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A systematic review on tracheostomy decannulation: a proposal of a quantitative semiquantitative clinical score

A systematic review on tracheostomy decannulation: a proposal of a quantitative semiquantitative... Background: Tracheostomy is one of the most common surgical procedures performed in critical care patient management; more specifically, ventilation through tracheal cannula allows removal of the endotracheal tube (ETT). Available literature about tracheostomy care and decannulation is mainly represented by expert opinions and no certain knowledge arises from it. Methods: In lack of statistical requirements, a systematic and critical review of literature regarding tracheostomy tube removal was performed in order to assess predictor factors of successful decannulation and to propose a predictive score. We combined 3 terms and a literature search has been performed using the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE via Ovid SP; EMBASE via Ovid SP; EBSCO. Abstracts were independently reviewed: for those studies fitting the inclusion criteria on the basis of the title and abstract, full-text was achieved. We included studies published from January 1, 1995 until March 31, 2014; any sort of review and expert opinion has been excluded by our survey. English language restriction was applied. Ten studies have been considered eligible for inclusion in the review and were analysed further. Results: Cough effectiveness and ability to tolerate tracheostomy tube capping are the most considered parameters in clinical practice; other parameters are taken into different consideration by many authors in order to proceed to decannulation. Among them, we distinguished between objective quantitative parameters and semi-quantitative parameters more dependent from clinician’s opinion. We then built a score (the Quantitative semi Quantitative score: QsQ score) based on selected parameters coming from literature. Conclusions: On our knowledge, this review provides the first proposal of decannulation score system based on current literature that is hypothetical and requires to be validated in daily practice. The key point of our proposal is to give a higher value to the objective parameters coming from literature compared to less quantifiable clinical ones. Keywords: Tracheostomy, Decannulation, Predictive score, Clinical score, Removal tube * Correspondence: pierachille.santus@unimi.it Department of Life Science, Università degli Studi di Milano. Pulmonary Rehabilitation Unit, Fondazione Salvatore Maugeri, Istituto Scientifico di Milano-IRCCS, Via Camaldoli, 64-20138 Milan, Italy Dipartimento di Scienze della Salute, Università degli Studi di Milano. Pulmonary Rehabilitation Unit, Fondazione Salvatore Maugeri, Scientific Institute of Milan-IRCCS, Via Camaldoli, 64-20138 Milan, Italy Full list of author information is available at the end of the article © 2014 Santus et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Santus et al. BMC Pulmonary Medicine 2014, 14:201 Page 2 of 8 http://www.biomedcentral.com/1471-2466/14/201 Background They recorded diaphragm pressure- time product per Tracheostomy is one of the most frequent procedures min (PTPdi/min), tension-time index of the diaphragm applicated in intensive care unit (ICU) patients: about (TTdi), and the ratio of respiratory rate to tidal volume 10% of patients requiring more than 3 days of mechanical (f/VT) for 2 different tracheotomy tube, with an inner ventilation are expected to undergo tracheostomy [1]. Fur- diameters 8 mm and 6.5 mm. The use of a smaller thermore, in the last years the development of less invasive diameter resulted in an increase of diaphragmatic effort, surgical techniques allowed tracheostomy to be safely decrease of VT and an increase of intrinsic PEEP. In performed at patient’s bedside and at present this conclusion, the authors assessed that, especially in techniques are growing more and more because of the hard to wean tracheostomized patients, the use of a increased number of patients requiring difficult or tracheostomy tube of small size can lead to alterations prolonged weaning from endotracheal tube (ETT), of some weanibility parameters, otherwise normal with due to aging and severe comorbidities [2]. Moreover, greater size tubes [9]. possibility of tracheotomy for prevention and better In addition, a single physiologic study by Criner et al. clinical management of ventilator-associated pneumo- reported that airways resistance and work of breathing nia was recently evaluated [3]. resulted higher with the tube in place, during As a result, the correct management of tracheosto- spontaneous breathing, when compared to breathing mized patients and defined procedures for decannulation after decannulation [10]. grew into a more important clinical issue. Humidification and heating - Normally upper airways play a fundamental function of heating and humidification Physiological modifications after tracheostomy of inspired air. In tracheostomized patients, the air In the following chapter we will discuss the main physio- bypasses the nasopharyngeal cavity and enters directly logical implications for breathing after tracheostomy. In the tracheobronchial tree; a system of artificial scientific literature, authors usually compare tracheos- humidification is needed. In the absence of adequate tomy to endotracheal intubation. In our purpose, we humidification, the epithelium of the trachea is involved intended to compare changes during tracheostomy to in a gradual inflammatory process resulting in squamous spontaneous breathing and the most relevant topics are: metaplasia and, consequentially , impairment of ciliary function and increased risk of respiratory infection [11]. Airflow resistance - Resistance of anatomically normal airways is firstly conditioned by upper airways (up to Physiological modifications after decannulation 80% during nose breathing and 50% during mouth While scientific literature has better investigated trache- breathing). Therefore, tracheostomy should virtually otomy effects on respiratory physiology, data about reduce flow resistance bypassing the respiratory upper respiratory mechanisms after decannulation are almost airways. Actually, data from scientific literature state totally lacking. Chadda et al. studied respiratory parame- the contrary, as the presence of tracheotomy tube, ters in nine neuromuscular patients after that the during spontaneous breathing, reduces airway radius upper airways were confirmed to be free of obstruc- leading to increased flow resistance and, of course, tions by fiberoptic bronchoscopy. In this experience, increased work of breathing (WOB) [4,5]. decannulation resulted in an increase of the tidal vol- This is according to Poiseuille equation, as the resistance ume and carbon dioxide partial pressure due to an in- to gas flow through a tube varies inversely with the crease of the dead space and work of breathing [12]. internal diameter of the tube (in particular, to the 4th However, the argument is still controversial. In a study power of the radius of the tube when flow is laminar). of few years ago, Dellweg et al. did not find a significant Secondly, secretions (stimulated even more by the difference in WOB in favour of tracheostomy when presence of the tube) still play an important role: compared to mouth breathing. Decannulation increases adhering to the inner lumen of the tube, they can lead or decreases airways resistance depending from case to to significant luminal narrowing, according to Wilson case and, in particular, from the morphology of the et al. [6], 15% of tubes are shrunk three sizes; other upper airways [13]. experiences from literature ultimately come to the To our knowledge, there are only few papers on physio- same conclusions [7,8]. logical modifications after decannulation; experts have It has been supposed that the inner diameter of a differing opinion on this topic and so further research smaller tracheostomy tube may induce increased flow and trials are desirable. resistance and WOB, if compared to spontaneous breathing. The first data from in vivo studies appeared Weaning from tracheostomy – problem generation recently by Valentini et al. trying to define the effect of Place a tracheostomy enables discharging the patient smaller tracheostomy tube sizes on diaphragm effort. from ICU to a rehabilitation unit [14]. However, despite Santus et al. BMC Pulmonary Medicine 2014, 14:201 Page 3 of 8 http://www.biomedcentral.com/1471-2466/14/201 decannulation is not risk-free, there is evidence of benefits applied. A flow chart diagram of the search strategy and for tracheostomy tube removal. The tracheostomy tube study selection is provided in Figure 1. may cause inflammation and stenosis or excessive cough and may impair swallowing by preventing the physio- Results logical trachea’s elevation against the epiglottis in order to The database search yielded 248 citations published prevent aspiration of food or secretions [15]. between January 1995 and September 2012 (with dupli- Furthermore, upper airways are excluded from breath- cates removed). 