Peak flow rate during induced cough: a predictor of successful decannulation of a tracheotomy tube in neurosurgical patients

A Pluridisciplinary Tracheostomy Weaning Protocol for Brain-Injured Patients, Outside of the Intensive Care Unit and Without Instrumental Assessment: Results of Pilot Study

Concurrently to the recent development of percutaneous tracheostomy techniques in the intensive care unit (ICU), the amount of tracheostomized brain-injured patients has increased. Despites its advantages, tracheostomy may represent an obstacle to their orientation towards conventional hospitalization or rehabilitation services. To date, there is no recommendation for tracheostomy weaning outside of the ICU. We created a pluridisciplinary tracheostomy weaning protocol relying on standardized criteria but adapted to each patient's characteristics and that does not require instrumental assessment. It was tested in a prospective, single-centre, non-randomized cohort study. Inclusion criteria were age > 18 years, hospitalized for an acquired brain injury (ABI), tracheostomized during an ICU stay, and weaned from mechanical ventilation. The exclusion criterion was severe malnutrition. Decannulation failure was defined as recannulation within 96 h after decannulation. Thirty tracheostomized ABI patients from our neurosurgery department were successively and exhaustively included after ICU discharge. Twenty-six patients were decannulated (decannulation rate, 90%). None of them were recannulated (success rate, 100%). Two patients never reached the decannulation stage. Two patients died during the procedure. Mean tracheostomy weaning duration (inclusion to decannulation) was 7.6 (standard deviation [SD]: 4.6) days and mean total tracheostomy time (insertion to decannulation) was 42.5 (SD: 24.8) days. Our results demonstrate that our protocol might be able to determine without instrumental assessment which patient can be successfully decannulated. Therefore, it may be used safely outside ICU or a specialized unit. Moreover, our tracheostomy weaning duration is very short as compared to the current literature.

Predictive Factors for Successful Decannulation in Patients with Tracheostomies and Brain Injuries: A Systematic Review

Neurological patients frequently have disorders of consciousness, swallowing disorders, or neurological states that are incompatible with extubation. Therefore, they frequently require tracheostomies during their stay in an intensive care unit. After the acute phase, tracheostomy weaning and decannulation are generally expected to promote rehabilitation. However, few reliable predictive factors (PFs) for decannulation have been identified in this patient population. We sought to identify PFs that may be used during tracheostomy weaning and decannulation in patients with brain injuries. We conducted a systematic review of the literature regarding potential PFs for decannulation; searches were performed on 16 March 2021 and 1 June 2022. The following databases were searched: MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, PEDro, OPENGREY, OPENSIGLE, Science Direct, CLINICAL TRIALS and CENTRAL. We searched for all article types, except systematic reviews, meta-analyses, abstracts, and position articles. Retrieved articles were published in English or French, with no date restriction. In total, 1433 articles were identified; 26 of these were eligible for inclusion in the review. PFs for successful decannulation in patients with acquired brain injuries (ABIs) included high neurological status, traumatic brain injuries rather than stroke or anoxic brain lesions, younger age, effective swallowing, an effective cough, and the absence of pulmonary infections. Secondary PFs included early tracheostomy, supratentorial lesions, the absence of critical illness polyneuropathy/myopathy, and the absence of tracheal lesions. To our knowledge, this is the first systematic review to identify PFs for decannulation in patients with ABIs. These PFs may be used by clinicians during tracheostomy weaning.

Cough flows as a criterion for decannulation of autonomously breathing patients with tracheostomy tubes

BACKGROUND

Adequate cough or exsufflation flow can indicate an option for safe tracheostomy decannulation to noninvasive management. Cough peak flow via the upper airways with the tube capped is an outcome predictor for decannulation readiness in patients with neuromuscular impairment. However, this threshold value is typically measured with tracheotomy tube removed, which is not acceptable culturally in China. The aim of this study was to assess the feasibility and safety of using cough flow measured with tracheostomy tube and speaking valve (CFSV) > 100 L/min as a cutoff value for decannulation.

