Embed Size (px)
Citation preview
REVIEW Open Access
The practice of tracheostomydecannulation—a systematic reviewRatender Kumar Singh*, Sai Saran and Arvind K. Baronia
Abstract
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 minimumrequirements for a successful decannulation. Objective criteria for each of these may help better the clinicaljudgement of decannulation. In this systematic review on decannulation, we focus attention to this importantaspect of tracheostomy care.
Keywords: Tracheostomy, Decannulation, Weaning
BackgroundTracheostomy is a common procedure in patientsrequiring prolonged mechanical ventilation (MV) andairway protection in intensive care unit (ICU) [1]. Theprocess of weaning from tracheostomy to maintenanceof spontaneous respiration and/or airway protection istermed “decannulation”. This apparently simple step re-quires a near perfect coordination of brain, swallowing,coughing, phonation and respiratory muscles [2].However, multifactorial aberrations in this complexinterplay can result in its failure. Moreover, inappropri-ate assessment of the above factors increases the risk ofaspiration during and after the decannulation process.Old age, obesity, poor neurological status, sepsis andtenacious secretions are the predominant reasons offailed decannulation [3].Inability to speak with tracheostomy tube (TT) in situ
results in significant anxiety and depression amongstpatients [4]. More often than not, the process of decan-nulation is slow and prolonged leading to increasedICU stay, nosocomial infections and costs [5]. Provisionof optimal tracheostomy care can help discharge thesepatients with TT in situ to ward, high dependency unit(HDU) and/or home. Repeat assessment and decannu-lation can then be performed during follow-up visits.
Several studies have emphasized the importance ofdecannulation within the ICU due to better andfocused care compared to HDU or ward [6, 7].Inspite of the relevance and importance of decannula-
tion, there is no universally accepted protocol for itsperformance. Variability in existing algorithms [8], non-randomized study design [9] and ambiguity in thescreening, technique and monitoring of decannulationlimits our understanding in this important area of care.In order to better understand the various practices oftracheostomy decannulation, we performed the presentsystematic review of the process of decannulation.
Material and methodsCriteria for including studiesCase series, case–control, prospective, retrospective, ran-domized or non-randomized studies or surveys dealingwith the process of decannulation were all included inthis systematic review.
PatientsAdult patients aged above 18 years and admitted inward, operation theater, ICU or HDU were included.
InterventionsPatients with surgical or percutaneous dilatationaltracheostomy who were subjected to the process ofdecannulation during weaning from MV were included.
* Correspondence: [email protected] of Critical Care Medicine, Sanjay Gandhi Post Graduate Instituteof Medical Sciences (SGPGIMS), Raebareli Road, Lucknow 226014, UttarPradesh, India
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Singh et al. Journal of Intensive Care (2017) 5:38 DOI 10.1186/s40560-017-0234-z
Outcome measuresPrimary outcome measure assessed was success ofweaning defined by a period of spontaneous breathingwithout having to resort to non-invasive ventilation(NIV) support or re-insertion of TT.
Identification of studiesTwo independent reviewers searched the electronicdatabase PubMed using mesh words “Tracheostomy”,“Decannulation” and “Decannulation process” as title forthe intervening period from 1995 to 2016 for identifica-tion of studies. The third independent reviewer thenscreened the two lists, removed the duplicates, and thensearched for the abstracts which fulfilled the inclusioncriteria. Full texts of the selected abstracts were then re-trieved. Studies which further detailed the aspects of the“process of decannulation” were included. References ofthe included studies were further searched for any add-itional relevant studies not identified through our formersearch.
Study selectionOnly studies wherein full texts were available were fi-nally included. In case full-text article was not availablefor a selected study, the institutes e-library using“ERMED consortium” and/or “Clinical key” were usedfor free access to journals. In the event free access to fulltext was still not available then the authors were con-tacted directly for copies. English language and full-textrestriction were used for inclusion of relevant studies.
Data extractionAuthor (s), year of publication, country, type of study(observational, cohort, case–control, randomized and orsurvey), characteristics of patients, nature and severity ofillness, site of care (ward, OT, HDU or ICU), method bywhich tracheostomy was performed [surgical or percu-taneous dilatational (PCD)], length of MV prior todecannulation, criteria and method of decannulationused, outcomes in terms of success or failure of decan-nulation, definition of failed decannulation and limita-tions of study were all assessed. For completeness ofdata, any missing information was retrieved by directlycontacting the respective authors.
Quality assessmentThe methodological quality of randomized controlledstudies was assessed by Jadad scale while non-randomizedstudies were assessed using the “Q-Coh” tool for cohortstudies in systematic reviews and meta-analyses [10]. Q-Coh is a 9-point tool which incorporates the attributes ofdesign, representativeness, and comparability of groups,exposure measures, and maintenance of comparability,
outcome measures, attrition, statistical analysis and theoverall assessment of each study.