226 articles were excluded on the title ing. At last, in most cases tracheostomized patients are and abstract. The full-text of potentially relevant arti- unable to speak; aphonia worsens patient’s quality of life cles was achieved for further evaluation. The final num- and slows down the recovery process, often leading to ber of papers taken into account is 10. Figure 1 shows anxiety and depression. the flow-chart explaining how many citations were A number of clinically important early and late compli- excluded from the analysis and for what reasons. After cations have been evaluated, including granulation tissue, analyzing the selected literature, we decided for a tracheal stenosis, tracheomalacia, tracheo-esophageal systematic and critical revision of literature on decan- fistula, ventilator-associated pneumonia and aspiration. nulation, due to lack of statistical requirements for a According to literature, chronic tracheostomy in severe meta-analysis. Specifically, in Table 1, primary and – Chronic Obstructive Pulmonary Disease (COPD) patients when present – secondary outcomes proposed by each is associated with a higher frequency of exacerbations author have been evaluated for each study. requiring antibiotic treatment [16]. The clinical relevance Studies targeting different outcomes from the ones of these complications may lead to death and most of predictors in decannulation were excluded, although patients weaned from mechanical ventilation through they considered tracheostomy tube removal of enrolled tracheostomy should undergo early decannulation. patients as a step. Surveys were also included. Context- As it is hard to schematize the approach for decannu- ually, papers exploring new and/or experimental tech- lation, we decided to perform the following revision of niques for the assessment of risk in trachestomy tube literature, with the aim of supporting or retracting current removal were excluded [17,18]. Such exclusion was statements. Which are then current issues in managing operated because the proposed approaches - such as tracheostomy? How does evidence-based medicine handle oscillometry impedance measurement or upper airway the process of weaning from tracheostomy tube? Now- resistance measurement – are difficult to apply in adays clinical habit derives from physiopathological know- every setting and are not easily reproducible in differ- ledge, from personal experience and from professional ent contexts. Nevertheless in this context innovative practice: there is limited evidence in literature regarding techniques, such those before reported, could probably be specifically decannulation processes. Little is known about useful to improve decannulation procedure in future. how clinicians decide to decannulate patients. Which are First of all, it must be noted that literature is mainly the criteria for choice? made of expert opinions and international surveys; the few reported clinical trials are mainly descriptive (retro- Methods spective and prospective); because of technical and ethical Criteria for considering studies for this systematic review problems, Randomized Clinical Trials (RCTs) are totally A literature search has been performed using the lacking. Cochrane Central Register of Controlled Trials (CENTRAL); It can be noticed from the data that the population MEDLINE via Ovid SP; EMBASE via Ovid SP; EBSCO. taken into consideration is heterogeneous for age, Research included, but was not limited to, 3 keywords comorbidities and causes of tracheostomy; it must also (tracheostomy, decannulation, weaning). Abstracts were be emphasized that studies take in consideration both independently reviewed: for those studies fitting the acute/reversible pathologies and chronic conditions at inclusion criteria on the basis of the title and abstract, different levels of severity (for instance, Budweiser et al. full-text was achieved. Reference lists were also exam- [2] considers prolonged weaning patients with persistent ined for any additional relevant studies not identified respiratory failure). Secondly, recommendations differ through the former search. We included studies pub- between clinicians who work in acute facilities and lished from January 1, 1995 until March 31, 2014. Such those who work at chronic wards and between respira- studies examined a population more than 18 years old, tory therapists and physicians. who received tracheostomy for any clinical reason, In our analysis cough effectiveness and ability to toler- excluded neuromuscular diseases, and hospitalized in ate tracheostomy tube capping are the most frequent any ward (ICU, rehabilitation wards, etc.); any sort of criteria used by clinicians in order to predict successful review and expert opinion has been excluded by our decannulation. In others studies a different importance survey. Including English language restriction was is also given to parameters such as oxygenation and Santus et al. BMC Pulmonary Medicine 2014, 14:201 Page 4 of 8 http://www.biomedcentral.com/1471-2466/14/201 Figure 1 Flow diagram of the search process. The number of references initially identified through each database was 248. References were usually excluded for more than one reason by a two consecutive steps. capnia, level of consciousness and neurological state, they were able to remove tracheotomy cannula in almost age, swallowing, quantity and quality of secretions, dur- 80% of patients with spontaneous breathing without major ation of mechanical ventilation, stability of haematic clinical complications. Principal parameters considered gases (PaO2 and PaCO2), aetiology of respiratory failure were patient's ability to remove secretions, swallowing and comorbidities. function, absence of psychiatric diseases, possibility of Bach et al. experienced in a population of patients reaching spontaneous breathing, and amount of respira- with respiratory failure due to different aetiologies some tory space [20]. parameters that can predict the success of the tracheos- Choate K and Barbetti J conducted a prospective tomy decannulation. The mostimportantpredictive fac- descriptive study of consecutive patients who received tor is PCF (Peak Cough Flow), in particular at least 160 a tracheostomy in ICU. Of the 823 decisions for decan- L/min; other important factors are also VC (Vital Cap- nulation, there were 40 episodes of failed decannula- acity) and age [19]. Ceriana e al. proposed a prospective tion, representing a failure rate of 4.8%. The main study to decide whether to remove tracheotomy in long- reason for decannulation failure was sputum retention term mechanically ventilated patients with respiratory and ineffective cough [21]. failure from different causes. By the use of a decisional Lastly, in a retrospective study on patients requiring flowchart based on clinical and physiological parameters, tracheostomy in ICU, Leung and his team identified risk Santus et al. BMC Pulmonary Medicine 2014, 14:201 Page 5 of 8 http://www.biomedcentral.com/1471-2466/14/201 Table 1 Primary and secondary outcomes evaluated for each study Authors Primary outcomes Secondary outcomes Bach et al. 1994 [19]. � PCF ≥ 160 L/min � VC � Age Ceriana et al. 2003 [20]. � Clinical stability (no active infection and hemodynamic stability) � Absence of psychiatric disorders � Effective cough (MEP ≥ 40 cmH2O) � PaCO2 < 60mmHg � Adequate swallowing (evaluated by gag or blue dye test) � Absence of tracheal stenosis (evaluated by endoscopy) Stelfox et al. 2008 [26]. � Ability to tolerate tube capping (24h vs. 72h) � Oxygenation (SaO2 95% with FiO2 0,3 vs. 0,5) � Cough effectiveness (strong vs. weak) � RR (18 bpm vs. 28 bpm) � Secretions (scan thin vs. moderate thick) � Swallowing (enteral nutrition via gastric tube and nothing p.o. vs. enteral nutrition via gastric tube and jelly and pudding) � Level of consciousness (alert vs. drowsy but arousable) � Indication for tracheostomy (pneumonia vs. COPD) � Difficulty of intubation (easy vs. difficult) � Comorbidities (no significant comorbidities vs. end-stage renal disease) � Age (45 yo vs. 75 yo) Stelfox et al. 2009 [27]. � Ability to tolerate tube capping (24h vs. 72h) � Oxygenation (SaO2 95% with FiO2 0,3 vs. 0,5) � Cough effectiveness (strong vs. weak) � RR (18 bpm vs. 28 bpm) � Secretions (scan thin vs. moderate thick) � Swallowing (enteral nutrition via gastric tube and nothing p.o. vs. enteral nutrition via gastric tube and jelly and pudding) � Level of consciousness (alert vs. drowsy but arousable) � Indication for tracheostomy (pneumonia vs. COPD) � Difficulty of intubation (easy vs. difficult) � Comorbidities (no significant comorbidities vs. end-stage renal disease) � Age (45 yo vs. 74 yo) Budweiser et al. 2011 [23]. � Ability to tolerate tube capping > 24h/48h � Serum creatinine � Oxygenation � Duration of former intubation and tracheostomy � Age O’Connor et al. 2009 [24]. � Shorter permanence at acute facility � Ability to tolerate tube capping � Cough effectiveness Marchese et al. 2010 [28]. � Stability or respiratory conditions (dyspnea, RR, SaO2, PaO2, PaCO2, pH) � Effective cough � Indication for tracheostomy (underlying disease) � Effective swallowing � No or mild hypercapnia (PaCO2 level in stable state) Choate et al. 2008 [21]. � Cough effectiveness Leung et al. 2003 [22]. � Indication for tracheostomy (unstable or obstructed airways vs. others) Tobin et al. 2008 [25]. � Ability to tolerate tube capping > 24h � Cough effectiveness (no need of suctioning) � Setting of cure (intensivist-led tracheostomy team vs. others) PCF = Peack Cough Flow; VC = Vital Capacity; MEP = Maximal Expiratory Pressure; PaCO2 = Partial pressure of carbon dioxide in the blood; RR = Respiratory Rate; SaO2 = ratio of oxyhaemoglobin to the total concentration of haemoglobin present in the blood; FiO2 = fraction of inspired oxygen concentration. Santus et al. BMC Pulmonary Medicine 2014, 14:201 Page 6 of 8 http://www.biomedcentral.com/1471-2466/14/201 factors that would indicate a low likelihood of early conditions before and after closure of tracheostomy tube, decannulation. The indications for tracheostomy were effective cough, underlying diseases and ability to swallow. prolonged mechanical ventilation, tracheobronchial Moreover, laryngo-tracheoscopy has been considered in toilet or risk of aspiration and unstable or obstructed order to exclude contraindications to decannulation [28]. airways. They concluded that the only indicator for early decannulation is tracheostomy insertion and Discussion other patient related variables are not significant. [22]. A new proposal The usefulness of a tracheostomy retainer (TR) and The parameters considered in literature and also re- the predictors of successful decannulation were also ported in Table 1 are worth of deeper analysis. evaluated by Budweiser and his team. In percutaneously First of all, we identified two different types of param- tracheostomized patients with prolonged weaning, the eters: Quantitative parameters: objective, described by use of a TR seems to facilitate the weaning process. Fur- means of numerical values and provided with cut-off thermore, also the duration of spontaneous breathing (such as, ability to tolerate tube capping > 24h); Semi- prior to decannulation, age and oxygenation predict the quantitative parameters: objective, but however not be risk of recannulation [23]. easily described by mean of a numerical value (as, for O’Connor et al. retrospectively examined the process instance, swallowing function). Our purpose is to sug- of decannulation following tracheostomy in patients gest a clinical score including all parameters – both transferred to a long-term care hospital for weaning quantitative and semiquantitative –considered by available from prolonged mechanical ventilation. Decannulation scientific literature in order to evaluate the feasibility of was successful in 35% of patients and main factors taken tracheostomy tube removal. in account were ability to tolerate tube capping and In our idea, objective quantitative parameters shall be cough effectiveness. Patients who failed decannulation taken into greater account in decisional process. Other had an earlier placed tracheostomy tube and had also a parameters should instead be evaluated, when it is pos- shorter permanence at the acute facility compared with sible, according to a binary system (e.g. dysphagia yes/no). patients who were decannulated [24]. Our intent is to give a high score (e.g. 20 pts) to patients Similar results were described by Tobin and his team; fitting quantitative objective parameters. When such re- the authors also demonstrated that an intensivist-led quirements are missing, the score of each single parameter tracheostomy team is associated with quicker decannula- will be 0 pts. This choice is to underline the fundamental tion time and a shorter hospitalization [25]. importance we assign to those parameters, being the Stelfox et al. performed a cross-sectional survey on most frequent measurable ones taken in consideration 200 physicians and respiratory therapists with expert- by current scientific literature; in lack of those parame- ise in the management of tracheostomized patients to ters, scientific evidence seems to predict a negative characterize state-of-art about tracheostomy decan- outcome for decannulation. nulation practice and to define their opinions about In the second place, our clinical score must comprehend factors influencing these practices. Clinicians rated pa- as well semi-quantitative objective clinical parameters tient level of consciousness, ability to tolerate tracheos- (e.g. dysphagia and secretions) and subjective parame- tomy tube capping, cough effectiveness, and secretions ters (e.g. clinician experience). In our systematic review as the most important factors in the decision to decan- the utility of bronchoscopy before and during decannu- nulateapatient.Decannulation failurewas definedas lation appears as an important tool that should be con- the need to reinsert an artificial airway within 48 hours sidered in clinical practice. (45% of respondents) to 96 hours (20% of respondents) Most of these parameters respond to the need for a of tracheostomy removal. In clinical scenarios, clini- straightforward and binary evaluation (yes/no = 5pts/ cians who worked in chronic care facilities (30%) were 0pts); a smaller numerical value has been assigned to less likely to recommend decannulation than clinicians them in order to lower their weight on the overall score who worked in rehabilitation (53%) or acute care (55%) versus objective parameters. facilities (p = 0.015). With reference to the two different types of parameters In a similar North American survey by same authors, taken into account, we suggest to name the proposed ability to tolerate capping, secretions, cough effective- score “QsQ score”,that is “Quantitative semi Quantitative ness, and level of consciousness as the most important score”. In Table 2 such approach is summarized. factors in the decannulation decision [26,27]. Another We underline that the twenty point and five points national one-year survey evaluating clinical criteria and threshold has been chosen a priori, without previously systems for performing decannulation was conducted by performing an experimental validation; our aim is to Marchese et al. in this population main clinical criteria highlight the role of objective parameters taken in con- chosen for decannulation are: stability of respiratory sideration by most of the studies. Santus et al. BMC Pulmonary Medicine 2014, 14:201 Page 7 of 8 http://www.biomedcentral.com/1471-2466/14/201 Table 2 QsQ score: Quantitative and semiquantitative parameters Parameter Cut-off Missing Fitting Objective quantitative parameters – Main criteria Cough MEP ≥ 40 cmH2O 0 20 PCF > 160 L/min Tube capping ≥24 h 0 20 Semi-quantitative parameters – Minor criteria Level of counsciousness Drowsy/Alert 0 5 Secretion (thick vs. thin) 0 5 Swallowing Impaired/Normal 0 5 Capnia paCO2 < 60 mmHg 0 5 Patent airway Tracheal stenosis < 50% seen by bronchoscopy 0 5 Age <70 0 5 Indication for tracheostomy Others/Pneumonia or airway obstruction 0 5 Comorbidities Present (≥1) or None 0 5 This hypothetical score have the objective quantitative parameters, named ‘major criteria’ , and semi-quantitative or subjective parameters, named ‘minor criteria’. For the proposed interpretation and clinical application see the text in Discussion section. MEP = Maximal Expiratory Pressure; PaCO2 = partial pressure of carbon dioxide in the blood; RR = Respiratory Rate; SaO2 = ratio of oxyhemoglobin to the total concentration of hemoglobin present in the blood; FiO2 = fraction of inspired oxygen concentration. Score: hypotheses and interpretations Abbreviations PCF: Peak Cough Flow; VC: Vital Capacity; MEP: Maximal Expiratory Pressure; We suggest an hypothetical score, that requires discus- PaCO2: partial pressure of carbon dioxide in the blood; RR: Respiratory Rate; sion and a prospective validation study. For a practical SaO2: Ratio of oxyhemoglobin to the total concentration of hemoglobin in usewewillnameobjective quantitative parameters blood; FiO2: Fraction of inspired oxygen concentration; QsQ: Quantitative and semiquantitative score. ‘major criteria’, and semi-quantitative or subjective parameters ‘minor criteria’. If all main criteria are