Decannulation Failure Research Articles

Tubercular mediastinal lymphadenopathy: An unusual cause of failed decannulation and tracheostomy

Literature has described many causes of failed decannulation and weaning. However, failed decannulation and weaning from ventilator due to a hilar lymph node compressing upon a bronchus has not been described. We report a case of a 30-year-old man with Guillain-Barré syndrome who had quadriparesis and respiratory distress. After 1 year of intensive care unit admission, he was ambulatory, haemodynamically stable, devoid of sepsis, had effective cough with tracheostomy in situ. Every attempt of decannulation led to pooling of secretions in left side of chest, hypercarbia and altered sensorium. This was followed by re-institution of ventilator support. Chest x-ray was unremarkable, but computed tomography (CT) chest done during this time showed a mass compressing upon left lower lobe bronchus. Flexible fibre-optic bronchoscopy and transbronchial biopsy confirmed the diagnosis to be tubercular lymph node. After 1 month of starting of anti-tubercular treatment, there was resolution of the mass with relief of the bronchial compression and a successful decannulation thereafter. Role of CT in difficult cases of weaning is emphasized, and role of bronchoscopy is highlighted in difficult cases of weaning and decannulation.

Removal of the Tracheal Tube after Prolonged Mechanical Ventilation: Assessment of Risk by Oscillatory Impedance

Background: Decannulation failure is usually due to tracheal obstruction. Prior to decannulation, inspection by the invasive procedure of bronchoscopy that permits morphological evaluation of a tracheal stenosis is standard practice. A non-invasive method enabling the quantification of the airway obstruction that requires little cooperation is measurement of the airway resistance by the forced oscillation technique. Objectives: The aim of the present study was to define oscillatory impedance thresholds which predict successful decannulation. Methods: A total of 131 patients were investigated prospectively. Step 1: Following probatory decannulation, measurement of the oscillatory impedance. Step 2: Blinded to the results of the impedance measurement, bronchoscopy-assisted decannulation attempt. The criteria for renewed cannulation were high-grade laryngeal or tracheal obstruction, dyspnea or stridor, or a drop in SaO₂ <90% under O₂ insufflation. Statistics: Determination of the ratio tracheal tube remains/tracheal tube removed (TT+/TT–) for every measured value of the oscillatory resistance at 5 Hz (Ros 5 Hz). Determination of specificity and positive predictive value for determined threshold values with respect to TT–. Results: The data of 126 patients were evaluated. TT+ n = 26, TT– n = 100. Decannulation on the basis of bronchoscopy criteria: Specificity and positive predictive value found out for Ros 5 Hz <0.35 kPa/l/s (n = 44) were 1.00 and 1.00, respectively, and for Ros 5 Hz <0.47 kPa/l/s (n = 71) 0.88 and 0.96, respectively. Conclusions: Measurement of the oscillatory airway resistance represents a practicable method prior to decannulation. Below a value of Ros 5 Hz <0.35 kPa/l/s, bronchoscopy would appear not to be necessary.

Successful Decannulation of T-Tubes According to Type of Tracheal Stenosis

Although the T-tube has been widely used as a therapeutic method for treatment of tracheal stenosis, predictors for success have not been much studied. The authors analyzed several factors to search for a factor that would be useful as a prognostic indicator for successful decannulation. A total of 41 patients who underwent T-tube insertion from 1995 to 2004 at Yonsei University Health System were included. The medical records were reviewed retrospectively, and several factors regarding the type of stenosis were evaluated. Age, sex, and multiplicity and severity of stenoses (p = 0.860) were not significantly related to successful decannulation. The longitudinal extent of stenosis had a significant influence on success (p = 0.035), and cases with a greater circumferential involvement tended to result in decannulation failure (p = 0.084). The severity of stenosis did not have a statistically significant relationship to the decannulation rate, although it was closely related to the patient's symptoms. The longitudinal extent and the circumferential involvement of stenosis were found to be correlated to the success rate and represented the extent of the damaged mucosal area. Therefore, it was assumed that the extent of the damaged mucosal area could be more important than the area of the granulation tissue or the patients' symptoms in predicting the decannulation of T-tubes.