ResultsOur PubMed database search yielded 62 articles pub-lished between January 1995 and December 2016. Four-teen articles were excluded as they were not related tothe process of decannulation. Another 9 articles frompaediatrics were also excluded. The remaining 39 articlesincluded 24 observational studies, 5 case series, 1 casereport, 4 editorials and special comments, 2 question-naires or expert opinions and 1 systematic review. Therewas no randomized controlled study. Six studies eachwere further excluded owing to non-availability of dataand use of language other than English. The final num-ber of full-text studies thus included in our analysis was18. The step-wise selection of studies along with reasonsfor exclusion was as enumerated in Fig. 1. After analyz-ing the selected studies, we decided to perform asystematic and critical review of the existing studies ondecannulation due to lack of statistical requirements fora meta-analysis.The detailed characteristics of the finally included 18
studies were as depicted in the Tables 1 and 2. Therewere 10 prospective [8, 9, 11–18], 6 retrospective studies[4, 19–23], and 2 questionnaire-based surveys [24, 25].There was no randomized controlled study. The 16 pro-spective and retrospective studies were all single centre,while both surveys were multicentre. Except one studyfrom India [9], all were from the developed world. In all,a total of 3977 patients with age varying between 24 and85 years were included in these studies. The largestnumbers of patients included were 981 in the prospect-ive study by Choate et al. in 2009 from Australia [14].Majority of the studied tracheostomized patients had
illnesses chronic in nature [8, 11]. The clinical spectrumincluded patients with stroke, quadriplegia, GBS, headtrauma, acute exacerbations of chronic obstructive pul-monary disease, obstructive sleep apnea, restrictive lungdisorder, acute respiratory distress syndrome, cardiacfailure, cancer and postoperative neurosurgical, cardio-thoracic and abdominal patients. The study by KennethB et al. specifically included critically ill obese patientswith an average body mass index of 41.9 ± 14 [21]. Fewstudies [8, 13, 20, 23] reported the severity of the illnessof included patients.Ten out of 18 studies did not report whether the trache-
ostomy was performed by surgical or percutaneous tech-nique. There were 2 studies each with tracheostomiesperformed by either surgical [8] or percutaneous [20]technique, while 5 studies included patients with bothtechniques [13, 14, 19, 21, 25].The duration of MV prior to decannulation was quite
variable. It was lesser than 3 days in the study by
Singh et al. Journal of Intensive Care (2017) 5:38 Page 2 of 12
Guerlain J et al. [18] to as long as 2224 days with Bachet al. [12].While the inclusion criteria were distinctly spelled out
in 12 studies [8, 11–17, 20, 22], the exclusion criteriawere only mentioned in 6 [14, 15, 17, 21, 23].Readiness to decannulate was assessed by qualitative
and quantitative determinants of coughing and swallow-ing in different studies. Peak cough flow (PCF) [20] andmaximum expiratory pressure (MEP) [8] were used asquantitative measures of coughing. Swallowing wasmostly assessed subjectively via gag reflex or dye test [2],except in the study by Wranecke et al. wherein fibreop-tic endoscopic evaluation of swallowing (FEES) was usedfor objective assessment [23].Specific method of decannulation was mentioned in all
studies except two [19, 21]. Patients satisfying the criter-ion for decannulation were initially switched over to asmaller downsized fenestrated or non-fenestrated TT,which was later uncuffed and/or capped for a variableobservation period before being finally removed. How-ever, capping without downsizing [4, 13] and abrupt TTremoval was also reported [9]. While spontaneous re-spiratory workload post downsizing TT was monitoredin most studies, Bach et al. used NIV support to de-crease the breathing workload [12].
While the primary outcome in most studies was a suc-cessful decannulation, the secondary outcomes werequite variable. These secondary outcomes included sur-vival, length of stay, prediction factors for success, andutility of a particular assessment technique [16] or ascreening tool [25]. In most studies, a successful decan-nulation occurred when there was no need of reinsertionof TT. However, the period of observation during whichre-insertion was averted varied widely from a minimumof 24 h [18] to 3–6 months [8] and/or until dischargefrom the unit or hospital [14, 19]. The success rate ofdecannulation in the studies varied from as low of 23%[25] to as high as 100% [23].The authors concluded from the studies that identifi-
cation of patients ready for decannulation via objectiveassessment of swallowing (FEES) [16], coughing [PCF orpeak [12, 18] inspiratory flow (PIF)] and use of a scoring(QsQ) system [26] performed by a multidisciplinarydecannulation team in ICU may prove to be moresuccessful.According to the Q-Coh tool [10] majority of the stud-
ies were of low quality, except the study by Ceriana et al.[8], Chaote et al. [14] and Wranecke et al. [13]. Detailsof all attributes of the Q-Coh tool were as depicted inthe Additional file 1: Table S1.
Fig. 1 Flow diagram of selection of studies
Singh et al. Journal of Intensive Care (2017) 5:38 Page 3 of 12
Table
1Characteristicsof
includ
edstud
ies
Autho
rCou
ntry
Year
ofpu
blication
Type
ofstud
yCateg
oryof
patients
Num
ber
ofpatients
Age
(years)
Durationof
MV(days)
priorto
decann
ulation
Surgical/PCT
Inclusioncriteria
Exclusioncriteria
GravesA
etal.[11]
USA
1995
Prospe
ctive
sing
lecentre
Chron
icne
urolog
ical
illne
ss20
5844–54
NA
1.Ventilatio
nfor4weeks
2.Successfullyweane
dofffor48
h3.Minuteventilatio
n<10
L/min
4.RR
<12
5.SaO2>90%
(0.4FiO2)
NA
Bach
etal.
[12]
USA
1996
Prospe
ctive
sing
lecentre
Chron
icne
urolog
ical
illne
ss49
24–62
287–2224
NA
Med
icallystable
Afebrile
NWBC
coun
tsNot
receivingIV
antib
iotics
Cog
nitivelyintact
Not
onnarcotics/sedatio
nPeak
coug
hflow
(PCF)
PaO2>60
mmHg
SaO2>92%
NPaCO
2±ventilatio
nanduse
ofmanually/m
echanically
assisted
coug
hing
NA
Ceriana
etal.[8]
Italy
2003
Prospe
ctive
sing
lecentre
Non
-respiratory,58%
Chron
icrespiratory
failure,40%
7259–77
8–72
Mainly
surgical
Clinicalstability
Absen
ceof
psychiatric
disorders
Effectivecoug
h(M
EP≥40
cmH2O
)PaCO
2<60
mmHg
Ade
quatesw
allowing(evaluated
bygagreflexor
blue
dyetest)
Notrache
alsten
osisen
doscop
ically
Spon
tane
ousbreathing≥5days.