STUDY DESIGN

Prospective observational study conducted between January 2019 and September 2022 in a tertiary rehabilitation hospital.

METHODS

Patients with prolonged tracheostomy tube placement were referred for screening. Each patient was assessed using a standardized tracheostomy decannulation protocol, in which CFSV greater than 100 L/min indicated that the patients' cough ability was sufficient for decannulation. Patients whose CFSV matched the threshold value and other protocol criteria were decannulated, and the reintubation and mortality rates were followed-up for 6 months.

RESULTS

A total of 218 patients were screened and 193 patients were included. A total of 105 patients underwent decannulation, 103 patients were decannulated successfully, and 2 patients decannulated failure, required reinsertion of the tracheostomy tube within 48 h (failure rate 1.9%). Three patients required reinsertion or translaryngeal intubation within 6 months.

CONCLUSIONS

CFSV greater than 100 L/min could be a reliable threshold value for successful decannulation in patients with various primary diseases with a tracheostomy tube.

TRIAL REGISTRATION

This observational study was not registered online.

BIS-guided sedation prevents the cough reaction of patients under general anaesthesia caused by extubation: a randomized controlled trial

Background

The multiple modes of SARS-CoV-2 transmission including airborne, droplet, contact and faecal–oral transmissions that cause coronavirus disease 2019 (COVID-19) contribute to a public threat to the lives of people worldwide. Heavy aerosol production by coughing and the big peak expiratory flow in patients with respiratory infections (especially SARS-CoV-2) during recovery from general anaesthesia are the highest risk factors for infection in healthcare workers. To perform sedation before extubation significantly reduced the incidence of coughing during recovery from general anaesthesia. However, there are few studies on endotracheal tube removal under BIS-guided sedation in postanaesthesia care unit (PACU). We speculated that the BIS-guided sedation with dexmedetomidine and propofol would better prevent coughing caused by tracheal extubation and reducing peak expiratory flow.

Methods

Patients with general anaesthesia were randomly assigned to Group S (dexmedetomidine was infused in the operating room for 30 min, and the bispectral index (BIS) value was maintained 60–70 by infusion propofol at 0.5~1.5 μg/ml in the PACU until the endotracheal tubes were pulled out) and Group C (no dexmedetomidine and propofol treatment, replaced with the saline treatment). The incidence of coughing, agitation and active extubation, endotracheal tube tolerance and the peak expiratory flow at spontaneous breathing and at extubation were assessed.

Results

A total of 101 patients were randomly assigned to Group S (51 cases) and Group C (50 cases). The incidence of coughing, agitation and active extubation was significantly lower (1(51), 0(51) and 0(51), respectively) in Group S than (11(50), 8(50) and 5(50), respectively) in Group C (p < 0.05 or p < 0.01, respectively); the scores of cough were significantly reduced (1(1, 1)) in Group S than (1(1, 2)) in Group C (p < 0.01); and the endotracheal tube tolerance was significantly improved (0(0, 1)) in Group S than (1(1, 3)) in Group C (p < 0.001). The peak expiratory flow at spontaneous breathing and at extubation was significantly reduced (5(5, 7) and 6.5(6, 8), respectively) in Group S than (8(5, 10) and 21(9, 32)) in Group C (p < 0.001).

Conclusions

BIS-guided sedation with dexmedetomidine and propofol significantly prevented coughing and reduced peak expiratory flow during recovery from general anaesthesia, which may play an important role in preventing medical staff from contracting COVID-19.

Trial registration

Chinese Clinical Trial Registry: ChiCTR2200058429 (registration date: 09-04-2022) “retrospectively registered”.

COVID-19 Transmission to Health Care Personnel During Tracheostomy Under a Multidisciplinary Safety Protocol

BACKGROUND

Tracheostomies are highly aerosolizing procedures yet are often indicated in patients with COVID-19 who require prolonged intubation. Robust investigations of the safety of tracheostomy protocols and provider adherence and evaluations are limited.

OBJECTIVES

To determine the rate of COVID-19 infection of health care personnel involved in COVID-19 tracheostomies under a multidisciplinary safety protocol and to investigate health care personnel's attitudes and suggested areas for improvement concerning the protocol.

