Importance of flexible bronchoscopy in decannulation of tracheostomy patients

Rodrigues, Leonardo Brand; Nunes, Tarcizo Afonso

doi:10.1590/0100-69912015002003

Cited by 13 publications

(13 citation statements)

References 18 publications

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“…Other prospective, observational, but noncomparative studies confirm [ 107 , 108 ]: 1) a higher incidence of swallowing dysfunction in tracheotomized patients ventilated for a prolonged period; 2) a longer intensive care stay and increased risk of inhalation and of pharyngolaryngeal lesions when tracheotomy is prolonged or decannulation is delayed.…”

Section: Methodsmentioning

confidence: 93%

Tracheotomy in the intensive care unit: guidelines from a French expert panel

Trouillet¹,

Collange²,

Belafia³

et al. 2018

Ann. Intensive Care

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Tracheotomy is widely used in intensive care units, albeit with great disparities between medical teams in terms of frequency and modality. Indications and techniques are, however, associated with variable levels of evidence based on inhomogeneous or even contradictory literature. Our aim was to conduct a systematic analysis of the published data in order to provide guidelines. We present herein recommendations for the use of tracheotomy in adult critically ill patients developed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. These guidelines were conducted by a group of experts from the French Intensive Care Society (Société de Réanimation de Langue Française) and the French Society of Anesthesia and Intensive Care Medicine (Société Francaise d’Anesthésie Réanimation) with the participation of the French Emergency Medicine Association (Société Française de Médecine d’Urgence), the French Society of Otorhinolaryngology. Sixteen experts and two coordinators agreed to consider questions concerning tracheotomy and its practical implementation. Five topics were defined: indications and contraindications for tracheotomy in intensive care, tracheotomy techniques in intensive care, modalities of tracheotomy in intensive care, management of patients undergoing tracheotomy in intensive care, and decannulation in intensive care. The summary made by the experts and the application of GRADE methodology led to the drawing up of 8 formal guidelines, 10 recommendations, and 3 treatment protocols. Among the 8 formal guidelines, 2 have a high level of proof (Grade 1+/−) and 6 a low level of proof (Grade 2+/−). For the 10 recommendations, GRADE methodology was not applicable and instead 10 expert opinions were produced.

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Section: Methodsmentioning

confidence: 93%

Tracheotomy in the intensive care unit: guidelines from a French expert panel

Trouillet¹,

Collange²,

Belafia³

et al. 2018

Ann. Intensive Care

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“…Most of the prior studies assessing risk factors for LT injuries have been on small cohorts of patients. 1,3,5,7,8 Though the cohort of patients with prohibitive laryngeal lesions is somewhat limited, this is overall the largest study evaluating the incidence and risk factors for intubation-related laryngeal injuries that specifically preclude tracheostomy decannulation. Of the 371 patients included in this study, 28.6% had LT lesions, and 13.2% had laryngeal lesions that precluded decannulation prior to treatment.…”

Section: Discussionmentioning

confidence: 99%

Intubation-Related Laryngeal Pathology Precluding Tracheostomy Decannulation: Incidence and Associated Risk Factors

