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The practice of tracheostomy decannulation—a systematic review

The practice of tracheostomy decannulation—a systematic review Decannulation is an essential step towards liberating tracheostomized patients from mechanical ventilation. However, despite its perceived importance, there is no universally accepted protocol for this vital transition. Presence of an intact sensorium coordinated swallowing and protective coughing are often the minimum requirements for a successful decannulation. Objective criteria for each of these may help better the clinical judgement of decannulation. In this systematic review on decannulation, we focus attention to this important aspect of tracheostomy care. Keywords: Tracheostomy, Decannulation, Weaning Background Several studies have emphasized the importance of Tracheostomy is a common procedure in patients decannulation within the ICU due to better and requiring prolonged mechanical ventilation (MV) and focused care compared to HDU or ward [6, 7]. airway protection in intensive care unit (ICU) [1]. The Inspite of the relevance and importance of decannula- process of weaning from tracheostomy to maintenance tion, there is no universally accepted protocol for its of spontaneous respiration and/or airway protection is performance. Variability in existing algorithms [8], non- termed “decannulation”. This apparently simple step re- randomized study design [9] and ambiguity in the quires a near perfect coordination of brain, swallowing, screening, technique and monitoring of decannulation coughing, phonation and respiratory muscles [2]. limits our understanding in this important area of care. However, multifactorial aberrations in this complex In order to better understand the various practices of interplay can result in its failure. Moreover, inappropri- tracheostomy decannulation, we performed the present ate assessment of the above factors increases the risk of systematic review of the process of decannulation. aspiration during and after the decannulation process. Old age, obesity, poor neurological status, sepsis and Material and methods tenacious secretions are the predominant reasons of Criteria for including studies failed decannulation [3]. Case series, case–control, prospective, retrospective, ran- Inability to speak with tracheostomy tube (TT) in situ domized or non-randomized studies or surveys dealing results in significant anxiety and depression amongst with the process of decannulation were all included in patients [4]. More often than not, the process of decan- this systematic review. nulation is slow and prolonged leading to increased ICU stay, nosocomial infections and costs [5]. Provision of optimal tracheostomy care can help discharge these Patients patients with TT in situ to ward, high dependency unit Adult patients aged above 18 years and admitted in (HDU) and/or home. Repeat assessment and decannu- ward, operation theater, ICU or HDU were included. lation can then be performed during follow-up visits. Interventions * Correspondence: ratender@sgpgi.ac.in Patients with surgical or percutaneous dilatational Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute tracheostomy who were subjected to the process of of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow 226014, Uttar Pradesh, India decannulation during weaning from MV were included. © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. 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. Singh et al. Journal of Intensive Care (2017) 5:38 Page 2 of 12 Outcome measures outcome measures, attrition, statistical analysis and the Primary outcome measure assessed was success of overall assessment of each study. weaning defined by a period of spontaneous breathing without having to resort to non-invasive ventilation Results (NIV) support or re-insertion of TT. Our PubMed database search yielded 62 articles pub- lished between January 1995 and December 2016. Four- teen articles were excluded as they were not related to Identification of studies the process of decannulation. Another 9 articles from Two independent reviewers