METHODS

All health care personnel involved in tracheostomies in COVID-19-positive patients from April 9 through July 11, 2020, were sent a 22-item electronic survey.

RESULTS

Among 107 health care personnel (80.5%) who responded to the survey, 5 reported a positive COVID-19 test result (n = 2) or symptoms of COVID-19 (n = 3) within 21 days of the tracheostomy. Respondents reported 100% adherence to use of adequate personal protective equipment. Most (91%) were familiar with the tracheostomy protocol and felt safe (92%) while performing tracheostomy. Suggested improvements included creating dedicated tracheostomy teams and increasing provider choices surrounding personal protective equipment.

CONCLUSIONS

Multidisciplinary engagement in the development and implementation of a COVID-19 tracheostomy protocol is associated with acceptable safety for all members of the care team.

Data-driven prediction of decannulation probability and timing in patients with severe acquired brain injury

BACKGROUND AND OBJECTIVES

From a rehabilitation perspective, removal of tracheostomy in patients with severe acquired brain injuries (sABI) is a crucial step. Predictive parameters for a successful decannulation are currently still a focus of the research for sABI patients, especially for those presenting a disorder of consciousness. For this reason, we adopted a data-driven approach predicting decannulation probability and timing using ensemble learning models in patients in intensive rehabilitation units.

METHODS

327 patients, 186 of which were successfully decannulated during their intensive rehabilitative stay, were recruited in a non-concurrent retrospective study. Decannulation probability and timing were predicted using data available within one week from admission at the rehabilitation unit. Two predictive models were trained and cross-validated independently, with the first being an ensemble of a Support Vector Machine and Random Forests and the second an Adaptive Boosting with a Support Vector Regression as weak learner. Confusion matrix, accuracy and AUC were considered as evaluation metrics for the classifier and median absolute error was considered for the regressor. To quantify the advantages in the clinical practice of using the latter prediction, we compared timing estimation with a timing guess (median) calculated on available data. The comparison was based on a Wilcoxon signed rank test.

RESULTS

Decannulation probability was successfully predicted with an accuracy of 84.8% (AUC = 0.85) and timing with a median absolute error of 25.7 days [IQR = 25.6]. This resulted in a significant improvement with respect to the weaning time guess (p<0.05) with an effect size of 71.7%. Furthermore, dichotomizing the regression prediction with a threshold (3 months from the event), resulted in a prediction accuracy of 77.5% (AUC = 0.82) on the test set.

DISCUSSIONS

A model capable of providing a prediction on decannulation probability and timing was developed and cross-validated, built on data taken at admission to the intensive rehabilitation unit. Translated in clinical practice, this information can support the clinical decision process and provide a mean to improve both in-hospital and domiciliary care organization.

Standardized Endoscopic Swallowing Evaluation for Tracheostomy Decannulation in Critically Ill Neurologic Patients - a prospective evaluation

Background

Removal of a tracheostomy tube in critically ill neurologic patients is a critical issue during intensive care treatment, particularly due to severe dysphagia and insufficient airway protection. The “Standardized Endoscopic Evaluation for Tracheostomy Decannulation in Critically Ill Neurologic Patients” (SESETD) is an objective measure of readiness for decannulation. This protocol includes the stepwise evaluation of secretion management, spontaneous swallowing, and laryngeal sensitivity during fiberoptic endoscopic evaluation of swallowing (FEES). Here, we first evaluated safety and secondly effectiveness of the protocol and sought to identify predictors of decannulation success and decannulation failure.

Methods

A prospective observational study was conducted in the neurological intensive care unit at Münster University Hospital, Germany between January 2013 and December 2017. Three hundred and seventy-seven tracheostomized patients with an acute neurologic disease completely weaned from mechanical ventilation were included, all of whom were examined by FEES within 72 h from end of mechanical ventilation. Using regression analysis, predictors of successful decannulation, as well as decannulation failure were investigated.