Proposal of a new classification for optimising outcome assessment following partial cricotracheal resections in severe pediatric subglottic stenosis

Objective Creation of a patent subglottic airway after partial cricotracheal resection (PCTR) may not always result in successful decannulation due to associated parameters such as co-morbidity and/or glottic involvement. We classified patients after incorporating these additional parameters into the original Myer–Cotton classification to assess whether this could better predict the outcome measures after PCTR. Methods One hundred children with Myer–Cotton grade III or IV subglottic stenosis who underwent PCTR between 1978 and 2008 were identified from a prospectively collected database. The patients were classified into four groups based on the association of co-morbidity and/or glottic involvement. Delay in decannulation, revision open surgery and rates of decannulation were the outcome measures compared between the groups. Results There were 68 children with Myer–Cotton grade III and 32 children with grade IV stenosis. Based on the new classification, there were 36 children with isolated SGS, 31 with associated co-morbidity, 19 with associated glottic involvement and 14 children with both co-morbidity and glottic involvement. A trend towards less optimal results was noticed with the association of co-morbidity and/or glottic involvement. Statistical significance was reached for maximum decannulation failure in the group with both co-morbidity and glottic involvement. Delayed decannulation significantly correlated in the group with associated glottic involvement. Conclusion This new classification is relatively simple and aimed at providing more accurate and uniform prognostic information to both patients and surgeons when dealing with the whole spectrum of severe SGS.

Arytenoid prolapse: A source of obstruction following laryngotracheoplasty

Objective Arytenoid prolapse is a potential source of upper airway obstruction following laryngotracheoplasty, and may be difficult to identify. We explored the incidence, clinical features, etiology, and surgical approach to patients with arytenoid prolapse following laryngotracheoplasty. Study Design Case series with chart review. Subjects and Methods The charts of 93 patients diagnosed with arytenoid prolapse following laryngotracheoplasty from 1981 to 2007 were reviewed. Results The incidence was 5.7 percent (93/1634). Forty-nine patients had unilateral prolapse; 44 had bilateral prolapse. Average time from laryngotracheoplasty to presentation was 36.8 months. Common symptoms were dyspnea on exertion, tracheostomy dependence, and sleep-disordered breathing. Fifty-four patients (58%) required surgical intervention, with arytenoid reduction performed in 45 patients. Nine underwent reduction during revision laryngotracheoplasty or cricotracheal resection. Fourteen patients required a second procedure for persistent prolapse. Thirty-nine (42%) required no intervention. Symptom resolution or decannulation was achieved in all patients in whom prolapse was the source of obstruction. Statistically significant differences were found when anterior vs posterior graft utilization was compared. Conclusions Arytenoid prolapse is a cause of airway obstruction following laryngotracheoplasty. Subtle airway complaints and decannulation failures are common features. Both endoscopic and open procedures can successfully treat arytenoid prolapse. Potential etiologies are discussed.

Tracheostomy decannulation failure rate following critical illness: A prospective descriptive study

Tracheostomy is a well established and practical approach to airway management for patients requiring extended periods of mechanical ventilation or airway protection. Little evidence is available to guide the process of weaning and optimal timing of tracheostomy tube removal. Thus, decannulation decisions are based on clinical judgement. The aim of this study was to describe decannulation practice and failure rates in patients with tracheostomy following critical illness. A prospective descriptive study was conducted of consecutive patients who received a tracheostomy at a tertiary metropolitan public hospital intensive care unit (ICU) between March 2002 and December 2006. Data were analysed using descriptive and inferential tests. Of the 823 decannulation decisions, there were 40 episodes of failed decannulation, a failure rate of 4.8%. These 40 episodes occurred in 35 patients: 31 patients failed once, 3 patients failed twice and 1 patient failed three times. There was no associated mortality. Simple stoma recannulation was required in 25 episodes, with none of these patients readmitted to ICU. Translaryngeal intubation and readmission to ICU took place for the remaining 15 episodes. The primary reason for decannulation failure was sputum retention. Twenty-four patients (60%) failed decannulation within 24h, with 14 of these occurring within 4h. Clinical assessments coupled with professional judgement to decide the optimal time to remove tracheostomy tubes in patients following critical illness resulted in a failure rate comparable with published data. Although reintubation and readmission to ICU was required in just over one third of failed decannulation episodes, there was no associated mortality or other significant adverse events. Our data suggest nurses need to exercise high levels of clinical vigilance during the first 24h following decannulation, particularly the first 4h to detect early signs of respiratory compromise to avoid adverse outcomes.

