Tracheostomy In Patients Research Articles

Value of endoscopic examination of airways and swallowing in tracheostomy decannulation

BackgroundTracheostomy decannulation decision is the major challenge in the clinical management of tracheostomy patients. Little evidence is available to guide the weaning process and optimal timing of tracheostomy tube removal. The purpose of the study was to investigate the value of endoscopic assessment in the tracheostomy decannulation decision.ResultsThe study included 154 tracheostomized adult patients. Bedside assessment was done for 112 patients, and the other 42 patients were deceased. The results of bedside assessment lead to successful decannulation in 18 patients (16%), while 94 patients (84%) were unfit for decannulation. The most common cause of unfitness was aspiration and poor swallowing in 41% of patients. The endoscopic assessment was done for 59 patients out of 94 patients that were unfit for decannulation; thirteen patients of them were fit for decannulation (22%). The final status of the patients before discharge was decannulated in 31 cases and 81 patients were discharged with a tracheostomy.ConclusionsThe results indicated the importance of endoscopic assessment in the decannulation decision of tracheostomized patients. A large proportion of patients who are unfit for decannulation by bedside assessment could be fit after endoscopic assessment. Endoscopic assessment is essential particularly in tracheostomized patients who have failed to achieve decannulation through conventional protocols.

Severe pain-related adverse events of percutaneous dilatational tracheostomy performed by a neurointensivist compared with conventional surgical tracheostomy in neurocritically ill patients

BackgroundWe evaluated severe pain-related adverse events (SAE) during the percutaneous dilatational tracheostomy (PDT) procedure performed by a neurointensivist and compared the outcomes with that of conventional surgical tracheostomy in neurocritically ill patients.MethodsThis was a retrospective and observational study of adult patients who were admitted to the neurosurgical intensive care unit between January 2014 and March 2018 and underwent tracheostomy. In this study, primary endpoints were incidence of SAE: cardiac arrest, arrhythmias, hypertension, hypotension, desaturation, bradypnea, or ventilatory distress. The secondary endpoint was procedure-induced complications.ResultsA total of 156 patients underwent tracheostomy during the study. Elective surgery of brain tumors (34.0%) and intracranial hemorrhage (20.5%) were the most common reasons for admission. The most common reasons for tracheostomy were difficult ventilator weaning or prolonged intubation (42.9%) and sedative reduction (23.7%). Tachycardia (30.1%) and hypertension (30.1%) were the most common SAE. Incidence of SAE was more common in conventional tracheostomy compared to PDT (67.1% vs. 42.3%, P = 0.002). The total duration of SAE (19.8 ± 23.0 min vs. 3.4 ± 5.3 min, P < 0.001) and procedural time (42.2 ± 21.8 min vs. 17.7 ± 9.2 min, P < 0.001) were longer in conventional tracheostomy compared to PDT. Multivariable adjustment revealed that only PDT by a neurointensivist significantly reduced the incidence of SAE by one third (adjusted odds ratio [OR]: 0.36, 95% confidence interval [CI]: 0.187–0.691). In addition, PDT by a neurointensivist deceased the duration of SAE by 8.64 min (β: -8.64, 95% CI: − 15.070 – -2.205, P = 0.009) and prolonging the procedure time by every one minute significantly increased the duration of SAE by 6.38 min (β: 6.38, 95% CI: 0.166–0.470, P < 0.001). Procedure-induced complications were more common in conventional tracheostomy compared to PDT (23.5% vs. 11.3%, P = 0.047).ConclusionsThis retrospective and exploratory study of our single-center limited cohort of tracheostomy patients revealed that decreased SAE may be associated with short procedural time during the PDT procedure performed by a neurointensivist. It is proposed that PDT by a neurointensivist may be safe and feasible in neurocritically ill patients.

Neurally Adjusted Ventilatory Assist in Difficult Weaning: Promising Findings on a Prickly Issue.

Neurally Adjusted Ventilatory Assist in Difficult Weaning: Promising Findings on a Prickly Issue.