NA
Leun
get
al.[19]
Australia
2003
Retrospe
ctive
sing
lecentre
Respiratory,35%
Neurological,35%
Trauma,17%
100
6525
Surgical,47
PCT,53
Not
men
tione
dNA
Tobinet
al.
[13]
Australia
2008
Prospe
ctive
sing
lecentre
Med
ical,40%
Surgical,14%
Cardiotho
racic,25%
Neurosurgical,23%
280
61.8
NA
How
ever,58pts
onprolon
gedMV
Surgical,15
PCT,85
Tolerate
capp
ing>24
hCou
gheffective
(None
edof
suctioning
).Speech
(with
Passey–M
uirvalve).
NA
Stelfox
etal.[24]
USA
2008
Questionn
aire-
basedstud
yMulticen
tre
(118
centres)
Stroke,166(24)
Respiratory
failure,
159(23)
Trauma,168(24)
Abd
ominalaortic
aneurysm
,182(27)
675case
scen
arios
NA
NA
How
ever,m
ajority
physicians
were
from
acutecare.
NA
NA
NA
Cho
ate
etal.[14]
Australia
2009
Prospe
ctive
sing
lecentre
Med
ical,190
Surgical,362
Trauma,429
981
35–77
9–25
Surgical,77%
PCT,23%
Weane
dfro
mventilator
Normalgagreflex
Effectivecoug
hReason
forTT
resolved
Abilityto
swallow
own
secretions
SaO2>90%
Trache
otom
ies
byEN
Tsurgeo
nswereexclud
ed
Singh et al. Journal of Intensive Care (2017) 5:38 Page 4 of 12
Table
1Characteristicsof
includ
edstud
ies(Con
tinued)
OCon
nor
etal.[4]
USA
2009
Retrospe
ctive
sing
lecentre
Pneumon
ia,25
Aspiratio
npn
eumon
iaor
pneumon
itis,25
AEC
OPD
,25
Septicshock,25
135
74(36–91)
45NA
NA
NA
ChanLYY
etal.[15]
Hon
gKo
ng2010
Prospe
ctive
sing
lecentre
Neurosurgical
patients
3249–80
13.32
NA
Hem
odynam
icallystable
Body
temp<38
°CInspiredO2≤4L/min
SpO2>90%
Inability
toprod
uce
voluntarycoug
hon
command
Fullventilator
supp
ort
Upp
erairw
ayob
struction
confirm
edby
FOB
Fully
alertand
prod
ucing
voluntarycoug
hon
command
Fene
stratedTT
inplace
Marchese
etal.[25]
Italy
2010
Retrospe
ctive
questio
nnaire
based
Multicen
trestud
y(22centres)
Acute
respiratory
failure,24
COPD
,34
Neuromuscular
diseases,28
Surgical,11
Thoracic
dysm
orph
ism,4
OSA
S,2
719
50–78
Not
men
tione
d.Majority
patientswith
chronicdiseases
Surgical,34%
PCT,66%
NA
NA
Budviewser
etal.[20]
Germany
2011
Retrospe
ctive
sing
lecentre
AEC
OPD
,63
Pneumon
ia,38
Cardiac
failure,18
Sepsis,8
ARD
S,7
384
60–74
38PC
T,100%
ToleratesTT
capp
ing>24–48h
Trache
ostomyretainer
(TR)
successfullyinserted
≥1h
NA
Shrestha
KKet
al.[9]
India
2012
Prospe
ctive
sing
lecentre
Severe
head
trauma
(GCS<8)
118
NA
NA
NA.
Gradu
alvs.abrup
tde
cann
ulation
compared
NA
Warne
ckeT
etal.[16]
Germany
2013
Prospe
ctive
sing
lecentre
Neurologically
illpatients,likestroke,
ICH,G
BS,
men
ingo
enceph
alitis
100
7–33
NA
Weane
doffventilator
Assessm
entby
CSE
which
includ
es:
Patient’svigilanceandcompliance,
coug
h,sw
allowingassessed
byfib
reop
ticen
doscop
icevaluatio
n(FESS)
with
FEES
protocol
step
s.Each
step
tobe
passed
for
decann
ulationto
beconsidered
,likesecretions,spo
ntaneo
ussw
allows,coug
h,pu
ree
consistencyandfluids.