searched the electronic paediatrics were also excluded. The remaining 39 articles database PubMed using mesh words “Tracheostomy”, included 24 observational studies, 5 case series, 1 case “Decannulation” and “Decannulation process” as title for report, 4 editorials and special comments, 2 question- the intervening period from 1995 to 2016 for identifica- naires or expert opinions and 1 systematic review. There tion of studies. The third independent reviewer then was no randomized controlled study. Six studies each screened the two lists, removed the duplicates, and then were further excluded owing to non-availability of data searched for the abstracts which fulfilled the inclusion and use of language other than English. The final num- criteria. Full texts of the selected abstracts were then re- ber of full-text studies thus included in our analysis was trieved. Studies which further detailed the aspects of the 18. The step-wise selection of studies along with reasons “process of decannulation” were included. References of for exclusion was as enumerated in Fig. 1. After analyz- the included studies were further searched for any add- ing the selected studies, we decided to perform a itional relevant studies not identified through our former systematic and critical review of the existing studies on search. decannulation due to lack of statistical requirements for a meta-analysis. Study selection The detailed characteristics of the finally included 18 Only studies wherein full texts were available were fi- studies were as depicted in the Tables 1 and 2. There nally included. In case full-text article was not available were 10 prospective [8, 9, 11–18], 6 retrospective studies for a selected study, the institutes e-library using [4, 19–23], and 2 questionnaire-based surveys [24, 25]. “ERMED consortium” and/or “Clinical key” were used There was no randomized controlled study. The 16 pro- for free access to journals. In the event free access to full spective and retrospective studies were all single centre, text was still not available then the authors were con- while both surveys were multicentre. Except one study tacted directly for copies. English language and full-text from India [9], all were from the developed world. In all, restriction were used for inclusion of relevant studies. a total of 3977 patients with age varying between 24 and 85 years were included in these studies. The largest Data extraction numbers of patients included were 981 in the prospect- Author (s), year of publication, country, type of study ive study by Choate et al. in 2009 from Australia [14]. (observational, cohort, case–control, randomized and or Majority of the studied tracheostomized patients had survey), characteristics of patients, nature and severity of illnesses chronic in nature [8, 11]. The clinical spectrum illness, site of care (ward, OT, HDU or ICU), method by included patients with stroke, quadriplegia, GBS, head which tracheostomy was performed [surgical or percu- trauma, acute exacerbations of chronic obstructive pul- taneous dilatational (PCD)], length of MV prior to monary disease, obstructive sleep apnea, restrictive lung decannulation, criteria and method of decannulation disorder, acute respiratory distress syndrome, cardiac used, outcomes in terms of success or failure of decan- failure, cancer and postoperative neurosurgical, cardio- nulation, definition of failed decannulation and limita- thoracic and abdominal patients. The study by Kenneth tions of study were all assessed. For completeness of B et al. specifically included critically ill obese patients data, any missing information was retrieved by directly with an average body mass index of 41.9 ± 14 [21]. Few contacting the respective authors. studies [8, 13, 20, 23] reported the severity of the illness of included patients. Quality assessment Ten out of 18 studies did not report whether the trache- The methodological quality of randomized controlled ostomy was performed by surgical or percutaneous tech- studies was assessed by Jadad scale while non-randomized nique. There were 2 studies each with tracheostomies studies