sat- Competing interests isfied, regardless of minor criteria, decannulation with The authors declare that they have no competing interests. high probability of positive outcome can be assumed. Authors’ contributions If only one of the two major criteria is satisfied, a PS conceived the study, was responsible for data collection, performed statistical careful evaluation of minor criteria should be required, analysis and drafted the manuscript. AG and DR performed statistical analysis and drafted the manuscript. All authors participated in the study design, data assuming a good probability of positive outcome when collection, read, supervised and approved the final manuscript for publication. the majority of minor criteria is satisfied. The same probability category reported above could be applied if, Acknowledgements The authors thank the Respiratory Physiotherapist Team of Rehabilitation in lack of major criteria, all of minor criteria are satis- Unit – Fondazione Salvatore Maugeri, IRCCS, Milano (Giuseppe Gaudiello, fied. Finally, if none of the major criteria and less than Rossana Ciraudo, Goffredo Alfieri and Grazia Lacala) for their support on three minor criteria are satisfied, a low probability of conceiving the study and giving suggestions about tracheostomy clinical management. positive outcome can be assumed. Author details Department of Life Science, Università degli Studi di Milano. Pulmonary Rehabilitation Unit, Fondazione Salvatore Maugeri, Istituto Scientifico di Conclusions Milano-IRCCS, Via Camaldoli, 64-20138 Milan, Italy. Department of Tracheostomy decannulation represents one of the Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS most important problems in the clinical and home care Fondazione Cà Granda Ospedale Maggiore Policlinico, Via F. Sforza, 33-20122 Milan, Italy. Department of Biomedical Sciences for Health, Università degli management of patients which undergo tracheostomy. Studi di Milano. Respiratory Unit, Policlinico San Donato IRCCS, Piazza E. No validated and specific pathway is followed when per- Malan, 1-20097 San Donato Milanese, Italy. Unit of Maxillo-Facial Surgery. forming a decannulation and this process is left to the Ospedale San Paolo, Milano, Università degli Studi di Milano, Milano, Via A. di Rudinì, 8-20141 Milan, Italy. Pulmonary Rehabilitation Unit, Fondazione clinical expertise. Considering this, we hypothesized a Salvatore Maugeri, Via Mazzini, 129- 26088 Lumezzane, Brescia, Italy. Alma clinical score, named QsQ, to help clinicians in choos- Mater University Department of Clinical, Integrated and Experimental ing decannulation timing. We underline that this score Medicine (DIMAS), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Via Albertoni, 10-40138 Bologna, Italy. Dipartimento di Scienze has never been validated in clinical real life and there- della Salute, Università degli Studi di Milano. Pulmonary Rehabilitation Unit, fore we suggest evaluating QsQ in further clinical trials Fondazione Salvatore Maugeri, Scientific Institute of Milan-IRCCS, Via Camal- to validate it. doli, 64-20138 Milan, Italy. Santus et al. BMC Pulmonary Medicine 2014, 14:201 Page 8 of 8 http://www.biomedcentral.com/1471-2466/14/201 Received: 2 July 2014 Accepted: 11 December 2014 25. Tobin AE, Santamaria JD: An intensivist-led tracheostomy review team Published: 15 December 2014 is associated with shorter decannulation time and lenght of stay: a prospective cohort study. Crit Care 2008, 12:R48. 26. Stelfox HT, Crimi C, Berra L, Noto A, Schmidt U, Bigatello LM, Hess D: References Determinants of tracheostomy decannulation: an international survey. 1. Durbin CG Jr: Tracheostomy: why, when, and how? Respir Care 2010, Crit Care 2008, 12:R26. 55:1056–1068. 27. Stelfox HT, Hess DR, Schmidt UH: A North American survey of respiratory 2. MacIntyre NR, Epstein SK, Carson S, Scheinhorn D, Christopher K, Muldoon S: therapist and physician tracheostomy decannulation practices. Respir Care Management of patients requiring prolonged mechanical ventilation: 2009, 54:1658–1664. report of a NAMDRC consensus conference. Chest 2005, 128:3937-3954. 28. Marchese S, Corrado A, Scala R, Corrao S, Ambrosino N: Tracheostomy in 3. Terragni PP, Antonelli M, Fumagalli R: Early vs late tracheotomy for patients with long-term mechanical ventilation: a survey. Respir Med prevention of pneumonia in mechanically ventilated adult ICU patients: 2010, 104:749–753. a randomized controlled trial. JAMA 2010, 303:1483–1489. 4. Cavo J, Ogura JH, Sessions DG, Nelson JR: Flow resistance in tracheotomy doi:10.1186/1471-2466-14-201 tubes. Ann Otol Rhinol Laryngol 1973, 82:827–830. Cite this article as: Santus et al.: A systematic review on tracheostomy 5. Heffner JE: Tracheotomy application and timing. Clin Chest Med 2003, decannulation: a proposal of a quantitative semiquantitative clinical 24:389–398. score. BMC Pulmonary Medicine 2014 14:201. 6. Wilson AM, Gray DM, Thomas JG: Increases in endotracheal tube resistance are unpredictable relative to duration of intubation. Chest 2009, 136:1006–1013. 7. Epstein SK, Ciubotaru RL: Influence of gender and endotracheal tube size on preextubation breathing pattern. Am J Respir Crit Care Med 1996, 154:1647–1652. 8. Mehta S, Heffer MJ, Maham N, Nelson DL, Klinger JR, Levy MM: Impact of endotracheal tube size on preextubation respiratory variables. J Crit Care 2010, 25:483–488. 9. Valentini I, Tonveronachi E, Gregoretti C, Mega C, Fasano L, Pisani L, Nava S: Different tracheotomy tube diameters influence diaphragmatic effort and indices of weanability in difficult to wean patients. Respir Care 2012, 57:2012–2018. 10. Criner G, Make B, Celli B: Respiratory muscle dysfunction secondary to chronic tracheostomy tube placement. Chest 1987, 91:139–141. 11. Epstein SK: Anatomy and physiology of tracheostomy. Respir Care 2005, 50:476–482. 12. Chadda K, Louis B, Benaissa L: Physiological effects of decannulation in tracheostomized patients. Intensive Care Med 2002, 28:1761–1767. 13. Dellweg D, Barchfeld T, Haidl P, Appelhans P, Kohler D: Tracheostomy decannulation: implication on respiratory mechanics. Head Neck 2007, 29:1121–1127. 14. Scheinhorn DJ, Chao DC, Hassenpflug MS, Gracey DR: Post-ICU weaning from mechanical ventilation: the role of long-term facilities. Chest 2001, 120:482S–484S. 15. Christopher KL: Tracheostomy decannulation. Respir Care 2005, 50:538–541. 16. Clini E, Vitacca M, Bianchi L, Porta R, Ambrosino N: Long term tracheostomy in severe COPD patients weaned from mechanical ventilation. Respir Care 1999, 44:415–420. 17. Franke KJ, Nilius G, Morgenstern S: Removal of the tracheal tube after prolonged mechanical ventilation: assessment of risk by oscillatory impedance. Respiration 2011, 81:118–123. 18. Gao C, Zhou L, Wei C, Hoffman MR, Li C, Jiang JJ: The evaluation of physiologic decannulation readiness according to upper airway resistance measurement. Otolaryngol Head Neck Surg 2008, 139:535–540. 19. Bach JR, Saporito LR: Indications and criteria for decannulation and transition from invasive to noninvasive long-term ventilatory support. Respir Care 1994, 39:515–528. 20. Ceriana P, Carlucci A, Navalesi P, Rampulla C, Delmastro M, Piaggi G, De Mattia E, Nava S: Weaning from tracheotomy in long-term mechanically ventilated patients: feasibility of a decisional flowchart and clinical Submit your next manuscript to BioMed Central outcome. Intensive Care Med 2003, 29:845–848. 21. Choate K, Barbetti J, Currey J: Tracheostomy decannulation failure rate and take full advantage of: following critical illness: a prospective descriptive study. Aust Crit Care 2009, 22:8–15. • Convenient online submission 22. Leung R, MacGregor L, Campbell D, Berkowitz RG: Decannulation and • Thorough peer review survival following tracheostomy in an intensive care unit. Ann Otol Rhinol Laryngol 2003, 112:853–858. • No space constraints or color figure charges 23. Budweiser S, Baur T, Jorres RA, Kollert F, Pfeifer M, Heinemann F: Predictors • Immediate publication on acceptance of successful decannulation using tracheostomy retainer in patients with • Inclusion in PubMed, CAS, Scopus and Google Scholar prolonged weaning and persisting respiratory failure. Respiration 2012, 84:469–476. • Research which is freely available for redistribution 24. O'Connor HH, Kirby KJ, Terrin N, Hill NS, White AC: Decannulation following tracheostomy for prolonged mechanical ventilation. J Intensive Care Med Submit your manuscript at 2009, 24:187–194. www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Pulmonary Medicine Springer Journals

A systematic review on tracheostomy decannulation: a proposal of a quantitative semiquantitative clinical score

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Springer Journals
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Copyright © 2014 by Santus et al.; licensee BioMed Central.