NA
Kenn
ethB
etal.[21]
USA
2014
Retrospe
ctive
sing
lecentre
Criticallyillob
ese
BMI41.9±14.3
102
NA
Surgical,74%
PCT,26%
NA
Malignancyor
trache
ostomies
perfo
rmed
outside
Singh et al. Journal of Intensive Care (2017) 5:38 Page 5 of 12
Table
1Characteristicsof
includ
edstud
ies(Con
tinued)
Data
missing
—2
Pand
ainV
etal.[17]
USA
2014
Prospe
ctive
sing
lecentre
NA
5721
NA
1.TT
size
≤4preferablycuffless
2.Breathes
comfortablywith
continuo
usfinge
rocclusion
ofTT
>1min
with
outtrapping
air,tolerate
speaking
valve
durin
gwakingho
urswith
out
distress,m
obilize
secretions
3.Suctionfre
quen
cyless
than
every4h
4.Nosedatio
ndu
ringcapp
ing
Not
satisfying
inclusioncriteria
Guerlain
Jet
al.[18]
France
2015
Prospe
ctive
sing
lecentre
Postop
erativehe
adandne
ckcancer
patients
56Short-term
(<3days)
Surgical,
100%
NA
NA
Pasqua
etal.[22]
Italy
2015
Retrospe
ctive
sing
lecentre
Respiratory
(COPD
,ILD,O
SAS),33
Cardiac,10
Abd
ominalsurgery,4
Ortho
paed
ic,1
4891.61–215.5
NA
Clinicalandhe
mod
ynam
icstability
Noeviden
ceof
sepsis
Expiratory
musclestreng
th(M
EP>50
cmH2O
)Absen
ceof
trache
alsten
osis/
granulom
aNormalde
glutition
PaCO
2<50
mm
Hg
PaO2/FiO2>200
Absen
ceof
nocturnal
oxyhem
oglobinde
saturatio
nPatient
consen
t
NA
Coh
enet
al.[23]
Israel
2016
Retrospe
ctive
sing
lecentre
Patientswith
≥3
co-m
orbidities,35%
4910
PCT,100%
Maturationof
TTstom
aNormalvitalsigns
Effectivecoug
hing
Normalsw
allowing
Positiveleak
test
Age
<18
years
Com
plications
durin
ginitialTT
placem
ent
Decannu
latio
nprocess
completed
outsideinstitu
te
Singh et al. Journal of Intensive Care (2017) 5:38 Page 6 of 12
Table
2Characteristicsof
includ
edstud
ies
Autho
r(Ref)
Metho
dof
decann
ulation
Prim
aryou
tcom
eSecond
ary
outcom
eFailure
rate
(%)
Timeto
recann
ulation
Limitatio
nsInference
GravesAet
al.[11]
TTocclusionprotocol
after
downsizingto
fene
strated
cuffed7/8po
rtex
tube
Decannu
latio
nDecannu
latio
n20
NA
NA
Even
with
outFO
Bde
cann
ulationcanbe
done
with
good
success
rate
followinglong
term
MV
Bach
etal.
[12]
After
measurin
gpe
akcoug
hflow
(PCF),switche
dto
fene
stratedcuffedTT
that
canbe
capp
ed.
Use
ofNasalIPPV
andMI–E,
tube
capp
ed.
Ifsuccessful,TTremoved
,site
closed
,NIV
andassisted
coug
hing
continued.
Decannu
latio
nFactorspred
ictin
gsuccessful
decann
ulation:
Age
Extent
ofpre-de
cann
ulation
ventilatoruse
Vitalcapacity
Peak
coug
hflow
(PCF)
32With
in3days
Specificto
neurom
uscularand
long
-term
MVpts
NIV
givento
decann
ulated
pts
Patientsde
cann
ulated
irrespe
ctiveof
their
ventilatorcapacity.
PCF>160L/min
pred
ictedsuccess
Whe
reas
<160L/min
pred
ictedne
edto
replace
thetube
Ceriana
etal.[8]
TTdo
wnsized
to6mm
and
capp
edfor3–4days
Clinicalstability
Absen
ceof
psychiatric
disorders
Effectivecoug
h(M
EP≥40
cmH2O
).PaCO2<60
mmHg
Ade
quatesw
allowing(Gag
reflexor
blue
dyetest)
Notrache
alsten
osis
endo
scop
ically
Spon
tane
ousbreathing
for≥5days
Decannu
latio
nNA
3.5
Upto
3and6mon
ths
NA
Largemajority
ofpatients
with
clinicalstability
can
bede
cann
ulated
with
reintubatio
nrate
less
than
3%after3mon
ths
Leun
get
al.
[19]
Not
men
tione
dDecannu
latio
nSurvival
6Duringho
spitalstay.
Smallsam
plesize.
Retrospe
ctivenature
ofthestud
y.
ICUpatientswho
requ
ireTT
have
high
mortality
(37%
).Allsurvivingpatientswere
decann
ulated
with
in25
days.
Patientswith
unstableor
obstructed
airw
ayhad
shortercann
ulationtim
ecomparedto
patientswith
chronicillne
ss.
Tobinet
al.
[13]
Tolerate
capp
ing>24
hCou
gheffective
(None
edof
suctioning
)Speech
(Passey–Muirvalve)
Decannu
latio
ntim
efro
mICU
discharge
LOSho
spital
LOSafterdischarge
from
ICU
13NA
Retrospe
ctivedata
collection
Lack
ofsimilarcare
inwards
Intensivist-ledTT
team
isassociated
with
shorter
decann
ulationtim
eand
leng
thof
stay.
Stelfoxet
al.[24]
ToleratesTT
capp
ing(24vs.72h)
Effectivecoug
h(stron
gvs.w
eak)
Secretions
(thick
vs.thin)
Levelo
fconsciou
sness(alert
vs.d
rowsy
butarou
sable)
Which
patient
factors
clinician’srate
asbe
ing
impo
rtantin
thede
cision
tode
cann
ulate?
Which
clinicianandpatient
factorsareassociated
with
NA
20.4
With
in48
h(45%
opinion)
to96
h(20%
opinion)
Accep
tablerate
offailure
as2–5%
.
Only73%
respon
ded
tothequ
estio
nnaire.
Patient’slevelo
fconsciou
sness,coug
heffectiven
ess,secretions,
andoxygen
ationareall
impo
rtantde
term
inants
tode
cide
decann
ulation.
Singh et al. Journal of Intensive Care (2017) 5:38 Page 7 of 12
Table
2Characteristicsof
includ
edstud
ies(Con
tinued)
clinician’srecommen
datio
nsto
decann
ulateTT?
Definede
cann
ulationfailure.
Whatdo
clinicians
consider
anacceptablerate
ofde
cann
ulationfailure?