were assessed using the “Q-Coh” tool for cohort performed by either surgical [8] or percutaneous [20] studies in systematic reviews and meta-analyses [10]. Q- technique, while 5 studies included patients with both Coh is a 9-point tool which incorporates the attributes of techniques [13, 14, 19, 21, 25]. design, representativeness, and comparability of groups, The duration of MV prior to decannulation was quite exposure measures, and maintenance of comparability, variable. It was lesser than 3 days in the study by Singh et al. Journal of Intensive Care (2017) 5:38 Page 3 of 12 Fig. 1 Flow diagram of selection of studies Guerlain J et al. [18] to as long as 2224 days with Bach While the primary outcome in most studies was a suc- et al. [12]. cessful decannulation, the secondary outcomes were While the inclusion criteria were distinctly spelled out quite variable. These secondary outcomes included sur- in 12 studies [8, 11–17, 20, 22], the exclusion criteria vival, length of stay, prediction factors for success, and were only mentioned in 6 [14, 15, 17, 21, 23]. utility of a particular assessment technique [16] or a Readiness to decannulate was assessed by qualitative screening tool [25]. In most studies, a successful decan- and quantitative determinants of coughing and swallow- nulation occurred when there was no need of reinsertion ing in different studies. Peak cough flow (PCF) [20] and of TT. However, the period of observation during which maximum expiratory pressure (MEP) [8] were used as re-insertion was averted varied widely from a minimum quantitative measures of coughing. Swallowing was of 24 h [18] to 3–6 months [8] and/or until discharge mostly assessed subjectively via gag reflex or dye test [2], from the unit or hospital [14, 19]. The success rate of except in the study by Wranecke et al. wherein fibreop- decannulation in the studies varied from as low of 23% tic endoscopic evaluation of swallowing (FEES) was used [25] to as high as 100% [23]. for objective assessment [23]. The authors concluded from the studies that identifi- Specific method of decannulation was mentioned in all cation of patients ready for decannulation via objective studies except two [19, 21]. Patients satisfying the criter- assessment of swallowing (FEES) [16], coughing [PCF or ion for decannulation were initially switched over to a peak [12, 18] inspiratory flow (PIF)] and use of a scoring smaller downsized fenestrated or non-fenestrated TT, (QsQ) system [26] performed by a multidisciplinary which was later uncuffed and/or capped for a variable decannulation team in ICU may prove to be more observation period before being finally removed. How- successful. ever, capping without downsizing [4, 13] and abrupt TT According to the Q-Coh tool [10] majority of the stud- removal was also reported [9]. While spontaneous re- ies were of low quality, except the study by Ceriana et al. spiratory workload post downsizing TT was monitored [8], Chaote et al. [14] and Wranecke et al. [13]. Details in most studies, Bach et al. used NIV support to de- of all attributes of the Q-Coh tool were as depicted in crease the breathing workload [12]. the Additional file 1: Table S1. Singh et al. Journal of Intensive Care (2017) 5:38 Page 4 of 12 Table 1 Characteristics of included studies Author Country Year of Type of study Category of patients Number Age Duration of MV (days) Surgical/PCT Inclusion criteria Exclusion criteria publication of patients (years) prior to decannulation Graves A USA 1995 Prospective Chronic neurological 20 58 44–54 NA 1. Ventilation for 4 weeks NA et al. [11] single centre illness 2. Successfully weaned off for 48 h 3. Minute ventilation <10 L/min 4. RR <12 5. SaO >90% (0.4 FiO2) Bach et al. USA 1996 Prospective Chronic neurological 49 24–62 287–2224 NA Medically stable NA [12] single centre illness Afebrile N WBC counts Not receiving IV antibiotics Cognitively intact Not on narcotics/sedation Peak cough flow (PCF) PaO >60 mmHg SaO2 >92% N PaCO ± ventilation and use of manually/mechanically assisted coughing Ceriana Italy 2003 Prospective Non-respiratory, 58% 72 59–77 8–72 Mainly Clinical stability