Results

Two hundred and twenty-seven patients (60.2%) could be decannulated during their stay according to the protocol, 59 of whom within 24 h from the initial FEES after completed weaning. 3.5% of patients had to be recannulated due to severe dysphagia or related complications. Prolonged mechanical ventilation showed to be a significant predictor of decannulation failure. Lower age was identified to be a significant predictor of early decannulation after end of weaning. Transforming the binary SESETD into a 4-point scale helped predicting decannulation success in patients not immediately ready for decannulation after the end of respiratory weaning (optimal cutoff ≥1; sensitivity: 64%, specifity: 66%).

Conclusions

The SESETD showed to be a safe and efficient tool to evaluate readiness for decannulation in our patient collective of critically ill neurologic patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s42466-021-00124-1.

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.

Decannulation After a Severe Acquired Brain Injury

OBJECTIVE

To identify the effect of some clinical characteristics of severe acquired brain injury (sABI) patients on decannulation success during their intensive rehabilitation unit (IRU) stay.

DESIGN

Nonconcurrent cohort study.

SETTING

Don Gnocchi Foundation Institute.

PARTICIPANTS

Patients (N=351) with sABI and tracheostomy were retrospectively selected from the database of the IRU of the Don Gnocchi Foundation Institute.

MAIN OUTCOME MEASURES

Potential predictors of decannulation were screened from variables collected at admission during clinical examination, conducted by trained and experienced examiners. The association between clinical characteristics and decannulation status was investigated through a Cox regression model. Kaplan-Meier curves were then created for time-event analysis.

RESULTS

Among the patients (mean age, 64.1±15.5y), 54.1% were decannulated during their IRU stay. Absence of pulmonary infections (P<.001), sepsis (P=.001), tracheal alteration at the fibrobronchoscopy examination (P=.004) and a higher Coma Recovery Scale-Revised (CRS-R) score (P<.001) or a better state of consciousness at admission (P=.001) were associated with a higher probability of decannulation.

CONCLUSIONS

Fibrobronchoscopy assessment of patency of airways and accurate evaluation of the state of consciousness using the CRS-R are relevant in this setting of care to better identify patients who are more likely to have the tracheostomy tube removed. These results may help clinicians choose the appropriate timing and intensity of rehabilitation interventions and plan for discharge.

Decannulation of tracheotomized patients after long-term mechanical ventilation - results of a prospective multicentric study in German neurological early rehabilitation hospitals

Background

In the course of neurological early rehabilitation, decannulation is attempted in tracheotomized patients after weaning due to its considerable prognostic significance. We aimed to identify predictors of a successful tracheostomy decannulation.

Methods

From 09/2014 to 03/2016, 831 tracheotomized and weaned patients (65.4 ± 12.9 years, 68% male) were included consecutively in a prospective multicentric observation study. At admission, sociodemographic and clinical data (e.g. relevant neurological and internistic diseases, duration of mechanical ventilation, tracheotomy technique, and nutrition) as well as functional assessments (Coma Recovery Scale-Revised (CRS-R), Early Rehabilitation Barthel Index, Bogenhausener Dysphagia Score) were collected. Complications and the success of the decannulation procedure were documented at discharge.

Results

Four hundred seventy patients (57%) were decannulated. The probability of decannulation was significantly negatively associated with increasing age (OR 0.68 per SD = 12.9 years, p < 0.001), prolonged duration of mechanical ventilation (OR 0.57 per 33.2 days, p < 0.001) and complications. An oral diet (OR 3.80; p < 0.001) and a higher alertness at admission (OR 3.07 per 7.18 CRS-R points; p < 0.001) were positively associated.

Conclusions

This study identified practically measurable predictors of decannulation, which in the future can be used for a decannulation prognosis and supply optimization at admission in the neurological early rehabilitation clinic.

Respiratory muscle strength and state of consciousness values measured prior to the decannulation in different levels of complexity. A longitudinal prospective case series study

OBJECTIVE

To describe the variables related to effective cough capacity and the state of consciousness measured prior to decannulation and compare their measured values between the different areas of care such as the Intensive Care Unit (ICU), General ward and Mechanical Ventilation Weaning and Rehabilitation Centers (MVWRC). Secondarily analyze the evolution of patients once decannulated.