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Medicine & Public Health; Pneumology/Respiratory System; Internal Medicine; Intensive / Critical Care Medicine
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1471-2466
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10.1186/1471-2466-14-201
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25510483
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Abstract

Background: Tracheostomy is one of the most common surgical procedures performed in critical care patient management; more specifically, ventilation through tracheal cannula allows removal of the endotracheal tube (ETT). Available literature about tracheostomy care and decannulation is mainly represented by expert opinions and no certain knowledge arises from it. Methods: In lack of statistical requirements, a systematic and critical review of literature regarding tracheostomy tube removal was performed in order to assess predictor factors of successful decannulation and to propose a predictive score. We combined 3 terms and a literature search has been performed using the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE via Ovid SP; EMBASE via Ovid SP; EBSCO. Abstracts were independently reviewed: for those studies fitting the inclusion criteria on the basis of the title and abstract, full-text was achieved. We included studies published from January 1, 1995 until March 31, 2014; any sort of review and expert opinion has been excluded by our survey. English language restriction was applied. Ten studies have been considered eligible for inclusion in the review and were analysed further. Results: Cough effectiveness and ability to tolerate tracheostomy tube capping are the most considered parameters in clinical practice; other parameters are taken into different consideration by many authors in order to proceed to decannulation. Among them, we distinguished between objective quantitative parameters and semi-quantitative parameters more dependent from clinician’s opinion. We then built a score (the Quantitative semi Quantitative score: QsQ score) based on selected parameters coming from literature. Conclusions: On our knowledge, this review provides the first proposal of decannulation score system based on current literature that is hypothetical and requires to be validated in daily practice. The key point of our proposal is to give a higher value to the objective parameters coming from literature compared to less quantifiable clinical ones. Keywords: Tracheostomy, Decannulation, Predictive score, Clinical score, Removal tube * Correspondence: pierachille.santus@unimi.it Department of Life Science, Università degli Studi di Milano. Pulmonary Rehabilitation Unit, Fondazione Salvatore Maugeri, Istituto Scientifico di Milano-IRCCS, Via Camaldoli, 64-20138 Milan, Italy Dipartimento di Scienze della Salute, Università degli Studi di Milano. Pulmonary Rehabilitation Unit, Fondazione Salvatore Maugeri, Scientific Institute of Milan-IRCCS, Via Camaldoli, 64-20138 Milan, Italy Full list of author information is available at the end of the article © 2014 Santus et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Santus et al. BMC Pulmonary Medicine 2014, 14:201 Page 2 of 8 http://www.biomedcentral.com/1471-2466/14/201 Background They recorded diaphragm pressure- time product per Tracheostomy is one of the most frequent procedures min (PTPdi/min), tension-time index of the diaphragm applicated in intensive care unit (ICU) patients: about (TTdi), and the ratio of respiratory rate to tidal volume 10% of patients requiring more than 3 days of mechanical (f/VT) for 2 different tracheotomy tube, with an inner ventilation are expected to undergo tracheostomy [1]. Fur- diameters 8 mm and 6.5 mm. The use of a smaller thermore, in the last years the development of less invasive diameter resulted in an increase of diaphragmatic effort, surgical techniques allowed tracheostomy to be safely decrease of VT and an increase of intrinsic PEEP. In performed at patient’s bedside and at present this conclusion, the authors assessed that, especially in techniques are growing more and more because of the hard to wean tracheostomized patients, the use of a increased number of patients requiring difficult or tracheostomy tube of small size can lead to alterations prolonged weaning from endotracheal tube (ETT), of some weanibility parameters, otherwise normal with due to aging and severe comorbidities [2]. Moreover, greater size tubes [9]. possibility of tracheotomy for prevention and better In addition, a single physiologic study by Criner et al. clinical management of ventilator-associated pneumo- reported that airways resistance and work of breathing nia was recently evaluated [3]. resulted higher with the tube in place, during As a result, the correct management of tracheosto- spontaneous breathing, when compared to breathing mized patients and defined procedures for decannulation after decannulation [10]. grew into a more important clinical issue. Humidification and heating - Normally upper airways play a fundamental function of heating and humidification Physiological modifications after tracheostomy of inspired air. In tracheostomized patients, the air In the following chapter we will discuss the main physio- bypasses the nasopharyngeal cavity and enters directly logical implications for breathing after tracheostomy. In the tracheobronchial tree; a system of artificial scientific literature, authors usually compare tracheos- humidification is needed. In the absence of adequate tomy to endotracheal intubation. In our purpose, we humidification, the epithelium of the trachea is involved intended to compare changes during tracheostomy to in a gradual inflammatory process resulting in squamous spontaneous breathing and the most relevant topics are: metaplasia and, consequentially , impairment of ciliary function and increased risk of respiratory infection [11]. Airflow resistance - Resistance of anatomically normal airways is firstly conditioned by upper airways (up to Physiological modifications after decannulation 80% during nose breathing and 50% during mouth While scientific literature has better investigated trache- breathing). Therefore, tracheostomy should virtually otomy effects on respiratory physiology, data about reduce flow resistance bypassing the respiratory upper respiratory mechanisms after decannulation are almost airways. Actually, data from scientific literature state totally lacking. Chadda et al. studied respiratory parame- the contrary, as the presence of tracheotomy tube, ters in nine neuromuscular patients after that the during spontaneous breathing, reduces airway radius upper airways were confirmed to be free of obstruc- leading to increased flow resistance and, of course, tions by fiberoptic bronchoscopy. In this experience, increased work of breathing (WOB) [4,5]. decannulation resulted in an increase of the tidal vol- This is according to Poiseuille equation, as the resistance ume and carbon dioxide partial pressure due to an in- to gas flow through a tube varies inversely with the crease of the dead space and work of breathing [12]. internal diameter of the tube (in particular, to the 4th However, the argument is still controversial. In a study power of the radius of the tube when flow is laminar). of few years ago, Dellweg et al. did not find a significant Secondly, secretions (stimulated even more by the difference in WOB in favour of tracheostomy when presence of the tube) still play an important role: compared to mouth breathing. Decannulation increases adhering to the inner lumen of the tube, they can lead or decreases airways resistance depending from case to to significant luminal narrowing, according to Wilson case and, in particular, from the morphology of the et al. [6], 15% of tubes are shrunk three sizes; other upper airways [13]. experiences from literature ultimately come to the To our knowledge, there are only few papers on physio- same conclusions [7,8]. logical modifications after decannulation; experts have It has been supposed that the inner diameter of a differing opinion on this topic and so further research smaller tracheostomy tube may induce increased flow and trials are desirable. resistance and WOB, if compared to spontaneous breathing. The first data from in vivo studies appeared Weaning from tracheostomy – problem generation recently by Valentini et al. trying to define the effect of Place a tracheostomy enables discharging the patient smaller tracheostomy tube sizes on diaphragm effort. from ICU to a rehabilitation unit [14]. However, despite Santus et al. BMC Pulmonary Medicine 2014, 14:201 Page 3 of 8 http://www.biomedcentral.com/1471-2466/14/201 decannulation is not risk-free, there is evidence of benefits applied. A flow chart diagram of the search strategy and for tracheostomy tube removal. The tracheostomy tube study selection is provided in Figure 1. may cause inflammation and stenosis or excessive cough and may impair swallowing by preventing the physio- Results logical trachea’s elevation against the epiglottis in order to The database search yielded 248 citations published prevent aspiration of food or secretions [15]. between January 1995 and September 2012 (with dupli- Furthermore, upper airways are excluded from breath- cates removed). 