THE CONFIDENCE LEVEL OF MEDICAL STAFF IN MANAGING PATIENTS WITH A TRACHEOSTOMY IN NATIONAL GUARD HEALTH AFFAIRS HOSPITAL, RIYADH, SAUDI ARABIA

TYPE: Abstract Publication TOPIC: Respiratory Care PURPOSE: The aim of the Study was to explore the confidence level among medical staff in managing patients with a tracheostomy at NGHA, and to compare the confidence level among different health care specialist in managing patients with tracheostomy METHODS: A cross-sectional study carried out among 188 medical staff including (Nurses and Respiratory Therapists) in Riyadh, during (August , September 2019 ). A questionnaire was used to assess the confidence level in managing patients with tracheostomy RESULTS: A total of 188 participants with 94 RTs and 94 Nurses were included in the study. Majority (56.4%) had more than 5 years of work experience. A greater part (64%) of the participants were working in wards. Ninety five percent opined that they feel confident in managing the tracheostomy patients (Rts= 94.7%, Nurses= 94.7%). The confidence level of participants in managing tracheostomy patients with a ventilator was observed to be 78% (RTs= 96%, Nurses= 60%, p value=0.001). The median (Interquartile Range, IQR) knowledge score was higher in nurses 6 (2) as compared to RTs 5 (1.5) and was statistically insignificant with p value as 0.087. CONCLUSIONS: The study concluded that the RTs were more confident in managing patients with both tracheostomy and ventilator than those with nurses. CLINICAL IMPLICATIONS: this study suggests that nurses.should be more confident in managing patients with both tracheostomy and ventilator DISCLOSURE: No significant relationships. KEYWORD: Tracheostomy, Respiratory Therapy, Patients Care.

Improving tracheostomy care in the United Kingdom: results of a guided quality improvement programme in 20 diverse hospitals

BackgroundInconsistent and poorly coordinated systems of tracheostomy care commonly result in frustrations, delays, and harm. Quality improvement strategies described by exemplar hospitals of the Global Tracheostomy Collaborative have potential to mitigate such problems. This 3 yr guided implementation programme investigated interventions designed to improve the quality and safety of tracheostomy care. MethodsThe programme management team guided the implementation of 18 interventions over three phases (baseline/implementation/evaluation). Mixed-methods interviews, focus groups, and Hospital Anxiety and Depression Scale questionnaires defined outcome measures, with patient-level databases tracking and benchmarking process metrics. Appreciative inquiry, interviews, and Normalisation Measure Development questionnaires explored change barriers and enablers. ResultsAll sites implemented at least 16/18 interventions, with the magnitude of some improvements linked to staff engagement (1536 questionnaires from 1019 staff), and 2405 admissions (1868 ICU/high-dependency unit; 7.3% children) were prospectively captured. Median stay was 50 hospital days, 23 ICU days, and 28 tracheostomy days. Incident severity score reduced significantly (n=606; P<0.01). There were significant reductions in ICU (−;0.25 days month−1), ventilator (−;0.11 days month−1), tracheostomy (−;0.35 days month−1), and hospital (−;0.78 days month−1) days (all P<0.01). Time to first vocalisation and first oral intake both decreased by 7 days (n=733; P<0.01). Anxiety decreased by 44% (from 35.9% to 20.0%), and depression decreased by 55% (from 38.7% to 18.3%) (n=385; both P<0.01). Independent economic analysis demonstrated £33 251 savings per patient, with projected annual UK National Health Service savings of £275 million. ConclusionsThis guided improvement programme for tracheostomy patients significantly improved the quality and safety of care, contributing rich qualitative improvement data. Patient-centred outcomes were improved along with significant efficiency and cost savings across diverse UK hospitals. Clinical trial registrationIRAS-ID-206955; REC-Ref-16/LO/1196; NIHR Portfolio CPMS ID 31544.

Tracheotomy in patients with COVID-19

Coronavirus disease 2019 (COVID-19) has become a public health problem by quickly evolving into a global pandemic. Although the disease causes mild to moderate symptoms in large parts of society, severe respiratory distress develops in a significant portion. These patients need to be treated in the intensive care unit, and some of them also need invasive mechanical ventilation due to respiratory failure. Prolonged mechanical ventilation can bring out a need for tracheotomy in these patients. However, tracheotomy is a high-risk procedure in terms of transmission due to the high potential of aerosol generation. Therefore, some recommendations about the measurements to be taken and personal protective equipment (PPE) use were published. Until now, we performed tracheotomy in six patients with COVID-19 in our center and all these procedures were performed at the bedside. During these procedures, standard and enhanced PPE, including a powered air-purifying respirator, were used. No sign of the infection was seen in any member of the team who performed the procedures. In conclusion, the tracheotomy procedure in the patients with COVID-19 seems to be safe in terms of the transmission risk to the healthcare workers, based on articles published during the severe acute respiratory syndrome epidemic and our experiences. However, we still need data collection and documentation to establish the timing and benefit of tracheotomy in these patients.