Arytenoid Prolapse following Laryngotracheoplasty

Objective Dynamic arytenoid prolapse (AP) is a potential and often late source of upper airway obstruction in children following laryngotrachoplasty (LTP). Reasons for this occurrence remain unclear. We examined the incidence and clinical features of AP in patients following LTP to explore the etiology and optimal surgical approach to this problem. Methods Retrospective database and chart review of children diagnosed with AP after LTP at a pediatric tertiary care institution from 1981–2007. Results 120 patients with no history of AP were diagnosed with AP following LTP (incidence 7.3% = 120/1634). 63 patients had unilateral prolapse, while 57 had bilateral AP. Average time from LTP to presentation was 44 months. Common symptoms were dyspnea on exertion, tracheostomy-dependence, and sleep-disordered breathing. Posterior cricoid interventions and revision LTP were most frequently associated with postoperative AP. 64% (n=77) of patients required surgical intervention. Endoscopic arytenoid reduction (AR) was performed in 54 patients, while 13 underwent AR during revision LTP. 2 patients underwent AR with cordotomy. Tracheostomy was performed with AR in another 2 patients. 28 patients required a second procedure for persistent prolapse. 36%(n=42) of patients did not require surgery. Airway complaints were relieved, or tracheostomy decannulation was achieved, in all patients after AR in which AP was the source of obstruction (avg. f/u=34.4mos). Conclusions Dynamic AP is a notable cause of airway obstruction following LTP. Subtle airway complaints and decannulation failures are common clinical features. Both endoscopic and open AR procedures are successful in relieving AP. Potential etiology for AP after LTP is discussed.

Determinants of tracheostomy decannulation: an international survey

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.

Surgical management of severe suprastomal cricotracheal collapse complicating pediatric tracheostomy

Suprastomal tracheal collapse may interfere with decannulation in tracheostomized patients. The purposes of the study are to evaluate the role of tracheotomy technique in the ethiology of suprastomal cricotracheal collapse and to report our results in the treatment of this complication. A retrospective review of children showing severe suprastomal collapse during the period 1990-2007, in a tertiary care children's hospital, was performed. Medical records were assessed for the following data: sex, age, original indication for tracheotomy, surgical technique, endoscopic findings, type of surgical correction, complications, result, and follow-up. Fourteen patients were included in the study, nine girls and five boys. Average age at tracheotomy was 17 months (range: 21 days-8 years), and prolonged ventilatory support was the most common indication (57%). Horizontal H-type tracheotomy was the most frequent technique in patients with suprastomal collapse (n=9), whereas only one patient with a vertical tracheotomy showed this complication (p<0.05). In every case bronchoscopy disclosed a suprastomal tracheal obstruction of at least 50% of the lumen. Mean age at surgical decannulation was 38 months (range: 12-147 months). Two surgical techniques have been used in the treatment of suprastomal collapse: anterior cricotracheal suspension (n=13) and reconstruction with autologous cartilage graft (n=1). All the patients were successfully decannulated although in one case two procedures were required. No recurrence has been observed during long-term follow-up (mean: 8.6 years). Endoscopical examination is essential for the diagnosis of suprastomal collapse and to rule out other causes of decannulation failure. In our experience, the tracheotomy technique seems to have an ethiologic role, and anterior cricotracheal suspension is a simple and effective procedure in the treatment of this tracheostomy related complication.

Treatment of Supraglottic Airway Edema by Local Hyaluronidase

Treatment of Supraglottic Airway Edema by Local Hyaluronidase

小児気管切開症例の臨床的検討

Tracheostomy was performed on 11 patients (9 males, 2 females) during an 11-year period (1984-1994) at the Osaka Prefectural General Hospital. The causative diseases were central nervous system disorders (5 cases), laryngo-tracheal stenosis (2 cases), achondroplasia (2 cases), Werdnig-Hoffmann disease (1 case)and Tay-Sacs disease (1 case). The indication of the tracheostomies was respiratory management in most of the cases. Complications after surgery included 5 cases of tracheal or stomal granulation, 1 case of tracheo-innomunate artery fistula, 1 case of failure of decannulation and 1 case of hypooxidecephalus due to obstruction of the T-tube. Regarding course and outcome, 5 of the 11 patients who underwent these tracheostomies left the hospital with a stoma and were under respiratory management in their homes and they achieved the improvement of the quality of life. Five patients died due to an aggravation of their primary disease.

Early diagnosis and treatment of laryngeal injuries from prolonged intubation in adults

Prolonged endotracheal intubation can cause injuries to 1 or more regions of the larynx, making safe extubation impossible and leading to tracheostomy in many patients. Unfortunately, a considerable number of these patients do not benefit from early laryngeal evaluation, which may reveal potentially treatable soft, obstructive tissue before it undergoes irreversible fibrosis. Between July 1992 and December 1995, we performed immediate direct telelaryngoscopy on 142 adults who required tracheostomy because of failed extubation. When present, obstructive tissue was removed with microsurgical techniques. One hundred twenty-nine (90%) patients were decannulated within 3 weeks. The 2 main reasons for failure of early decannulation were intractable granulation (in patients with insulin-dependent diabetes) and coexisting tracheal stenosis. Immediate telelaryngoscopy is recommended in all patients who require tracheostomy because of failed extubation. Flexible laryngoscopy is not adequate for thorough assessment of laryngeal damage from prolonged intubation. (Otolaryngol Head Neck Surg 1999;120:25-9.)