Meenan

Bhatnagar

Guardiani

2021

Ann Otol Rhinol Laryngol

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Objectives: To identify the incidence and risk factors for intubation-related laryngeal lesions that preclude tracheostomy decannulation in a large population. Methods: A 3-year retrospective case-control study was performed of tracheotomized adults in acute rehabilitation facilities who underwent routine endoscopic evaluation of the airway as part of the facilities’ decannulation protocol. Patients with known upper airway pathology, external laryngeal trauma, cricothyrotomy or emergent tracheostomy, prior head and neck radiation, isolated tracheal lesions, and patients with incomplete reports were excluded. The laryngeal pathologies were classified, and demographics and clinical features were compared between those whose lesions precluded decannulation and all other patients. Results: Three hundred seventy-one patients met inclusion criteria. One hundred six (28.6%) had laryngotracheal lesions. Forty-nine patients (13.2%) had intubation-related lesions of the larynx that precluded decannulation. These lesions included posterior glottic stenosis (30.6%), granulation tissue (24.5%), vocal fold immobility (16.3%), subglottic stenosis (16.3%), a combination of granulation tissue and stenosis (10.2%), and glottic edema (2.0%). A BMI ≥ 25 kg/m2 was associated with laryngeal lesions precluding decannulation. There was no difference in age, sex, race, diabetes mellitus, endotracheal tube size, number of days intubated, and number of intubations between groups. Seventy-eight percent of patients with lesions precluding decannulation were decannulated after medical or surgical therapy. The decannulation rate of patients without lesions precluding decannulation was 79.9%. Conclusions: BMI ≥ 25 kg/m2 may increase the risk of development of laryngeal lesions preventing decannulation. Given that 13.2% of tracheotomized patients have laryngeal lesions precluding decannulation, an endoscopic evaluation of the airway is important to prevent decannulation failure and future airway symptoms.

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“…Decannulation is contraindicated in the following circumstances: lesion of bilateral vocal cords in adduction, subglottic obstruction or lesion >50% or grade II or higher obstruction according to Cotton classification, abundant peristomal granulation tissue >50% from the lumen that cannot be resected, grade 4 tracheobronchomalacia, grade 4 Expiratory Central Airway Collapse classification, spontaneous massive bronchoaspiration of oropharyngeal secretions according to the Donzelli scale, or a score >4 in the food Penetration-Aspiration scale; regarding functioning, absence of cough reflex, no secretion clearing after three deglutitions, chordal palsy, and deglutition disorders with the various media. 39 Placement of phonation valves allows the patient to speak, increasing motivation and accelerating recovery. 40 Clinical Audit downloaded from https://www.…”

Section: Stop Swallowing Testmentioning

confidence: 99%

Evaluation protocol before, during, and after bronchoscopy-guided swallowing test for decannulation: clinical audit proposal

Sánchez-Cabral¹,

Santillán-Doherty²,

Martínez-Mendoza³

2018

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Swallowing is a complex act. In some series, it was found that ~20% of patients under invasive mechanical ventilation in intensive care units are subjected to percutaneous tracheostomy; however, the presence of tracheostomy causes an increase in the amount of tracheal secretions, changes in the deglutition mechanism, a higher risk of airway infection, bleeding, and hinders vocalization, causing late complications. Decannulation must be performed as soon as possible, since it facilitates phonation and deglutition. This project presents the methods for undertaking a clinical audit to evaluate patients with tracheostomy before, during, and after bronchoscopy-guided swallowing test for decannulation purposes. The main goal is to evaluate the effectiveness of decannulation in patients with percutaneous tracheostomy through physiological and anatomical examination of the airway and the swallowing mechanism using the bronchoscopic method. This method consists of a series of the following evaluations: 1) select patient candidate for swallowing test; 2) prior preparation of the patient for the swallowing test; and 3) transnasal phase, which decides if the patient should be decannulated, consisting of evaluation of the bronchoscopy-guided swallowing test. The patient should not have alterations. If he/she has no alterations in the transnasal and/or transtracheostomy phases, the patient is decannulated. A reliable procedure will be performed by the study data collectors. Data will be analyzed according to the nature of the variables. Decannulation success will be determined by inferential statistics.

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Importance of flexible bronchoscopy in decannulation of tracheostomy patients

Abstract: flexible bronchoscopy showed a large number of laryngotracheal injuries, the most frequent being the vocal cords injury in the larynx and the granuloma in the trachea, which contributed to increase the decannulation procedure safety.

Cited by 13 publications

References 18 publications

Tracheotomy in the intensive care unit: guidelines from a French expert panel

Tracheotomy in the intensive care unit: guidelines from a French expert panel

Intubation-Related Laryngeal Pathology Precluding Tracheostomy Decannulation: Incidence and Associated Risk Factors

Evaluation protocol before, during, and after bronchoscopy-guided swallowing test for decannulation: clinical audit proposal

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