Cho
ateet
al.[14]
Cuffless
then
checkairflow
throug
hup
perairw
ayfollowed
byTT
removal
TDpracticeandfailure
rates
durin
g4-year
and10-m
onth
stud
ype
riod
NA
5Untildischarge
from
hospital
Sing
lecentre
stud
yHigh%
oftraumaand
neurosurgicalp
atients
Descriptivedata
Decannu
latio
ncriteria
notspecified
Old
age,prolon
geddu
ratio
nof
TTandretentionof
sputum
wereriskfactorsforfailure
OCon
nor
etal.[4]
TTocclusionwith
redcap/
sleepapne
atube
/Passy–
Muirvalve
Processof
decann
ulationin
patientsof
long
-term
acute
care
(LTA
C)with
prolon
ged
MV(PMV)
NA
19NA
Retrospe
ctivedata
collection
Decannu
latio
nwas
achieved
in35%
ofpatientstransferred
toLTACforweaning
inpatientswith
PMV
ChanLYY
etal.[15]
Amou
ntof
TTsecretions
atdifferent
timeintervals
(4tim
es;2
hapart)in
the
samedayfollowed
byindu
cedpe
akcoug
hflow
rate
(PCFR)by
suctioncatheter
Decannu
latio
nNA
6With
in72
hAirleakagedu
ringPC
Frate
estim
ationas
most
ofthem
wereon
uncuffedTT
Sing
lecentre
Smallsam
ple
Indu
cedPC
Frate:42.6L/min
insuccessful
vs.29L/min
inun
successful,w
here
29L/min
may
beconsidered
asthe
determ
inantpo
int
Marchese
etal.[25]
Scores
forspecificactio
nCapping
,92/110
Trache
oscopy,79/110
Trache
ostomybu
tton
,60/110
Dow
nsizing,
44/110
Decannu
latio
nCalculusscore
Each
parameter
score—
0to
5(m
axscore–110)
1:Difficultintubatio
n2:1+
H/O
Chron
icrespiratory
failure
3:Hom
eventilatio
n4:3+
ventilatio
nhrs/day
5:PaCO2in
stablestate
6:Im
pairedsw
allowing
7:Und
erlyingdisease
8:Cou
gheffectiven
ess
9:Relapserate
lastyear
77NA
NA
Substantial%
maintaine
dTT
despite
norequ
iremen
tof
MV
Noconsen
suson
indicatio
nsandsystem
sforclosureof
TT
Budviewser
etal.[20]
Inpatientswith
adeq
uate
coug
handsw
allowing,
the
disc
trache
ostomyretainer
(TR)
iscutas
persize
ofTT.
Then
inserted
inamanne
rthat
ittouche
stheventral
partof
thetrache
a,thereb
ycompletelysealingtheTT
channe
l.
Decannu
latio
nNA
28Entirepe
riodof
hospitalstay
Did
notmeasure
PCF
Feasibility,efficacy
andsafety
ofTR
inpatientswith
prolon
ged
weaning
with
high
riskfor
recurren
tor
persistent
hype
rcapnicrespiratory
failure
Shrestha
KKet
al.[9]
Abrup
t:TT
removal
instantane
ously.
Gradu
al:D
ownsizingTT
followed
bystrapp
ingover
thetube
followed
bystrapp
ingover
thestom
a.
Decannu
latio
nFactorsen
hancing
successful
decann
ulation
Gradu
al(G)—
1.5
Abrup
t(A)—
6S(G)—
98.5
S(A)—
94
NA
NA
Factorsassociated
with
success
werecoug
hreflex,nu
mbe
rof
suctioning
requ
iredpe
rday,
standard
X-rayanduseof
antib
iotics≥7days
Singh et al. Journal of Intensive Care (2017) 5:38 Page 8 of 12
Table
2Characteristicsof
includ
edstud
ies(Con
tinued)
Gradu
al(68)
vs.A
brup
t(50)
Warne
ckeT
etal.[16]
Clinicalsw
allowingassessmen
t(CSE)followed
byfib
reop
ticen
doscop
icevaluatio
nof
swallowing(FEES)
with
decision
tode
cann
ulatebasedon
lyon
FEES
Decannu
latio
nbased
onFEES
Tocompare
how
many
couldhave
been
decann
ulated
with
out
FEES
1.9
Tilldischargefro
mho
spital
Small%
with
neurom
uscular
weakness
FEES
isan
efficient,reliable,
bedsidetool,p
erform
edsafely
intrache
ostomized
critically
illne
urolog
icpatientsto
guide
decann
ulation.
Kenn
ethB
etal.[21]
Not
men
tione
dTrache
ostomytype
and
patient
outcom
ein
term
sof
depe
nden
ce,
decann
ulationand
death.
Patient
factorsassociated
with
outcom
es49
NA
Retrospe
ctivedata
collection.
Variabilityin
co-
morbidities(incomplete/
incorrectmed
ical
records)
Increasedtrache
ostomy
depe
nden
cein
OSA
,and
surgicaltrache
ostomy
Pand
ainV
etal.[17]
Capping
Qualityim
provem
ent
projectto
developa
standardized
protocol
forTT
capp
ingand
decann
ulationprocess
NA
1.7
Toleratescapp
ing12–
24h
No↑FiO2>40%,
shortnessof
breath,
suctionrequ
iremen
t,he
mod
ynam
icinstability
isde
fined
assuccess
Smallsam
plesize
Non
-rando
mized
Labo
ur-in
tensive
protocol
Multid
isciplinaryprotocol
for
determ
iningreadinessto
capp
ingtrialp
riorto
decann
ulation
Guerlain
Jet
al.[18]
Peak
inspiratory
flow
(PIF)
assessmen
tthroug
horal
cavity
afterblocking
TTcann
ula
Minim
umpe
akinspiratory
flow
(PIF)
requ
iredforsuccessful
decann
ulation
NA
13With
in24
hNA
PIFim
proves
quality
ofcare
andop
timizes
outcom
esfollowingde
cann
ulation
Pasqua
etal.[22]
Insertionof
afene
strated
cann
ulain
theTT
followed
byits
closurewith
acapfor
prog
ressivelylong
erpe
riods
upto
48h
Evaluate
efficacyof
protocol
toanalyze
factorsthat
could
pred
ictsuccessful
decann
ulation
NA
37NA
NA
Using
specificprotocol,
decann
ulationcanbe
done
.How
ever,large
rprospe
ctive
stud
iesrequ
ired.