In Situ Simulation to Assess Pediatric Tracheostomy Care Safety: A Novel Multicenter Quality Improvement Program.

Our objectives were (1) to use in situ simulation to assess the clinical environment and identify latent safety threats (LSTs) related to the management of pediatric tracheostomy patients and (2) to analyze the effects of systems interventions and team factors on LSTs and simulation performance. A multicenter, prospective study to assess LSTs related to pediatric tracheostomy care management was conducted in emergency departments (EDs) and intensive care units (ICUs). LSTs were identified through equipment checklists and in situ simulations via structured debriefs and blinded ratings of team performance. The research team and unit champions developed action plans with interventions to address each LST. Reassessment by equipment checklists and in situ simulations was repeated after 6 to 9 months. Forty-one LSTs were identified over 21 simulations, 24 in the preintervention group and 17 in the postintervention group. These included LSTs in access to equipment (ie, availability of suction catheters, lack of awareness of the location of tracheostomy tubes) and clinical knowledge gaps. Mean equipment checklist scores improved from 76% to 87%. Twenty-one unique teams (65 participants) participated in the simulations. The average simulation score was 6.19 out of 16 points. In situ simulation is feasible and effective as an assessment tool to identify latent safety threats and thus measure the system-level performance of a clinical care environment. In situ simulation can be used to identify and reassess latent safety threats related to pediatric tracheostomy management and thereby support quality improvement and educational initiatives.

Occurrence of ventilator associated pneumonia using a tracheostomy tube with subglottic secretion drainage.

Ventilator-associated pneumonia (VAP) is a significant cause of morbidity and mortality in critically ill patients who require mechanical ventilation (MV). Subglottic secretions above the endotracheal cuff are associated with bacteria colonization of lower respiratory tract, causing VAP. A preventive strategy to avoid subglottic secretion progression is the drainage with special tracheal tubes effective in preventing both early onset and late onset VAP. The purpose of this study was to measure VAP incidence in tracheostomized patients with suction above the cuff. The authors performed a matched cohort study with historical control in three academic Intensive Care Units (ICUs): upon ICU admission, patients requiring MV were submitted to tracheostomy with a tracheal tube allowing drainage of subglottic secretions (treatment group). A control group without suctioning above the cuff was selected applying the propensity score matching on dataset of previous ELT Study. VAP occurrence at 28-days from intubation was the primary endpoint; hospital mortality and ICU-free days at 28-days were the secondary endpoints. Between July 2014 and April 2016, 125 tracheostomized patients were included in the analysis. 232 tracheostomized patients without suctioning were selected as a control group for the matched cohort study. The application of propensity score matching selected 60 patients to compare the two groups. Incidence of VAP was 8% in treatment group and 19.4% in the control group (P value =0.004). After balance with propensity score matching VAP was 8.3% and 21.7% (P value =0.0408), respectively. Subglottic secretion drainage reduces incidence of VAP in critically ill patients requiring ongoing MV via tracheostomy.

Risk Assessment and Early Mobilization Pathway Following Pediatric Tracheostomy: A Pilot Study.

To confirm the standard of care pertaining to postoperative mobilization practices following initial tracheostomy, to establish face validity of novel early mobilization tools, and to conduct a safety and feasibility pilot study. Multi-institutional survey and prospective cohort study. Experts at our tertiary-care children's hospital developed an Early Pediatric Mobility Pathway for tracheostomy patients utilizing a novel risk-assessment tool. Surveys were distributed to professional colleagues in similar children's hospitals to establish face validity and incorporate respondent feedback. Additional surveys were disseminated to tertiary-care children's hospitals across the country to establish the current standard of care, and a pilot study was conducted. Seventy-seven percent of respondents from tertiary hospitals across the country confirmed the standard of care to defer mobilization until the first trach change. Greater than 83% of the respondents used to establish face validity of the tools agreed with the clinical components and scoring structure. The safety and feasibility of early mobilization prior to initial trach change was confirmed with a pilot of 10 pediatric patients without any adverse events. Mobilization of pediatric patients prior to initial trach change is feasible and can be safe when risk factors are assessed by a multidisciplinary team. 4 Laryngoscope, 131:E653-E658, 2021.