NA et al. [8] single centre Chronic respiratory surgical Absence of psychiatric disorders failure, 40% Effective cough (MEP ≥40 cmH O) PaCO <60 mmHg Adequate swallowing (evaluated by gag reflex or blue dye test) No tracheal stenosis endoscopically Spontaneous breathing ≥5 days. Leung Australia 2003 Retrospective Respiratory, 35% 100 65 25 Surgical, 47 Not mentioned NA et al. [19] single centre Neurological, 35% PCT, 53 Trauma, 17% Tobin et al. Australia 2008 Prospective Medical, 40% 280 61.8 NA Surgical, 15 Tolerate capping >24 h NA [13] single centre Surgical, 14% However, 58 pts PCT, 85 Cough effective Cardiothoracic, 25% on prolonged MV (No need of suctioning). Neurosurgical, 23% Speech (with Passey–Muir valve). Stelfox USA 2008 Questionnaire- Stroke, 166(24) 675 case NA NA NA NA NA et al. [24] based study Respiratory failure, scenarios However, majority Multicentre 159(23) physicians were (118 centres) Trauma, 168(24) from acute care. Abdominal aortic aneurysm, 182(27) Choate Australia 2009 Prospective Medical, 190 981 35–77 9–25 Surgical, 77% Weaned from ventilator Tracheotomies et al. [14] single centre Surgical, 362 PCT, 23% Normal gag reflex by ENT surgeons Trauma, 429 Effective cough were excluded Reason for TT resolved Ability to swallow own secretions SaO >90% 2 Singh et al. Journal of Intensive Care (2017) 5:38 Page 5 of 12 Table 1 Characteristics of included studies (Continued) O Connor USA 2009 Retrospective Pneumonia, 25 135 74(36–91) 45 NA NA NA et al. [4] single centre Aspiration pneumonia or pneumonitis, 25 AECOPD, 25 Septic shock, 25 Chan LYY Hong 2010 Prospective Neurosurgical 32 49–80 13.32 NA Hemodynamically stable Full ventilator et al. [15] Kong single centre patients Body temp <38 °C support Inspired O ≤4 L/min Upper airway SpO >90% obstruction Inability to produce confirmed by FOB voluntary cough on Fully alert and command producing voluntary cough on command Fenestrated TT in place Marchese Italy 2010 Retrospective Acute respiratory 719 50–78 Not mentioned. Surgical, 34% NA NA et al. [25] questionnaire failure, 24 Majority patients with PCT, 66% based COPD, 34 chronic diseases Multicentre study Neuromuscular (22 centres) diseases, 28 Surgical, 11 Thoracic dysmorphism, 4 OSAS, 2 Budviewser Germany 2011 Retrospective AECOPD, 63 384 60–74 38 PCT, 100% Tolerates TT capping >24–48 h NA et al. [20] single centre Pneumonia, 38 Tracheostomy retainer (TR) Cardiac failure, 18 successfully inserted ≥1h Sepsis, 8 ARDS, 7 Shrestha KK India 2012 Prospective Severe head trauma 118 NA NA NA. NA et al. [9] single centre (GCS <8) Gradual vs. abrupt decannulation compared Warnecke T Germany 2013 Prospective Neurologically ill 100 7–33 NA Weaned off ventilator NA et al. [16] single centre patients, like stroke, Assessment by CSE which includes: ICH, GBS, Patient’s vigilance and compliance, meningoencephalitis cough, swallowing assessed by fibreoptic endoscopic evaluation (FESS) with FEES protocol steps. Each step to be passed for decannulation to be considered, like secretions, spontaneous swallows, cough, puree consistency and fluids. Kenneth B USA 2014 Retrospective Critically ill obese 102 NA Surgical, 74% NA Malignancy or et al. [21] single centre BMI 41.9 ± 14.3 PCT, 26% tracheostomies performed outside Singh et al. Journal of Intensive Care (2017) 5:38 Page 6 of 12 Table 1 Characteristics of included studies (Continued) Data missing—2 Pandain V USA 2014 Prospective NA 57 21 NA 1.TT size ≤4 preferably cuffless Not satisfying et al. [17] single centre 2. Breathes comfortably with inclusion criteria continuous finger occlusion of TT >1 min without trapping air, tolerate speaking valve during waking hours without distress, mobilize secretions 3. Suction frequency less than every 4 h 4. No sedation during capping Guerlain J France 2015 Prospective Postoperative head 56 Short-term (<3 days) Surgical, NA NA et al. [18] single centre and neck cancer 100% patients Pasqua Italy 2015 Retrospective Respiratory (COPD, 48 91.61–215.5 NA Clinical and hemodynamic NA et al. [22] single centre ILD, OSAS), 33 stability Cardiac, 10 No evidence of sepsis Abdominal surgery, 4 Expiratory