The Great Ormond Street protocol for ward decannulation of children with tracheostomy: increasing safety and decreasing cost

Ward decannulation is the eventual endpoint for the majority of the 40 children managed by tracheostomy at Great Ormond Street Hospital each year. Our previous protocol dictated a 10 day stay in hospital for the 25 children decannulated annually. The aim of this retrospective study was to determine the minimum safe duration for this inpatient stay. In addition, we hoped to identify any factors which might distinguish potentially successful candidates from those likely to fail decannulation. Of 104 patients decannulated between January 1991 and January 1996, complete nursing and medical records were retrieved for 84 children. These notes were retrospectively reviewed and in this group of patients there were 101 attempted decannulations. Information about the initial pathology, interim course and details of the decannulation were collected. Summary statistics were generated. There was no relation between initial pathology or duration of tracheostomy and eventual success or failure of decannulation. Observations by the nursing staff of restlessness, anxiety and recession appeared more frequently in children who eventually failed decannulation. All failures occurred within 48 h of the 24 h trial of tracheostomy blocking. Our results suggest that a safe decannulation protocol can allow discharge after day five.

Peristomal complications of paediatric tracheostomy

Failure of decannulation after paediatric tracheostomy, once the underlying disorder has resolved, is almost always due to peristomal complications. Granulation tissue formation in the raw tissue of the stoma and its subsequent fibrosis requires removal (50 of the 293 tracheostomies from the Red Cross War Memorial Children's Hospital). It is suggested that this can be avoided by creating a formal skin-to-trachea stoma at the time of tracheostomy. Suprastomal depression of the anterior wall of the trachea ( 52 293 ) appears to be unavoidable when using standard tracheostomy tubes. Localised stomal site tracheomalacia and stenosis (numbers of this complication are unknown) results from damage to cartilage of the trachea either by incision or by necrosis from pressure of the tracheostomy tube. Trauma to the cartilage needs to be minimised by careful design of the tracheal incision. It is suggested that consideration should be given to creating a formal tracheostomy stoma for any paediatric tracheostomy that is likely to be required for more than a short period of time.

Infant tracheotomy — endoscopy and decannulation

The records of 73 infants aged 24 months or less who underwent tracheotomy in a 10-year period were reviewed. Two common problems before decannulation were granulations and suprastomal collapse of the anterior tracheal wall above the internal stoma. There were no decannulation failures which could not be accounted for by the primary airway problem. There was no evidence of unexplained “dependence” on the tracheotomy. The results confirm that tracheotomy in the infant patient can be safe both short-term and long-term. There has been no similar long-term review of tracheotomy in small infants indicating the place of endoscopy and the technique of decannulation.

Tracheostomy in children — The Red Cross War Memorial Children's Hospital experience 1980–1985

During the 6 years (1980–1985) at The Red Cross Children's Hospital 293 children required a tracheostomy during treatment of a variety of disorders. Of these children 44% were under 1 year of age. Indications are discussed of which the commonest was LTB. Of the 3500 children seen with laryngotracheobronchitis (LTB) 4.6% had a tracheostomy—28% of those requiring airway intervention. Overall 67% of the children were decannulated within 10 weeks and 92% within a year. For 56% one or more further procedures prior to decannulation were required, including 34 children who required a laryngotracheoplasty. Obstructing stomal granulation tissue had to be removed from 51 children and suprastomal collapse was a cause of decannulation failure in 52 children. Use of an expiratory valve as an aid to decannulation is discussed. Five children died of tracheostomy airway complications and 25 children of a medical disorder. One complication, laryngeal incompetence, was particularly associated with herpetic laryngeal ulceration. Staphylococcus aureus and Hemophilus influenzae were the main organisms cultured in the early weeks, with Pseudomonas and Streptococcus species predominating later.

Tracheostomy decannulation.

Tracheostomy in pediatric patients involves major morbidity that is often reflected in prolonged decannulation difficulty. A review of 123 consecutive pediatric tracheostomies shows that 44 patients experienced such difficulties. Among those patients suffering decannulation delay, subglottic stenosis had developed in 39%, tracheal granuloma in 25%, fused cords in 11%, and temporary laryngeal abductor failure in 25%. Although the overall incidence of decannulation failure is high, more than 60% of those patients affected respond to treatment when diagnosis is prompt and accurate. In this regard, the laryngologist may play a central role in the management of the pediatric decannulation process.

A skin-lined tube as a complication of tracheostomy.

A child who had undergone tracheostomy at 15 days of age and could not be decannulated died at 15 months of age after accidental decannulation. The larynx and cervical trachea were removed at autopsy. A skin-lined tracheostomy tract was found extending from the surface of the neck into the lumen of the trachea. This lesion explains the decannulation failure and represents a previously undescribed complication of tracheostomy.