Colonization rates of tracheostomy tubes associated with the frequency of tube changes.

Tracheostomy-tube change protocols are implemented primarily due to concern regarding infections. Currently changes vary from within 4 weeks post-insertion to 3 monthly thereafter. However, currently no evidence-based guidelines exist to justify these protocols. This study aims to assess the colonization of tracheostomy-tubes associated with the frequency of changes. A prospective cohort study over 18-months of adult tracheostomy patients at a single institution (inpatient/outpatients). Patients were grouped based on whether tubes were changed at ≤4 weeks or >4 weeks and microbiology swabs sent for microscopy, culture and sensitivities. A total of 65 patients were enrolled. No statistically significant difference in colonization in patients undergoing tube changes more than every 4 weeks to those less than every 4 weeks was found (56.2% versus 57.1%, χ2 = 0.004, P = 0.95). The timing of tracheostomy-tube changes may not affect colonization and infection rates. Routine changes for the purpose of reducing infection risk may not be needed unless clinically indicated.

Walking the line between benefit and harm from tracheostomy in COVID-19

Walking the line between benefit and harm from tracheostomy in COVID-19

Tracheostomy weaning in community and the importance of the Multi-Disciplinary Team (MDT) to optimise outcomes - a case report

Purpose: Patients discharged in to the community with a percutaneous tracheostomy often receive no follow up. The implications of this are huge. A previous pilot scheme resulted in the decannulation of 5 patients who were living in community with tracheostomies. This led to improved quality of life and demonstrated significant cost savings. This highlighted the need for continual review and assessment of tracheostomy patients with regards to their future weaning potential. This case report will discuss the success for one patient as part of a 10-month community MDT pilot scheme. The team comprised of a dedicated nurse, speech and language therapist (SLT) and physiotherapist. We highlight the importance of a collaborative MDT approach in order to optimise outcomes for patients with tracheostomies.

A Surgical Safety Checklist for Performing Tracheotomy in Patients with Coronavirus Disease 19.

Performance of tracheotomy is a potential necessary step in the patient with coronavirus disease 19 (COVID-19) and prolonged mechanical ventilation. Due to viral aerosolization, tracheotomy carries a high risk of transmission of COVID-19 to the health care team performing the procedure. We share our institution's surgical safety checklist for performing tracheotomy in patients with COVID-19, including key modifications intended to mitigate risk to the surgical team.

Bioabsorbable Microplates as an External Stent for Suprastomal Collapse: A Retrospective Review.

To assess the long-term decannulation outcomes of bioresorbable microplates as an external stent for pediatric tracheostomy patients with suprastomal collapse. Retrospective cohort study. Hospital records of all patients who underwent a bioresorbable microplate for suprastomal collapse from 2016 to 2019 were reviewed at a single institution. The primary outcome measure was tracheostomy decannulation. A total of nine patients underwent placement of bioabsorbable microplates to treat suprastomal collapse. After initial tracheostomy, four patients received a laryngotracheal reconstruction prior to their external stent placement, and one patient received a mandibular distraction. The average age at the time of external stent placement was 32 (±21) months, excluding one patient who received a stent at the age of 29 years. Eight patients (88.9%) were successfully decannulated following the procedure. Decannulated patients were followed for an average of 21 (±12.5) months postoperatively, and all these patients have remained decannulated since their initial procedure. This is a total of 173 months (14.4 years) of observation postprocedure in which these patients have remained decannulated. One patient experienced postoperative crepitus requiring washout but still maintained decannulation. Bioabsorbable microplates have a reasonable chance of long-term successful decannulation when an appropriate patient is selected. Decannulation is maintained beyond the 6-month time frame in which the 85:15 poly(L-lactide-co-glycolide) polymer that comprises the external stent takes to bioabsorb. This procedure should be considered for the often difficult problem of pediatric tracheostomy with isolated suprastomal collapse. 4 Laryngoscope, 131:E631-E634, 2021.

Impact of vital capacity on outcome after total arch replacement.