DESIGN

Case series, longitudinal and prospective.

SCOPE

Multicentric 31 ICUs (polyvalent) and 5 MVWRC.

PATIENTS

Tracheostomized adults prior to decannulation.

MEASUREMENTS

Maximum expiratory pressure, peak expiratory flow coughed (PEFC), Glasgow Coma Scale (GCS).

RESULTS

Two hundred and seven decannulated patients, 124 (60%) in ICU, 59 (28%) General ward and 24 (12%) in MVWRC. The PEFC presented differences between the patients (ICU 110 - 190 l/min versus MVWRC 167.5 - 232.5 l/min, p <.01). The GCS was different between General ward (9 -15) versus ICU (10-15) and MVWRC (12-15); p <.01 and p <.01, respectively. There were differences in the days of hospitalization (p <.01), days with tracheostomy (<0.01) and the number of patients referred at home (p =.02) between the different scenarios.

CONCLUSION

There are differences in the values of PEFC and GCS observed when decannulating between different areas. A considerable number of patients are decannulated with values of PEFC and maximum expiratory pressure below the suggested cut-off points as predictors of failure in the literature. No patient in our series was decanulated with an GCS <8, this reflects the importance that the treating team gives to the state of consciousness prior to decannulation.

The practice of tracheostomy decannulation-a systematic review

Decannulation is an essential step towards liberating tracheostomized patients from mechanical ventilation. However, despite its perceived importance, there is no universally accepted protocol for this vital transition. Presence of an intact sensorium coordinated swallowing and protective coughing are often the minimum requirements for a successful decannulation. Objective criteria for each of these may help better the clinical judgement of decannulation. In this systematic review on decannulation, we focus attention to this important aspect of tracheostomy care.

Extubation Failure in Brain-injured Patients: Risk Factors and Development of a Prediction Score in a Preliminary Prospective Cohort Study

BACKGROUND

The decision to extubate brain-injured patients with residual impaired consciousness holds a high degree of uncertainty of success. The authors developed a pragmatic clinical score predictive of extubation failure in brain-injured patients.

METHODS

One hundred and forty brain-injured patients were prospectively included after the first spontaneous breathing trial success. Assessment of multiparametric hemodynamic, respiratory, and neurologic functions was performed just before extubation. Extubation failure was defined as the need for ventilatory support during intensive care unit stay. Extubation failure within 48 h was also analyzed. Neurologic outcomes were recorded at 6 months.

RESULTS

Extubation failure occurred in 43 (31%) patients with 31 (24%) within 48 h. Predictors of extubation failure consisted of upper-airway functions (cough, gag reflex, and deglutition) and neurologic status (Coma Recovery Scale-Revised visual subscale). From the odds ratios, a four-item predictive score was developed (area under the curve, 0.85; 95% CI, 0.77 to 0.92) and internally validated by bootstrap. Cutoff was determined with sensitivity of 92%, specificity of 50%, positive predictive value of 82%, and negative predictive value of 70% for extubation failure. Failure before and beyond 48 h shared similar risk factors. Low consciousness level patients were extubated with 85% probability of success providing the presence of at least two operating airway functions.

CONCLUSIONS

A simplified clinical pragmatic score assessing cough, deglutition, gag reflex, and neurologic status was developed in a preliminary prospective cohort of brain-injured patients and was internally validated (bootstrapping). Extubation appears possible, providing functioning upper airways and irrespective of neurologic status. Clinical practice generalizability urgently needs external validation.

Parameters Influencing Tracheostomy Decannulation in Patients Undergoing Rehabilitation after severe Acquired Brain Injury (sABI)

Introduction  Tracheostomy weaning in patients who suffered a severe acquired brain injury is often a challenge and decannulation failures are not uncommon.

Objective  Our study objective is to describe the decannulation failure rate in patients undergoing rehabilitation following a severe acquired brain injury (sABI); to describe the factors associated with a successful tube weaning.