Coh
enet
al.
[23]
Stud
ygrou
p:3step
endo
scop
yStep
1—nasolaryng
eal
endo
scop
yconfirm
ing
vocalcordmob
ility
and
norm
alsupraglottis
Step
2—TT
removal
Step
3—up
anddo
wn
look
throug
hTT
stom
aCon
trol
grou
p:↓TTor
capp
ing
Safety
andfeasibility
ofim
med
iate
decann
ulation
comparedto
tradition
alde
cann
ulation
NA
20:con
trol
0:stud
ygrou
psrespectively
Sing
lecentre
Retrospe
ctiveanalysis
Clinicalde
cision
sbased
onsing
lepe
rson
opinion
Potentialb
ias
Immed
iate
decann
ulation
may
beasaferalternative
forweaning
Abb
reviations:N
Ano
tavailable,
RRrespira
tory
rate,SaO
2arteria
loxyge
nsaturatio
n,TT
trache
ostomytube
,FOBfib
reop
ticbron
choscope
,MVmecha
nicalv
entilation,
Nno
rmal,PaO
2pa
rtialp
ressureof
arteria
loxyge
n,IV
intraven
ous,IPPV
interm
itten
tpo
sitiv
epressure
ventilatio
n,MI–Emecha
nicalinsufflator–exsufflator,NIV
non-invasive
ventilatio
n,PC
Fpe
akcoug
hflo
w,P
IFpe
akinspira
tory
flow,M
EPmaxim
umexpiratory
pressure,P
aCO2arteria
lpartia
lpressureof
carbon
dioxide,
LOSleng
thof
stay,ICU
intensivecare
unit,
AEC
OPD
acuteexacerba
tionof
chronicob
structivepu
lmon
arydisease,
PCTpe
r-cutane
oustrache
ostomy,LTAClong
-term
acutecare,P
MVprolon
gedmecha
nicalv
entilation,
ARD
Sacuterespira
tory
distress
synd
rome,
GCS
Glasgow
comascale,
ICHintracranial
haem
orrhag
e,GBS
Guil-
lain–B
arré
synd
rome,
CSEclinical
swallowingexam
ination,
FESS
fibreop
ticen
doscop
icevalua
tionof
swallowing,
SCIspina
lcordinjury,TRtrache
ostomyretainer,O
SAob
structivesleepap
neasynd
rome,
ILDinterstitiallun
gdisease,
FiO2fractio
nof
inspire
doxyg
enconcen
tration
Singh et al. Journal of Intensive Care (2017) 5:38 Page 9 of 12
After this systematic review, we designed a protoco-lized bedside decannulation algorithm for use in ourICU (Fig. 2). This protocol is being currently studied ina prospective randomized manner to assess its feasibilityin adult mechanically ventilated ICU patients.
DiscussionDecannulation in tracheostomized patient is the finalstep towards liberation from MV. Despite its relevance,lack of a universally accepted protocol for decannula-tion continues to plague this vital transition. In orderto focus attention on various practices of the process oftracheostomy decannulation, we decided to do this sys-tematic review. The main finding from this review isthat there is no randomized controlled study on thiscritical issue. Several individualized, non-comparativeand non-validated decannulation protocols exist. How-ever, a blinded randomized controlled study, eithercomparing protocolized and non-protocolized (usual
practice) decannulation or comparing two differentdecannulation protocols, is urgently needed.After ascertaining intactness of sensorium, further
identification of patient’s readiness to decannulate ismostly based on the assessment of coughing and swal-lowing. More often than not these assessments are basedon subjective clinical impression of the physician whomay or may not be the most experienced one at the timeof decannulation. This is an avoidable lacuna in care oftracheostomized patients. Busy units and busy physiciansmay devote minimal time for this transition. Protoco-lized decannulation in our opinion may guaranteeconsistency and objectivity of care.As is obvious from the studies included in our system-
atic review, assessments were mostly subjective, al-though objective FEES [16] and of coughing with PCF[12] or PIF [18] have also been attempted. Endoscopicevaluation of swallowing though technically demandingprovides an objective assessment. However, studies insupport of this approach are limited. Only two studies
Fig. 2 Decannulation algorithm
Singh et al. Journal of Intensive Care (2017) 5:38 Page 10 of 12
[16, 23] out of 18 incorporated fibreoptic endoscopicevaluation of vocal cords and/or swallowing prior todecannulation. Warnecke T et al. in their study per-formed a mandatory step of FEES in their decannulationprocess [16]. In a recent retrospective study by Cohen etal., a three-step endoscopic confirmation of vocal cordmobility and normal supraglottis was ascertained priorto immediate decannulation [23]. He considered imme-diate decannulation as a safer and shorter alternative forweaning in tracheostomized patients as compared totraditional decannulation. When so many decannula-tions can happen without FEES, then what extra benefitdoes this technically demanding step offer over clinicalswallowing evaluation (CSE) needs to be ascertained.Graves et al. [11] also concluded about good success ratewithout fibreoptic evaluation prior to decannulation oflong-term MV patients. Availability and technical ex-pertise of FEES needs to be ensured before including itin any decannulation protocol.Similarly, subjective assessment of coughing is the
usual norm. Only Bach et al. [12] in 1996, Ceriana et al.[8] in 2003, Chan LYY et al. [15] in 2010 and Guerlain Jet al. [18] in 2015 used an objective measure of aneffective cough to decide about decannulation. PCF, MEPand PIF are all parameters used by these investigators asmeasures of an effective cough. However, superiority ofone over the other is undecided.The adopted method of decannulation is also variable.