Although chronic obstructive pulmonary disease has been recognized as a significant risk factor for open-heart surgery, the relationship between vital capacity and postoperative outcomes remains unclear. Our objective was to analyze the effect of vital capacity on outcomes after total arch replacement. Between January 2003 and December 2018, 228 patients undergoing total arch replacement who were elective cases with preoperative spirometry records were retrospectively reviewed. Patients were divided into two groups, based on whether their preoperative vital capacity was less than or greater than 2.5 L. We compared perioperative data and long-term outcome after adjusting their backgrounds by propensity score matching analysis. The lower vital capacity group had more tracheostomy patients (5.1% vs 0.0%; p = 0.045). The actuarial survival rate was 58.0% in the lower vital capacity group and 86.3% in the higher vital capacity group at 8 years. Log-rank analysis revealed a significant difference between the two groups (p = 0.011). In the multivariate Cox proportional hazard model, vital capacity < 2.5 L (p = 0.024) and estimated glomerular filtration rate < 30mL/minute/1.73 m2 (p = 0.012) showed a significant association with a higher risk of long-term mortality. Vital capacity should be considered an important risk factor for postoperative respiratory complications and long-term mortality in patients undergoing total arch replacement.

Expert consensus on preventing nosocomial transmission during respiratory care for critically ill patients infected by 2019 novel coronavirus pneumonia

Definite evidence has shown that the novel coronavirus (COVID-19) could be transmitted from person to person, so far more than 1 700 bedside clinicians have been infected. A lot of respiratory treatments for critically ill patients are deemed as high-risk factors for nosocomial transmission, such as intubation, manual ventilation by resuscitator, noninvasive ventilation, high-flow nasal cannula, bronchoscopy examination, suction and patient transportation, etc, due to its high possibility to cause or worsen the spread of the virus. As such, we developed this consensus recommendations on all those high-risk treatments, based on the current evidence as well as the resource limitation in some areas, with the aim to reduce the nosocomial transmission and optimize the treatment for the COVID-19 pneumonia patients. Those recommendations include: (1)Standard prevention and protection, and patient isolation; (2)Patient wearing mask during HFNC treatment; (3)Using dual limb ventilator with filters placed at the ventilator outlets, or using heat-moisture exchanger (HME) instead of heated humidification in single limb ventilator with HME placed between exhalation port and mask; avoid using mask with exhalation port on the mask; (4)Placing filter between resuscitator and mask or artificial airway; (5)For spontaneous breathing patients, placing mask for patients during bronchoscopy examination; for patients receiving noninvasive ventilation, using the special mask with bronchoscopy port to perform bronchoscopy; (6)Using sedation and paralytics during intubation, cuff pressure should be maintained between 25-30 cmH(2)O(1 cmH(2)O=0.098 kPa); (7)In-line suction catheter is recommended and it can be used for one week; (8)Dual-limb heated wire circuits are recommended and only changed with visible soiled; (9)For patients who need breathing support during transportation, placing an HME between ventilator and patient; (10)PSV is recommended for implementing spontaneous breathing trial (SBT), avoid using T-piece to do SBT. When tracheotomy patients are weaned from ventilator, HME should be used, avoid using T-piece or tracheostomy mask. (11)Avoid unnecessary bronchial hygiene therapy; (12) For patients who need aerosol therapy, dry powder inhaler metered dose inhaler with spacer is recommended for spontaneous breathing patients; while vibrating mesh nebulizer is recommended for ventilated patients and additional filter is recommended to be placed at the expiratory port of ventilation during nebulization.

Implementation of an interdisciplinary tracheostomy care protocol to decrease rates of tracheostomy-related pressure ulcers and injuries.

Tracheostomy-related pressure injuries (TRPI) have been demonstrated to occur in approximately 10% of tracheostomy patients. In this study, we present TRPI outcomes after implementation of a standardized tracheostomy care protocol. A tracheostomy care protocol was developed by an interdisciplinary quality improvement program and implemented on July 1, 2016. The protocol was designed to minimize factors that contribute to the development of TRPI. Rates of TRPI over the subsequent 20months were compared to the year before implementation. 9 out of 85 patients (10.6%) developed TRPI in the pre-protocol cohort compared to 0 of 137 (0%) in the post-protocol cohort, which was a statistically significant decrease by Fisher's exact test with a p-value of 0.0001. Pearson's correlation coefficient demonstrated a negative correlation between age and post-operative day of diagnosis (r=-0.641, p=0.063), indicating that older patients develop TRPI more quickly. Interdisciplinary peri-operative tracheostomy care protocols can be effective in decreasing rates of TRPI.