226 articles were excluded on the title ing. At last, in most cases tracheostomized patients are and abstract. The full-text of potentially relevant arti- unable to speak; aphonia worsens patient’s quality of life cles was achieved for further evaluation. The final num- and slows down the recovery process, often leading to ber of papers taken into account is 10. Figure 1 shows anxiety and depression. the flow-chart explaining how many citations were A number of clinically important early and late compli- excluded from the analysis and for what reasons. After cations have been evaluated, including granulation tissue, analyzing the selected literature, we decided for a tracheal stenosis, tracheomalacia, tracheo-esophageal systematic and critical revision of literature on decan- fistula, ventilator-associated pneumonia and aspiration. nulation, due to lack of statistical requirements for a According to literature, chronic tracheostomy in severe meta-analysis. Specifically, in Table 1, primary and – Chronic Obstructive Pulmonary Disease (COPD) patients when present – secondary outcomes proposed by each is associated with a higher frequency of exacerbations author have been evaluated for each study. requiring antibiotic treatment [16]. The clinical relevance Studies targeting different outcomes from the ones of these complications may lead to death and most of predictors in decannulation were excluded, although patients weaned from mechanical ventilation through they considered tracheostomy tube removal of enrolled tracheostomy should undergo early decannulation. patients as a step. Surveys were also included. Context- As it is hard to schematize the approach for decannu- ually, papers exploring new and/or experimental tech- lation, we decided to perform the following revision of niques for the assessment of risk in trachestomy tube literature, with the aim of supporting or retracting current removal were excluded [17,18]. Such exclusion was statements. Which are then current issues in managing operated because the proposed approaches - such as tracheostomy? How does evidence-based medicine handle oscillometry impedance measurement or upper airway the process of weaning from tracheostomy tube? Now- resistance measurement – are difficult to apply in adays clinical habit derives from physiopathological know- every setting and are not easily reproducible in differ- ledge, from personal experience and from professional ent contexts. Nevertheless in this context innovative practice: there is limited evidence in literature regarding techniques, such those before reported, could probably be specifically decannulation processes. Little is known about useful to improve decannulation procedure in future. how clinicians decide to decannulate patients. Which are First of all, it must be noted that literature is mainly the criteria for choice? made of expert opinions and international surveys; the few reported clinical trials are mainly descriptive (retro- Methods spective and prospective); because of technical and ethical Criteria for considering studies for this systematic review problems, Randomized Clinical Trials (RCTs) are totally A literature search has been performed using the lacking. Cochrane Central Register of Controlled Trials (CENTRAL); It can be noticed from the data that the population MEDLINE via Ovid SP; EMBASE via Ovid SP; EBSCO. taken into consideration is heterogeneous for age, Research included, but was not limited to, 3 keywords comorbidities and causes of tracheostomy; it must also (tracheostomy, decannulation, weaning). Abstracts were be emphasized that studies take in consideration both independently reviewed: for those studies fitting the acute/reversible pathologies and chronic conditions at inclusion criteria on the basis of the title and abstract, different levels of severity (for instance, Budweiser et al. full-text was achieved. Reference lists were also exam- [2] considers prolonged weaning patients with persistent ined for any additional relevant studies not identified respiratory failure). Secondly, recommendations differ through the former search. We included studies pub- between clinicians who work in acute facilities and lished from January 1, 1995 until March 31, 2014. Such those who work at chronic wards and between respira- studies examined a population more than 18 years old, tory therapists and physicians. who received tracheostomy for any clinical reason, In our analysis cough effectiveness and ability to toler- excluded neuromuscular diseases, and hospitalized in ate tracheostomy tube capping are the most frequent any ward (ICU, rehabilitation wards, etc.); any sort of criteria used by clinicians in order to predict successful review and expert opinion has been excluded by our decannulation. In others studies a different importance survey. Including English language restriction was is also given to parameters such as oxygenation and Santus et al. BMC Pulmonary Medicine 2014, 14:201 Page 4 of 8 http://www.biomedcentral.com/1471-2466/14/201 Figure 1 Flow diagram of the search process. The number of references initially identified through each database was 248. References were usually excluded for more than one reason by a two consecutive steps. capnia, level of consciousness and neurological state, they were able to remove tracheotomy cannula in almost age, swallowing, quantity and quality of secretions, dur- 80% of patients with spontaneous breathing without major ation of mechanical ventilation, stability of haematic clinical complications. Principal parameters considered gases (PaO2 and PaCO2), aetiology of respiratory failure were patient's ability to remove secretions, swallowing and comorbidities. function, absence of psychiatric diseases, possibility of Bach et al. experienced in a population of patients reaching spontaneous breathing, and amount of respira- with respiratory failure due to different aetiologies some tory space [20]. parameters that can predict the success of the tracheos- Choate K and Barbetti J conducted a prospective tomy decannulation. The mostimportantpredictive fac- descriptive study of consecutive patients who received tor is PCF (Peak Cough Flow), in particular at least 160 a tracheostomy in ICU. Of the 823 decisions for decan- L/min; other important factors are also VC (Vital Cap- nulation, there were 40 episodes of failed decannula- acity) and age [19]. Ceriana e al. proposed a prospective tion, representing a failure rate of 4.8%. The main study to decide whether to remove tracheotomy in long- reason for decannulation failure was sputum retention term mechanically ventilated patients with respiratory and ineffective cough [21]. failure from different causes. By the use of a decisional Lastly, in a retrospective study on patients requiring flowchart based on clinical and physiological parameters, tracheostomy in ICU, Leung and his team identified risk Santus et al. BMC Pulmonary Medicine 2014, 14:201 Page 5 of 8 http://www.biomedcentral.com/1471-2466/14/201 Table 1 Primary and secondary outcomes evaluated for each study Authors Primary outcomes Secondary outcomes Bach et al. 1994 [19]. � PCF ≥ 160 L/min � VC � Age Ceriana et al. 2003 [20]. � Clinical stability (no active infection and hemodynamic stability) � Absence of psychiatric disorders � Effective cough (MEP ≥ 40 cmH2O) � PaCO2 < 60mmHg � Adequate swallowing (evaluated by gag or blue dye test) � Absence of tracheal stenosis (evaluated by endoscopy) Stelfox et al. 2008 [26]. � Ability to tolerate tube capping (24h vs. 72h) � Oxygenation (SaO2 95% with FiO2 0,3 vs. 0,5) � Cough effectiveness (strong vs. weak) � RR (18 bpm vs. 28 bpm) � Secretions (scan thin vs. moderate thick) � Swallowing (enteral nutrition via gastric tube and nothing p.o. vs. enteral nutrition via gastric tube and jelly and pudding) � Level of consciousness (alert vs. drowsy but arousable) � Indication for tracheostomy (pneumonia vs. COPD) � Difficulty of intubation (easy vs. difficult) � Comorbidities (no significant comorbidities vs. end-stage renal disease) � Age (45 yo vs. 75 yo) Stelfox et al. 2009 [27]. � Ability to tolerate tube capping (24h vs. 72h) � Oxygenation (SaO2 95% with FiO2 0,3 vs. 0,5) � Cough effectiveness (strong vs. weak) � RR (18 bpm vs. 28 bpm) � Secretions (scan thin vs. moderate thick) � Swallowing (enteral nutrition via gastric tube and