Methods  We conduct a retrospective analysis of charts, consecutively retrieved considering a 3-year window. Variables analyzed were: age, sex, body mass index (BMI), Glasgow Coma Scale (GCS), cause of hospitalization (stroke, trauma, cardiac arrest), date of the pathological event, gap between the index event and the first day of hospitalization, duration of Neurorehabilitation Ward hospitalization, comorbidities, chest morphological alteration, kind of tracheostomy tube used (overall dimension, cap, fenestration), SpO2, presentation and quantification of pulmonary secretion, maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), respiratory frequency and pattern, cardiac frequency, presence of spontaneous cough, cough strength, and blood gas analysis.

Results  We analyzed 45 tracheostomised sABI patients following stroke, trauma, or cardiac arrest. The weaning success percentage was higher in Head Trauma patients and in patients presenting positive spontaneous cough. Failures seem to be associated with presence of secretions and anoxic brain damage. GCS seemed not related to the decannulation outcome.

Conclusions  Parameters that could be used as positive predictors of weaning are: mean expiratory pressure, presence of spontaneous cough, and cough strength. Provoked cough and GCS were not predictive of weaning success.

Open airway reconstruction in adults: Outcomes and prognostic factors

PURPOSE

The purpose was to assess the success of open tracheal resection and re-anastomosis for non-malignant tracheal stenosis in adults. Successful operations were defined as T-tube or tracheostomy-free status by 6months post-operatively.

MATERIALS AND METHODS

Retrospective chart review was performed and data were recorded in a de-identified manner. The primary outcome was T-tube or tracheostomy-free status by 6months following tracheal resection. Clinical and demographic characteristics were evaluated as potential prognostic variables.

RESULTS

Thirty-two patients met inclusion criteria, with a median age of 46. Seven patients underwent tracheal resection with primary closure, without stenting. Successful tracheal resection was defined as tracheostomy or T-tube free by 6months post-operation, and this was possible in 21 patients (66%). Eighty-two percent of patients with cricoid cartilage-sparing tracheal resection had a successful outcome, versus 30% of patients who underwent cricoid cartilage resection (HR 5.02, 95% CI 1.46-17.3; p=0.011). Patients with a history of tracheostomy-dependence were four times more likely to remain tube-dependent at 6months (HR 4.15, 95% CI 1.56-10.86; p=0.004).

CONCLUSIONS

Tracheal stenosis remains a very difficult problem to treat. In our series, we confirm that patients with cricoid involvement or with a history of tracheostomy were more likely to be tube dependent at 6-months post-operation.

Predictors of Failed and Delayed Decannulation after Head and Neck Surgery

Objective

To determine the variables that are predictive of failed decannulation (FD), delayed decannulation (DD), and days to decannulation in patients who underwent head and neck cancer resection with free tissue transfer reconstruction for head and neck squamous cell carcinoma.

Design

Case series with chart review.

Setting

Tertiary care otolaryngology–head and neck surgery referral center.

Subject and Methods

Patients (N = 108) were included who underwent head and neck cancer resection with free tissue transfer reconstruction and tracheostomy between 2011 and June 2014. Patients with laryngectomy, previous tracheostomy, and other airway pathology necessitating tracheotomy were excluded. Preoperative patient variables and cancer site/staging variables were analyzed, as well as extent of structures resected and type of reconstruction. Univariate and multivariate binary logistic and Cox regression analyses were used to determine predictors of FD and DD. Cox regression analysis was used to determine predictors of days to decannulation.

Results

Of the 108 included patients, 16 had FD, and 26 had DD. Univariate analysis demonstrated that advanced stage ( r = 0.233, P = .021), total glossectomy ( r = 0.924, P < .001), anterolateral thigh flap reconstruction ( r = 0.906, P < .001), smoking at time of surgery ( r = 0.319, P = .002), and pack years ( r = 0.322, P = .001) were associated with FD. Cox regression analysis showed that total glossectomy, exp(B) = 15.837 (95% confidence interval [95% CI]: 1.949-128.679); anterolateral thigh flap reconstruction, exp(B) = 8.439 (95% CI: 2.435-29.620); and smoking status, exp(B) = 2.970 (95% CI: 1.617-5.456) were independent predictors of days to decannulation and FD.