muscle strength Orthopaedic, 1 (MEP >50 cm H O) Absence of tracheal stenosis/ granuloma Normal deglutition PaCO <50 mm Hg PaO /FiO >200 2 2 Absence of nocturnal oxyhemoglobin desaturation Patient consent Cohen Israel 2016 Retrospective Patients with ≥3 49 10 PCT, 100% Maturation of TT stoma Age <18 years et al. [23] single centre co-morbidities, 35% Normal vital signs Complications Effective coughing during initial TT Normal swallowing placement Positive leak test Decannulation process completed outside institute Singh et al. Journal of Intensive Care (2017) 5:38 Page 7 of 12 Table 2 Characteristics of included studies Author (Ref) Method of decannulation Primary outcome Secondary Failure rate (%) Time to Limitations Inference outcome recannulation Graves A et TT occlusion protocol after Decannulation Decannulation 20 NA NA Even without FOB al. [11] downsizing to fenestrated decannulation can be cuffed 7/8 portex tube done with good success rate following long term MV Bach et al. After measuring peak cough Decannulation Factors predicting 32 Within 3 days Specific to Patients decannulated [12] flow (PCF), switched to successful decannulation: neuromuscular and irrespective of their fenestrated cuffed TT that Age long-term MV pts ventilator capacity. can be capped. Extent of pre-decannulation NIV given to PCF >160 L/min Use of Nasal IPPV and MI–E, ventilator use decannulated pts predicted success tube capped. Vital capacity Whereas <160 L/min If successful, TT removed, Peak cough flow (PCF) predicted need to replace site closed, NIV and assisted the tube coughing continued. Ceriana et TT downsized to 6 mm and Decannulation NA 3.5 Up to 3 and 6 months NA Large majority of patients al. [8] capped for 3–4 days with clinical stability can Clinical stability be decannulated with Absence of psychiatric reintubation rate less disorders than 3% after 3 months Effective cough (MEP ≥40 cmH O). PaCO <60 mmHg Adequate swallowing (Gag reflex or blue dye test) No tracheal stenosis endoscopically Spontaneous breathing for ≥5 days Leung et al. Not mentioned Decannulation Survival 6 During hospital stay. Small sample size. ICU patients who require [19] Retrospective nature TT have high mortality of the study. (37%). All surviving patients were decannulated within 25 days. Patients with unstable or obstructed airway had shorter cannulation time compared to patients with chronic illness. Tobin et al. Tolerate capping >24 h Decannulation time from ICU LOS hospital 13 NA Retrospective data Intensivist-led TT team [13] Cough effective discharge LOS after discharge collection is associated with shorter (No need of suctioning) from ICU Lack of similar care decannulation time and Speech (Passey–Muir valve) in wards length of stay. Stelfox et Tolerates TT capping (24 vs. 72 h) Which patient factors NA 20.4 Within 48 h Only 73% responded Patient’s level of al. [24] Effective cough (strong vs. weak) clinician’s rate as being (45% opinion) to the questionnaire. consciousness, cough Secretions (thick vs. thin) important in the decision to to 96 h (20% effectiveness, secretions, Level of consciousness (alert decannulate? opinion) and oxygenation are all vs. drowsy but arousable) Which clinician and patient Acceptable rate important determinants factors are associated with of failure as 2–5%. to decide decannulation. Singh et al. Journal of Intensive Care (2017) 5:38 Page 8 of 12 Table 2 Characteristics of included studies (Continued) clinician’s recommendations to decannulate TT? Define decannulation failure. What do clinicians consider an acceptable rate of decannulation failure? Choate et Cuffless then check airflow TD practice and failure rates NA 5 Until discharge Single centre study Old age, prolonged duration al. [14] through upper airway during 4-year and 10-month from hospital High % of trauma and of TT and retention of sputum followed by TT removal study period neurosurgical patients were risk factors for failure Descriptive data Decannulation criteria not specified O Connor TT occlusion with red cap/ Process of decannulation in NA 19 NA Retrospective data Decannulation was achieved et al. [4] sleep