nothing p.o. vs. enteral nutrition via gastric tube and jelly and pudding) � Level of consciousness (alert vs. drowsy but arousable) � Indication for tracheostomy (pneumonia vs. COPD) � Difficulty of intubation (easy vs. difficult) � Comorbidities (no significant comorbidities vs. end-stage renal disease) � Age (45 yo vs. 74 yo) Budweiser et al. 2011 [23]. � Ability to tolerate tube capping > 24h/48h � Serum creatinine � Oxygenation � Duration of former intubation and tracheostomy � Age O’Connor et al. 2009 [24]. � Shorter permanence at acute facility � Ability to tolerate tube capping � Cough effectiveness Marchese et al. 2010 [28]. � Stability or respiratory conditions (dyspnea, RR, SaO2, PaO2, PaCO2, pH) � Effective cough � Indication for tracheostomy (underlying disease) � Effective swallowing � No or mild hypercapnia (PaCO2 level in stable state) Choate et al. 2008 [21]. � Cough effectiveness Leung et al. 2003 [22]. � Indication for tracheostomy (unstable or obstructed airways vs. others) Tobin et al. 2008 [25]. � Ability to tolerate tube capping > 24h � Cough effectiveness (no need of suctioning) � Setting of cure (intensivist-led tracheostomy team vs. others) PCF = Peack Cough Flow; VC = Vital Capacity; MEP = Maximal Expiratory Pressure; PaCO2 = Partial pressure of carbon dioxide in the blood; RR = Respiratory Rate; SaO2 = ratio of oxyhaemoglobin to the total concentration of haemoglobin present in the blood; FiO2 = fraction of inspired oxygen concentration. Santus et al. BMC Pulmonary Medicine 2014, 14:201 Page 6 of 8 http://www.biomedcentral.com/1471-2466/14/201 factors that would indicate a low likelihood of early conditions before and after closure of tracheostomy tube, decannulation. The indications for tracheostomy were effective cough, underlying diseases and ability to swallow. prolonged mechanical ventilation, tracheobronchial Moreover, laryngo-tracheoscopy has been considered in toilet or risk of aspiration and unstable or obstructed order to exclude contraindications to decannulation [28]. airways. They concluded that the only indicator for early decannulation is tracheostomy insertion and Discussion other patient related variables are not significant. [22]. A new proposal The usefulness of a tracheostomy retainer (TR) and The parameters considered in literature and also re- the predictors of successful decannulation were also ported in Table 1 are worth of deeper analysis. evaluated by Budweiser and his team. In percutaneously First of all, we identified two different types of param- tracheostomized patients with prolonged weaning, the eters: Quantitative parameters: objective, described by use of a TR seems to facilitate the weaning process. Fur- means of numerical values and provided with cut-off thermore, also the duration of spontaneous breathing (such as, ability to tolerate tube capping > 24h); Semi- prior to decannulation, age and oxygenation predict the quantitative parameters: objective, but however not be risk of recannulation [23]. easily described by mean of a numerical value (as, for O’Connor et al. retrospectively examined the process instance, swallowing function). Our purpose is to sug- of decannulation following tracheostomy in patients gest a clinical score including all parameters – both transferred to a long-term care hospital for weaning quantitative and semiquantitative –considered by available from prolonged mechanical ventilation. Decannulation scientific literature in order to evaluate the feasibility of was successful in 35% of patients and main factors taken tracheostomy tube removal. in account were ability to tolerate tube capping and In our idea, objective quantitative parameters shall be cough effectiveness. Patients who failed decannulation taken into greater account in decisional process. Other had an earlier placed tracheostomy tube and had also a parameters should instead be evaluated, when it is pos- shorter permanence at the acute facility compared with sible, according to a binary system (e.g. dysphagia yes/no). patients who were decannulated [24]. Our intent is to give a high score (e.g. 20 pts) to patients Similar results were described by Tobin and his team; fitting quantitative objective parameters. When such re- the authors also demonstrated that an intensivist-led quirements are missing, the score of each single parameter tracheostomy team is associated with quicker decannula- will be 0 pts. This choice is to underline the fundamental tion time and a shorter hospitalization [25]. importance we assign to those parameters, being the Stelfox et al. performed a cross-sectional survey on most frequent measurable ones taken in consideration 200 physicians and respiratory therapists with expert- by current scientific literature; in lack of those parame- ise in the management of tracheostomized patients to ters, scientific evidence seems to predict a negative characterize state-of-art about tracheostomy decan- outcome for decannulation. nulation practice and to define their opinions about In the second place, our clinical score must comprehend factors influencing these practices. Clinicians rated pa- as well semi-quantitative objective clinical parameters tient level of consciousness, ability to tolerate tracheos- (e.g. dysphagia and secretions) and subjective parame- tomy tube capping, cough effectiveness, and secretions ters (e.g. clinician experience). In our systematic review as the most important factors in the decision to decan- the utility of bronchoscopy before and during decannu- nulateapatient.Decannulation failurewas definedas lation appears as an important tool that should be con- the need to reinsert an artificial airway within 48 hours sidered in clinical practice. (45% of respondents) to 96 hours (20% of respondents) Most of these parameters respond to the need for a of tracheostomy removal. In clinical scenarios, clini- straightforward and binary evaluation (yes/no = 5pts/ cians who worked in chronic care facilities (30%) were 0pts); a smaller numerical value has been assigned to less likely to recommend decannulation than clinicians them in order to lower their weight on the overall score who worked in rehabilitation (53%) or acute care (55%) versus objective parameters. facilities (p = 0.015). With reference to the two different types of parameters In a similar North American survey by same authors, taken into account, we suggest to name the proposed ability to tolerate capping, secretions, cough effective- score “QsQ score”,that is “Quantitative semi Quantitative ness, and level of consciousness as the most important score”. In Table 2 such approach is summarized. factors in the decannulation decision [26,27]. Another We underline that the twenty point and five points national one-year survey evaluating clinical criteria and threshold has been chosen a priori, without previously systems for performing decannulation was conducted by performing an experimental validation; our aim is to Marchese et al. in this population main clinical criteria highlight the role of objective parameters taken in con- chosen for decannulation are: stability of respiratory sideration by most of the studies. Santus et al. BMC Pulmonary Medicine 2014, 14:201 Page 7 of 8 http://www.biomedcentral.com/1471-2466/14/201 Table 2 QsQ score: Quantitative and semiquantitative parameters Parameter Cut-off Missing Fitting Objective quantitative parameters – Main criteria Cough MEP ≥ 40 cmH2O 0 20 PCF > 160 L/min Tube capping ≥24 h 0 20 Semi-quantitative parameters – Minor criteria Level of counsciousness Drowsy/Alert 0 5 Secretion (thick vs. thin) 0 5 Swallowing Impaired/Normal 0 5 Capnia paCO2 < 60 mmHg 0 5 Patent airway Tracheal stenosis < 50% seen by bronchoscopy 0 5 Age <70 0 5 Indication for tracheostomy Others/Pneumonia or airway obstruction 0 5 Comorbidities Present (≥1) or None 0 5 This hypothetical score have the objective quantitative parameters, named ‘major criteria’ , and semi-quantitative or subjective parameters, named ‘minor criteria’. For the proposed interpretation and clinical application see the text in Discussion section. MEP = Maximal Expiratory Pressure; PaCO2 = partial pressure of carbon dioxide in the blood; RR = Respiratory Rate; SaO2 = ratio of oxyhemoglobin to the total concentration of hemoglobin present in the blood; FiO2 = fraction of inspired oxygen concentration. Score: hypotheses and interpretations Abbreviations PCF: Peak Cough Flow; VC: Vital Capacity; MEP: Maximal Expiratory Pressure; We suggest an hypothetical score, that requires discus- PaCO2: partial pressure of carbon dioxide in the blood; RR: Respiratory Rate; sion and a prospective validation study. For a practical SaO2: Ratio of oxyhemoglobin to the total concentration of hemoglobin in usewewillnameobjective quantitative parameters blood; FiO2: Fraction of inspired oxygen concentration; QsQ: Quantitative and semiquantitative score. ‘major criteria’, and semi-quantitative or subjective parameters ‘minor criteria’. If all main criteria are sat- Competing interests isfied, regardless of minor criteria, decannulation with The authors declare that they have no competing interests. high probability of positive outcome can be assumed. Authors’ contributions If only one of the two major criteria is satisfied, a PS conceived the study, was responsible for data collection, performed statistical careful evaluation of minor criteria should be required, analysis and drafted the manuscript. AG and DR performed statistical analysis and drafted the manuscript. All authors participated in the study design, data assuming a good probability of positive outcome when collection, read, supervised and approved the final manuscript for publication. the majority of minor criteria is satisfied. The same probability category reported above could be applied if, Acknowledgements The authors thank the Respiratory Physiotherapist Team of Rehabilitation in lack of major criteria, all of minor criteria are satis- Unit – Fondazione Salvatore Maugeri, IRCCS, Milano (Giuseppe Gaudiello, fied. Finally, if none of the major criteria and less than Rossana Ciraudo, Goffredo Alfieri and Grazia Lacala) for their support on three minor criteria are satisfied, a low probability of conceiving the study and giving suggestions about tracheostomy clinical management. positive outcome can be assumed. Author details Department of Life Science, Università degli Studi di Milano. Pulmonary Rehabilitation Unit, Fondazione Salvatore Maugeri, Istituto Scientifico di Conclusions Milano-IRCCS, Via Camaldoli, 64-20138 Milan, Italy. Department of Tracheostomy decannulation represents one of the Pathophysiology and Transplantation, Università degli Studi di Milano, IRCCS most important problems in the clinical and home care Fondazione Cà Granda Ospedale Maggiore Policlinico, Via F. Sforza, 33-20122 Milan, Italy. Department of Biomedical Sciences for Health, Università degli management of patients which undergo tracheostomy. Studi di Milano. Respiratory Unit, Policlinico San Donato IRCCS, Piazza E. No validated and specific pathway is followed when per- Malan, 1-20097 San Donato Milanese, Italy. Unit of Maxillo-Facial Surgery. forming a decannulation and this process is left to the Ospedale San Paolo, Milano, Università degli Studi di Milano, Milano, Via A. di Rudinì, 8-20141 Milan, Italy. Pulmonary Rehabilitation Unit, Fondazione clinical expertise. Considering this, we hypothesized a Salvatore Maugeri, Via Mazzini, 129- 26088 Lumezzane, Brescia, Italy. Alma clinical score, named QsQ, to help clinicians in choos- Mater University Department of Clinical, Integrated and Experimental ing decannulation timing. We underline that this score Medicine (DIMAS), Respiratory and Critical Care Unit, S. Orsola-Malpighi Hospital, Via Albertoni, 10-40138 Bologna, Italy. Dipartimento di Scienze has never been validated in clinical real life and there- della Salute, Università degli Studi di Milano. Pulmonary Rehabilitation Unit, fore we suggest evaluating QsQ in further clinical trials Fondazione Salvatore Maugeri, Scientific Institute of Milan-IRCCS, Via Camal- to validate it. doli, 64-20138 Milan, Italy. Santus et al. BMC Pulmonary Medicine 2014, 14:201 Page 8 of 8 http://www.biomedcentral.com/1471-2466/14/201 Received: 2 July 2014 Accepted: 11 December 2014 25. Tobin AE, Santamaria JD: An intensivist-led tracheostomy review team Published: 15 December 2014 is associated with shorter decannulation time and lenght of stay: a prospective cohort study. Crit Care 2008, 12:R48. 26. Stelfox HT, Crimi C, Berra L, Noto A, Schmidt U, Bigatello LM, Hess D: References Determinants of tracheostomy decannulation: an international survey. 1. Durbin CG Jr: Tracheostomy: why, when, and how? Respir Care 2010, Crit Care 2008, 12:R26. 55:1056–1068. 27. Stelfox HT, Hess DR, Schmidt UH: A North American survey of respiratory 2. MacIntyre NR, Epstein SK, Carson S, Scheinhorn D, Christopher K, Muldoon S: therapist and physician tracheostomy decannulation practices. Respir Care Management of patients requiring prolonged mechanical ventilation: 2009, 54:1658–1664. report of a NAMDRC consensus conference. Chest 2005, 128:3937-3954. 28. Marchese S, Corrado A, Scala R, Corrao S, Ambrosino N: Tracheostomy in 3. Terragni PP, Antonelli M, Fumagalli R: Early vs late tracheotomy for patients with long-term mechanical ventilation: a survey. Respir Med prevention of pneumonia in mechanically ventilated adult ICU patients: 2010, 104:749–753. a randomized controlled trial. JAMA 2010, 303:1483–1489. 4. Cavo J, Ogura JH, Sessions DG, Nelson JR: Flow resistance in tracheotomy doi:10.1186/1471-2466-14-201 tubes. Ann Otol Rhinol Laryngol 1973, 82:827–830. Cite this article as: Santus et al.: A systematic review on tracheostomy 5. Heffner JE: Tracheotomy application and timing. Clin Chest Med 2003, decannulation: a proposal of a quantitative semiquantitative clinical 24:389–398. score. BMC Pulmonary Medicine 2014 14:201. 6. Wilson AM, Gray DM, Thomas JG: Increases in endotracheal tube resistance are unpredictable relative to duration of intubation. Chest 2009, 136:1006–1013. 7. Epstein SK, Ciubotaru RL: Influence of gender and endotracheal tube size on preextubation breathing pattern. Am J Respir Crit Care Med 1996, 154:1647–1652. 8. Mehta S, Heffer MJ, Maham N, Nelson DL, Klinger JR, Levy MM: Impact of endotracheal tube size on preextubation respiratory variables. J Crit Care 2010, 25:483–488. 9. Valentini I, Tonveronachi E, Gregoretti C, Mega C, Fasano L, Pisani L, Nava S: Different tracheotomy tube diameters influence diaphragmatic effort and indices of weanability in difficult to wean patients. Respir Care 2012, 57:2012–2018. 10. Criner G, Make B, Celli B: Respiratory muscle dysfunction secondary to chronic tracheostomy tube placement. Chest 1987, 91:139–141. 11. Epstein SK: Anatomy and physiology of tracheostomy. Respir Care 2005, 50:476–482. 12. Chadda K, Louis B, Benaissa L: Physiological effects of decannulation in tracheostomized patients. Intensive Care Med 2002, 28:1761–1767. 13. Dellweg D, Barchfeld T, Haidl P, Appelhans P, Kohler D: Tracheostomy decannulation: implication on respiratory mechanics. Head Neck 2007, 29:1121–1127. 14. Scheinhorn DJ, Chao DC, Hassenpflug MS, Gracey DR: Post-ICU weaning from mechanical ventilation: the role of long-term facilities. Chest 2001, 120:482S–484S. 15. Christopher KL: Tracheostomy decannulation. Respir Care 2005, 50:538–541. 16. Clini E, Vitacca M, Bianchi L, Porta R, Ambrosino N: Long term tracheostomy in severe COPD patients weaned from mechanical ventilation. Respir Care 1999, 44:415–420. 17. Franke KJ, Nilius G, Morgenstern S: Removal of the tracheal tube after prolonged mechanical ventilation: assessment of risk by oscillatory impedance. Respiration 2011, 81:118–123. 18. Gao C, Zhou L, Wei C, Hoffman MR, Li C, Jiang JJ: The evaluation of physiologic decannulation readiness according to upper airway resistance measurement. Otolaryngol Head Neck Surg 2008, 139:535–540. 19. Bach JR, Saporito LR: Indications and criteria for decannulation and transition from invasive to noninvasive long-term ventilatory support. Respir Care 1994, 39:515–528. 20. Ceriana P, Carlucci A, Navalesi P, Rampulla C, Delmastro M, Piaggi G, De Mattia E, Nava S: Weaning from tracheotomy in long-term mechanically ventilated patients: feasibility of a decisional flowchart and clinical Submit your next manuscript to BioMed Central outcome. Intensive Care Med 2003, 29:845–848. 21. Choate K, Barbetti J, Currey J: Tracheostomy decannulation failure rate and take full advantage of: following critical illness: a prospective descriptive study. Aust Crit Care 2009, 22:8–15. • Convenient online submission 22. Leung R, MacGregor L, Campbell D, Berkowitz RG: Decannulation and • Thorough peer review survival following tracheostomy in an intensive care unit. Ann Otol Rhinol Laryngol 2003, 112:853–858. • No space constraints or color figure charges 23. Budweiser S, Baur T, Jorres RA, Kollert F, Pfeifer M, Heinemann F: Predictors • Immediate publication on acceptance of successful decannulation using tracheostomy retainer in patients with • Inclusion in PubMed, CAS, Scopus and Google Scholar prolonged weaning and persisting respiratory failure. Respiration 2012, 84:469–476. • Research which is freely available for redistribution 24. O'Connor HH, Kirby KJ, Terrin N, Hill NS, White AC: Decannulation following tracheostomy for prolonged mechanical ventilation. J Intensive Care Med Submit your manuscript at 2009, 24:187–194. www.biomedcentral.com/submit

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BMC Pulmonary MedicineSpringer Journals

Published: Dec 15, 2014

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