Predictors of Successful Decannulation Using a Tracheostomy Retainer in Patients with Prolonged Weaning and Persisting Respiratory Failure

Abstract

Background: For percutaneously tracheostomized patients with prolonged weaning and persisting respiratory failure, the adequate time point for safe decannulation and switch to noninvasive ventilation is an important clinical issue. Objectives: We aimed to evaluate the usefulness of a tracheostomy retainer (TR) and the predictors of successful decannulation. Methods: We studied 166 of 384 patients with prolonged weaning in whom a TR was inserted into a tracheostoma. Patients were analyzed with regard to successful decannulation and characterized by blood gas values, the duration of previous spontaneous breathing, Simplified Acute Physiology Score (SAPS) and laboratory parameters. Results: In 47 patients (28.3%) recannulation was necessary, mostly due to respiratory decompensation and aspiration. Overall, 80.6% of the patients could be liberated from a tracheostomy with the help of a TR. The need for recannulation was associated with a shorter duration of spontaneous breathing within the last 24/48 h (p < 0.01 each), lower arterial oxygen tension (p = 0.025), greater age (p = 0.025), and a higher creatinine level (p = 0.003) and SAPS (p < 0.001). The risk for recannulation was 9.5% when patients breathed spontaneously for 19–24 h within the 24 h prior to decannulation, but 75.0% when patients breathed for only 0–6 h without ventilatory support (p < 0.001). According to ROC analysis, the SAPS best predicted successful decannulation [AUC 0.725 (95% CI: 0.634–0.815), p < 0.001]. Recannulated patients had longer durations of intubation (p = 0.046), tracheostomy (p = 0.003) and hospital stay (p < 0.001). Conclusion: In percutaneously tracheostomized patients with prolonged weaning, the use of a TR seems to facilitate and improve the weaning process considerably. The duration of spontaneous breathing prior to decannulation, age and oxygenation describe the risk for recannulation in these patients.

The practice of tracheostomy decannulation—a systematic review

“…The study by Kenneth B et al specifically included critically ill obese patients with an average body mass index of 41.9 ± 14 [21]. Few studies [8, 13, 20, 23] reported the severity of the illness of included patients.…”

“…There were 2 studies each with tracheostomies performed by either surgical [8] or percutaneous [20] technique, while 5 studies included patients with both techniques [13, 14, 19, 21, 25]. …”

“…While the inclusion criteria were distinctly spelled out in 12 studies [8, 11–17, 20, 22], the exclusion criteria were only mentioned in 6 [14, 15, 17, 21, 23]. …”

“…Peak cough flow (PCF) [20] and maximum expiratory pressure (MEP) [8] were used as quantitative measures of coughing. Swallowing was mostly assessed subjectively via gag reflex or dye test [2], except in the study by Wranecke et al wherein fibreoptic endoscopic evaluation of swallowing (FEES) was used for objective assessment [23].…”

Respiratory problems and management in people with spinal cord injury

“…Removal of the tracheostomy tube in the patient with SCI requires assessment of cough effectiveness, airway patency and adequacy of the swallow [129, 130]. Other considerations such as co-operation of the patient, oxygen requirements, medical stability, presence of respiratory infection or pending surgery should be taken into account [131, 132].…”