While some authors preferred TT occlusion after down-sizing to fenestrated or non-fenestrated tube [8, 11],others straight away capped the TT without downsizing[4, 13], while some abruptly removed the TT [9, 14].The choice of the method is based on patient’s tolerabil-ity of the procedure and also on the physician’s experi-ence. There exists no universally accepted method.Furthermore, discrepancy also exists in the period ofobservation before which decannulation is deemedsuccessful. Probably, a combination of factors like theperiod of MV prior to decannulation, anticipation ofneuromuscular fatigue on account of respiratory work-load and protection of airway all play a role.The self-confessed limitations of the included studies
were as depicted in Table 2. Specific illness group, smallsample size, retrospective design, and non-standardized,non-protocolized and non-validated method of decannu-lation are the major limitations of the included studies.But above all, absence of a randomized controlled study inthis aspect of care is a major hurdle. The previously pub-lished systematic review on tracheostomy decannulationwas by Santus P et al. [26] in 2014. Our systematic reviewhas included 10 of these studies apart from addition of an-other 8. While he compared primary and secondary out-comes of included studies, our review is much moreexhaustive in that it incorporates the relevant details of 18
studies in a concise tabular form. Our systematic reviewalso incorporates the Q-Coh tool [10] to assess the meth-odological quality of included cohort studies. As none ofthe studies included are of desired quality, the need forrandomized controlled study on decannulation cannot beover emphasized. However, our systematic review also hasseveral limitations. We have not searched other databaseslike Google Scholar, Scopus or EMBASE and also not in-cluded non-English language articles.Our protocolized decannulation algorithm (Fig. 2) in-
corporates easy to use bed-side checklist for evaluationof patients deemed fit for decannulation. The screeningchecklist includes assessment for intactness of sensor-ium, characteristics of secretions and need and fre-quency of suctioning, effectiveness of swallowing andcoughing, patency of airway and successfulness of a pro-longed spontaneous breathing trial (SBT). The patientshould be conscious, oriented and be able to maintain apatent airway. Secretions should be easy to handle bythe patient and frequency of suctioning should be lessthan 4 in the previous 24 hours. The patient must beable to swallow liquids/semisolids without risk of aspir-ation, have adequate cough with good peak expiratoryflow rate (PEFR) (>160 L/min) and be able to maintain apatent airway. Patency of the airway can be assessedbedside by simply deflating the cuff and occluding theTT with a gloved finger for testing phonation of the pa-tient. In patients with prolonged MV of greater than4 weeks, the duration of successful SBT should prefera-bly be 48 hours or more. After the initial screeningchecklist, decision about the decannulation technique isbased on the duration of MV and presence of neuromus-cular weakness. Patients with less than 4 weeks of MVand with no suspicion of neuromuscular weakness aresubjected to a corking trial. This trial involves blockingthe existing TT after cuff deflation followed by carefulinstructions to the bedside nurse/physician to re-inflatethe cuff in case of respiratory distress. Depending on thetolerability and absence of any distress the TT is decan-nulated. However, in case of a failed corking trial the TTcan be downsized and blocked followed by a period ofcareful observation for few hours. If the observationperiod is not associated with any respiratory distressdecannulation can then be performed. Patients whofailed the corking trail as well as downsizing & blockingand are in respiratory distress need immediate upsizingof the TT to resume ventilation. Further assessmentwarrants a FOB examination to explore the cause of fail-ure. In patients with MV for more than 4 weeks andwith suspicion of neuromuscular weakness the decannu-lation technique is that of downsizing and blocking. Incase of failure and respiratory distress, approach remainssame as above. This protocol is currently under evalu-ation in our unit via a randomized study.
Singh et al. Journal of Intensive Care (2017) 5:38 Page 11 of 12
ConclusionsDecannulation is an essential step towards liberating atracheostomized patient from mechanical ventilation.This transition is more often individualized than proto-colized. Universally accepted protocol is needed forbetter standardization. Randomized controlled studies inthis aspect of tracheostomy care can make it moreevidence based.
Additional file
Additional file 1: Table S1. Quality of cohort studies as assessed by Q-Coh tool. (DOCX 26 kb)
AbbreviationsCSE: Clinical swallowing examination; FESS: Fibreoptic endoscopic evaluationof swallowing; HDU: High dependency unit; ICU: Intensive care unit;MEP: Maximum expiratory pressure; MV: Mechanical ventilation; NIV: Non-invasive ventilation; PCDT: Percutaneous dilatational tracheostomy; PCF: Peakcough flow; PIF: Peak inspiratory flow; TT: Tracheostomy tube
AcknowledgementsNot applicable.
FundingThe author(s) received no financial support this study.
Availability of data and materialsData sharing is not applicable to this article as no datasets were generatedor analyzed during the current study.
Authors’ contributionsRKS, SS and AKB contributed equally to the design, data acquisition andmanuscript preparation. All authors read and approved the final manuscript.
Competing interestsThe author(s) declare that they have no competing interests.
Consent for publicationNot applicable.
Ethics approval and consent to participateNot applicable.
Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.
Received: 9 May 2017 Accepted: 14 June 2017
References1. Esteban A, Anzueto A, Alía I, Gordo F, Apezteguía C, Pálizas F, et al. How is
mechanical ventilation employed in the intensive care unit? An internationalutilization review. Am J Respir Crit Care Med. 2000;161(5):1450–8.
2. Garuti G, Reverberi C, Briganti A, Massobrio M, Lombardi F, Lusuardi M.Swallowing disorders in tracheostomised patients: a multidisciplinary/multiprofessional approach in decannulation protocols. Multidiscip RespirMed. 2014;9(1):36.
