monitored the different phases of management and rehabilitation. Different temporal parameters, in relation to tracheotomy, fenestration of the tracheal tube, and decannulation time, were taken into account and compared between these two approaches.

RESULTS

The decannulation time, management of the tracheal tube, and recovery of swallowing function were significantly shorter in patients who were treated according to the SA (p < 0.05). The presence of the tracheal tube and the site of the damage did not affect the outcome in the different study groups (p > 0.05).