The Trach Safe Initiative: A Quality Improvement Initiative to Reduce Mortality among Pediatric Tracheostomy Patients.

To describe the Trach Safe Initiative and assess its impact on unanticipated tracheostomy-related mortality in outpatient tracheostomy-dependent children (TDC). An interdisciplinary team including parents and providers designed the initiative with quality improvement methods. Three practice changes were prioritized: (1) surveillance airway endoscopy prior to hospital discharge from tracheostomy placement, (2) education for community-based nurses on TDC-focused emergency airway management, and (3) routine assessment of airway events for TDC in clinic. The primary outcome was annual unanticipated mortality after hospital discharge from tracheostomy placement before and after the initiative. In the 5 years before and after the initiative, 131 children and 155 children underwent tracheostomy placement, respectively. At the end of the study period, the institution sustained Trach Safe practices: (1) surveillance bronchoscopies increased from 104 to 429 bronchoscopies, (2) the course trained 209 community-based nurses, and (3) the survey was used in 488 home ventilator clinic visits to identify near-miss airway events. Prior to the initiative, 9 deaths were unanticipated. After Trach Safe implementation, 1 death was unanticipated. Control chart analysis demonstrates significant special-cause variation in reduced unanticipated mortality. We describe a system shift in reduced unanticipated mortality for TDC through 3 major practice changes of the Trach Safe Initiative. Death in a child with a tracheostomy tube at home may represent modifiable tracheostomy-related airway events. Using Trach Safe practices, we address multiple facets to improve safety of TDC out of the hospital.

Multidisciplinary Bedside Procedure Service

A specialized multidisciplinary service was created for the placement and management of bedside tracheostomies and gastrostomies. Patients from August 2013 to May 2018 were reviewed, and 1074 tracheostomies and 591 percutaneous endoscopic gastrostomies (PEGs) were identified. Complications requiring an additional procedure occurred in 2% of the tracheostomy patients. PEG was performed successfully at bedside in 96%. After PEG was attempted, 4% of patients required additional procedures. Among identifiable subgroups, 75.5% of tracheostomies (n = 417) and 61% of PEGs (n = 417) were performed within 1 day of consult. A multidisciplinary consult service is a safe and efficient model for performing bedside tracheostomies and PEGs in the intensive care unit.

Prophylactic noninvasive positive pressure ventilation in the weaning of difficult-weaning tracheotomy patients.

BackgroundProphylactic noninvasive positive pressure ventilation (NPPV) reduces reintubation in endotracheal intubation patients. However, the efficacy of using the prophylactic NPPV in the weaning of tracheotomy patients is unclear.MethodsWe performed prophylactic NPPV in 11 tracheotomy patients who passed a spontaneous breathing trial (SBT), removed the tracheotomy tube, and closed the incision (intervention group). We matched another 11 tracheotomy patients who also passed an SBT but weaning and removing of tracheotomy tube were managed as conventional methods (control group).ResultsPatients in the control group had reinstitution of mechanical ventilation 36 times after the initial SBT success. Compared with the control group, the interventional group had fewer weaning days (3.0±2.1 vs. 11.3±9.2, P=0.01) from initial SBT success to successful weaning and shorter intensive care unit (ICU) length of stay (11.6±4.2 vs. 20.3±11.6, P=0.03) after initial SBT success. The interventional group had lower nosocomial pneumonia rates after initial SBT success (0/11 vs. 2/11), lower ICU mortality (0/11 vs. 2/11), lower hospital mortality (0/11 vs. 3/11), and higher successful weaning rate (11/11 vs. 8/11), but it didn’t reach significant difference. Also, there was no significant difference between groups in total duration of ventilation (25.5±13.3 vs. 34.7±24.2 days), hospital stay after initial SBT success (24.0±22.3 vs. 37.4±31.3 days), total ICU stay (35.7±15.3 vs. 45.0±29.5 days), and total hospital stay (48.7±33.1 vs. 68.6±52.6 days).ConclusionsProphylactic NPPV may be useful to accelerate weaning, and shorten ICU stay after initial SBT success in tracheotomy patients.