3. Schmidt U, Hess D, Bittner E. To decannulate or not to decannulate: acombination of readiness for the floor and floor readiness? Crit Care Med.2011;39(10):2360–1.
4. O ’connor HH, Kirby Ctr KJ, Terrin N, Hill NS, White AC. Decannulationfollowing tracheostomy for prolonged mechanical ventilation. J IntensiveCare Med. 2009;24(3):187–94.
5. Heffner JE, Hess D. Tracheostomy management in the chronically ventilatedpatient. Clin Chest Med. 2001;22(1):55–69.
6. Martinez GH, Fernandez R, Casado MS, Cuena R, Lopez-Reina P, Zamora S,et al. Tracheostomy tube in place at intensive care unit discharge isassociated with increased ward mortality. Respir Care. 2009;54(12):1644–52.
7. Fernandez R, Bacelar N, Hernandez G, Tubau I, Baigorri F, Gili G, et al. Wardmortality in patients discharged from the ICU with tracheostomy maydepend on patient’s vulnerability. Intensive Care Med. 2008;34(10):1878–82.
8. Ceriana P, Carlucci A, Navalesi P, Rampulla C, Delmastro M, Piaggi G, et al.Weaning from tracheotomy in long-term mechanically ventilated patients:feasibility of a decisional flowchart and clinical outcome. Intensive CareMed. 2003;29(5):845–8.
9. Shrestha KK, Mohindra S, Mohindra S. How to decannulate tracheostomisedsevere head trauma patients: a comparison of gradual vs abrupt technique.Nepal Med Coll J. 2012;14(3):207–11.
10. Jarde A, Losilla J, Vives J, Rodrigo MF. Q-Coh: a tool to screen themethodological quality of cohort studies in systematic reviews and meta-analyses. Int J Clin Heal Psychol. 2013;13:138–46.
11. Rumbak MJ, Graves AE, Scott MP, Sporn GK, Walsh FW, Anderson WM,Goldman AL. Tracheostomy tube occlusion protoc predict success trachealdecannulation follow long term mech vent. Crit Care Med. 1997;25(3):413–7.
12. Bach JR, Saporito LR. Criteria for extubation and tracheostomy tube removalfor patients with ventilatory failure: a different approach to weaning. Chest.1996;110(6):1566–71.
13. Tobin AE, Santamaria JD. An intensivist-led tracheostomy review team isassociated with shorter decannulation time and length of stay: aprospective cohort study. Crit Care. 2008;12(2):R48.
14. Choate K, Barbetti J, Currey J. Tracheostomy decannulation failure ratefollowing critical illness: a prospective descriptive study. Aust Crit Care. 2009;22(1):8–15.
15. Chan LYY, Jones AYM, Chung RCK, Hung KN. Peak flow rate during inducedcough: a predictor of successful decannulation of a tracheotomy tube inneurosurgical patients. Am J Crit Care. 2010;19(3):278–84.
16. Warnecke T, Suntrup S, Teismann IK, Hamacher C, Oelenberg S, Dziewas R.Standardized endoscopic swallowing evaluation for tracheostomy decannulationin critically ill neurologic patients. Crit Care Med. 2013;41(7):1728–32.
17. Pandian V, Miller CR, Schiavi AJ, Yarmus L, Contractor A, Haut ER, et al.Utilization of a standardized tracheostomy capping and decannulationprotocol to improve patient safety. Laryngoscope. 2014;124(8):1794–800.
18. Guerlain J, Guerrero JAS, Baujat B, St Guily JL, Périé S. Peak inspiratory flowis a simple means of predicting decannulation success following head andneck cancer surgery: a prospective study of fifty-six patients. Laryngoscope.2015;125(2):365–70.
19. Leung R, MacGregor L, Campbell D, Berkowitz RG. Decannulation andsurvival following tracheostomy in an intensive care unit. Ann Otol RhinolLaryngol. 2003;112(10):853–8.
20. Budweiser S, Baur T, Jörres RA, Kollert F, Pfeifer M, Heinemann F. Predictorsof successful decannulation using a tracheostomy retainer in patients withprolonged weaning and persisting respiratory failure. Respiration. 2012;84(6):469–76.
21. Byrd JK, Ranasinghe VJ, Day KE, Wolf BJ, Lentsch EJ. Predictors of clinicaloutcome after tracheotomy in critically ill obese patients. Laryngoscope.2014;124(5):1118–22.
22. Pasqua F, Nardi I, Provenzano A, Mari A. Weaning from tracheostomy insubjects undergoing pulmonary rehabilitation. Multidiscip Respir Med. 2015;10(11):35.
23. Cohen O, Tzelnick S, Lahav Y, Stavi D, Shoffel-Havakuk H, Hain M, et al.Feasibility of a single-stage tracheostomy decannulation protocol withendoscopy in adult patients. Laryngoscope. 2016;126(9):2057–62.
24. Stelfox HT, Crimi C, Berra L, Noto A, Schmidt U, Bigatello LM, et al.Determinants of tracheostomy decannulation: an international survey. CritCare. 2008;12(1):R26.
25. Marchese S, Corrado A, Scala R, Corrao S, Ambrosino N. Tracheostomy inpatients with long-term mechanical ventilation: a survey. Respir Med. 2010;104(5):749–53.
26. Santus P, Gramegna A, Radovanovic D, Raccanelli R, Valenti V, Rabbiosi D, etal. A systematic review on tracheostomy decannulation: a proposal of aquantitative semiquantitative clinical score. BMC Pulm Med. 2014;14:201.
Singh et al. Journal of Intensive Care (2017) 5:38 Page 12 of 12
