Determinants of tracheostomy decannulation: an international survey

Henry Stelfox,Lorenzo Berra,Dean Hess,Claudia Crimi,Ulrich Schmidt,Luca M Bigatello,Alberto Noto

doi:10.1186/cc6802

Abstract

BackgroundAlthough tracheostomy is probably the most common surgical procedure performed on critically ill patients, it is unknown when a tracheostomy tube can be safely removed.MethodsWe performed a cross-sectional survey of physicians and respiratory therapists with expertise in the management of tracheostomized patients at 118 medical centers to characterize contemporary opinions about tracheostomy decannulation practice and to define factors that influence these practices.ResultsWe surveyed 309 clinicians, of whom 225 responded (73%). Clinicians rated patient level of consciousness, ability to tolerate tracheostomy tube capping, cough effectiveness, and secretions as the most important factors in the decision to decannulate a patient. Decannulation failure was defined as the need to reinsert an artificial airway within 48 hours (45% of respondents) to 96 hours (20% of respondents) of tracheostomy removal, and 2% to 5% was the most frequent recommendation for an acceptable recannulation rate (44% of respondents). In clinical scenarios, clinicians who worked in chronic care facilities (30%) were less likely to recommend decannulation than clinicians who worked in weaning (47%), rehabilitation (53%), or acute care (55%) facilities (p = 0.015). Patients were most likely to be recommended for decannulation if they were alert and interactive (odds ratio [OR] 4.76, 95% confidence interval [CI] 3.27 to 6.90; p < 0.001), had a strong cough (OR 3.84, 95% CI 2.66 to 5.54; p < 0.001), had scant thin secretions (OR 2.23, 95% CI 1.56 to 3.19; p < 0.001), and required minimal supplemental oxygen (OR 2.04, 95% CI 1.45 to 2.86; p < 0.001).ConclusionPatient level of consciousness, cough effectiveness, secretions, and oxygenation are important determinants of clinicians' tracheostomy decannulation opinions. Most surveyed clinicians defined decannulation failure as the need to reinsert an artificial airway within 48 to 96 hours of planned tracheostomy removal.

Highlights

Tracheostomy is probably the most common surgical procedure performed on critically ill patients [1]
What time frame do clinicians consider for tracheostomy decannulation failure? (d) What do clinicians consider to be an acceptable rate of tracheostomy decannulation failure?
We conducted semi-structured interviews with 18 attending physicians (5 intensive care unit (ICU) physicians, 5 pulmonary medicine physicians, 5 physicians who work in a mechanical ventilation weaning unit, and 3 surgeons who perform tracheostomies), 10 respiratory therapists, 2 nurse practitioners, and 2 speech therapists to generate a list of factors contributing to the decision to decannulate a tracheostomized patient

Summary

Introduction

Tracheostomy is probably the most common surgical procedure performed on critically ill patients [1]. 10% of mechanically ventilated critically ill patients receive a tracheostomy to facilitate prolonged airway and ventilatory support [2,3,4,5]. Prolonged tracheostomy tube placement may expose patients to an increased risk of late complications, including tracheal stenoses, bleeding, fistulas, infections, and aspiration [7,8,9,10,11]. Removing a tracheostomy is a fundamental step in rehabilitating a patient recovering from critical illness [13]. Tracheostomy is probably the most common surgical procedure performed on critically ill patients, it is unknown when a tracheostomy tube can be safely removed

Methods

Results

Discussion

Conclusion