Conclusions

Patients with total glossectomy defects and those who continue to smoke are at increased risk for FD and DD. Aggressive smoking cessation programs may decrease the risk of FD and DD. Patients should be counseled about their risk profiles.

The value of cough peak flow measurements in the assessment of extubation or decannulation readiness

Insufficient cough strength has a major role in extubation and decannulation outcomes. Cough capacity can be easily evaluated by measuring flows during coughing. Values vary depending on whether cough flows are measured through the mouth or through a tracheostomy or endotracheal tube. It is important to standardize these measurements and start using them routinely in the extubation and decannulation processes. Values of cough peak flow >160 L/min measured at the mouth or a value of cough PEF >60 L/min measured at the endotracheal tube suggest successful decannulation or extubation.

Decannulation of critically ill patients after long-term mechanical ventilation – predictors from clinical routine data

Introduction: Variables predicting successful decannulation from a tracheotomy tube after long-term mechanical ventilation remain obscure.

Material and methods: To identify such predictors, data from 150 consecutive critically ill patients with a tracheotomy for the purpose of mechanical ventilation were analyzed retrospectively. Of the 150 tracheotomized patients who were admitted to a rehabilitation center, 103 were successfully decannulated. Items concerning socio-demographic data, indication for mechanical ventilation (neurologic, cardiologic, respiratory or gastro-intestinal disease), comorbidities, tracheotomy technique (dilatational vs. surgical), duration of mechanical ventilation, complications during weaning from tracheotomy tube, and also care dependency, alertness and the degree of aspiration at admission to the rehabilitation clinic were tested using a multiple logistic regression model.

Results: A successful decannulation was associated with no complications during decannulation procedure (OR 0.175, 95% CI; p=0.002), high alertness at the beginning of rehabilitation (OR 1.079, 95% CI; p=0.014), female gender (OR 0.338, 95% CI; p=0.031), a low number of comorbidities (OR 0.737, 95% CI; p=0.043), and dilatational tracheotomy (OR 2.375, 95% CI; p=0.054).

Conclusions: The identified predictor variables can be collected easily in the clinical routine. Except for complications during decannulation procedure all predictors can be assessed at admission with the result that a prediction of decannulation success is possible very early in clinical course.

Polysomnography: assessment of decannulation readiness in chronic upper airway obstruction

OBJECTIVES/HYPOTHESIS

To evaluate the clinical value of polysomnography in patients with a tracheotomy due to chronic upper airway obstruction prior to attempting decannulation.

STUDY DESIGN

Retrospective chart review.

METHODS

Subjects with chronic upper airway obstruction were identified using a clinical database between 2000 and 2014. All subjects had a tracheotomy, were assessed by the senior author in a tertiary care academic center, and underwent polysomnography prior to attempting decannulation. Patients were excluded if they did not undergo polysomnography or had severe obstructive sleep apnea as the primary indication for tracheotomy.

RESULTS

Fifteen patients were identified. The majority (87.5%) of patients were successfully decannulated after their first polysomnography showed acceptable results when carried out with the tracheotomy occluded. Obstructive sleep apnea was identified in four of the nine patients who tolerated overnight tracheotomy occlusion, and continuous positive airway pressure (CPAP) was initiated. An additional four of the remaining six patients were decannulated after subsequent polysomnography demonstrated improvement with CPAP, and two required an additional airway procedure.

CONCLUSIONS

Chronic upper airway obstruction requiring tracheotomy can be challenging to treat and successfully decannulate. Indirect laryngoscopy is essential to evaluate the anatomy of the larynx; however, it cannot assess potential increased obstruction during sleep. The study indicates that polysomnography can assist with the evaluation of decannulation readiness in patients with chronic upper airway obstruction as an adjunct measure in addition to imaging and laryngoscopy.

LEVEL OF EVIDENCE

4.