apnea tube/Passy– patients of long-term acute collection in 35% of patients transferred Muir valve care (LTAC) with prolonged to LTAC for weaning in MV (PMV) patients with PMV Chan LYY Amount of TT secretions Decannulation NA 6 Within 72 h Air leakage during PCF Induced PCF rate: 42.6 L/min et al. [15] at different time intervals rate estimation as most in successful vs. 29 L/min in (4 times; 2 h apart) in the of them were on unsuccessful, where 29 L/min same day followed by uncuffed TT may be considered as the induced peak cough Single centre determinant point flow rate (PCFR) by Small sample suction catheter Marchese Scores for specific action Decannulation Calculus score 77 NA NA Substantial % maintained TT et al. [25] Capping, 92/110 Each parameter score—0 despite no requirement of MV Tracheoscopy, 79/110 to 5 (max score–110) No consensus on indications Tracheostomy button, 1: Difficult intubation and systems for closure of TT 60/110 2: 1+ H/O Chronic Downsizing, 44/110 respiratory failure 3: Home ventilation 4: 3+ ventilation hrs/day 5: PaCO in stable state 6: Impaired swallowing 7: Underlying disease 8: Cough effectiveness 9: Relapse rate last year Budviewser In patients with adequate Decannulation NA 28 Entire period of Did not measure PCF Feasibility, efficacy and safety of et al. [20] cough and swallowing, the hospital stay TR in patients with prolonged disc tracheostomy retainer weaning with high risk for (TR) is cut as per size of TT. recurrent or persistent Then inserted in a manner hypercapnic respiratory that it touches the ventral failure part of the trachea, thereby completely sealing the TT channel. Shrestha KK Abrupt: TT removal Decannulation Factors enhancing Gradual NA NA Factors associated with success et al. [9] instantaneously. successful decannulation (G)—1.5 were cough reflex, number of Gradual: Downsizing TT Abrupt(A)—6 suctioning required per day, followed by strapping over S (G)—98.5 standard X-ray and use of the tube followed by S (A)—94 antibiotics ≥7 days strapping over the stoma. Singh et al. Journal of Intensive Care (2017) 5:38 Page 9 of 12 Table 2 Characteristics of included studies (Continued) Gradual (68) vs. Abrupt (50) Warnecke T Clinical swallowing assessment Decannulation based To compare how many 1.9 Till discharge from Small % with FEES is an efficient, reliable, et al. [16] (CSE) followed by fibreoptic on FEES could have been hospital neuromuscular bedside tool, performed safely endoscopic evaluation of decannulated without weakness in tracheostomized critically ill swallowing (FEES) with decision FEES neurologic patients to guide to decannulate based only on decannulation. FEES Kenneth B Not mentioned Tracheostomy type and Patient factors associated 49 NA Retrospective data Increased tracheostomy et al. [21] patient outcome in with outcomes collection. dependence in OSA, and terms of dependence, Variability in co- surgical tracheostomy decannulation and morbidities(incomplete/ death. incorrect medical records) Pandain V Capping Quality improvement NA 1.7 Tolerates capping 12– Small sample size Multidisciplinary protocol for et al. [17] project to develop a 24 h Non-randomized determining readiness to standardized protocol No ↑ FiO >40%, Labour-intensive capping trial prior to for TT capping and shortness of breath, protocol decannulation decannulation process suction requirement, hemodynamic instability is defined as success Guerlain J Peak inspiratory flow (PIF) Minimum peak NA 13 Within 24 h NA PIF improves quality of care et al. [18] assessment through oral inspiratory flow (PIF) and optimizes outcomes cavity after blocking TT required for successful following decannulation cannula decannulation Pasqua et Insertion of a fenestrated Evaluate efficacy of NA 37 NA NA Using specific protocol, al. [22] cannula in the TT followed protocol to analyze decannulation can be done. by its closure with a cap for factors that could However, larger prospective progressively longer periods predict successful studies required. up to 48 h decannulation Cohen et al. Study group: Safety and feasibility NA 20: control Single centre Immediate decannulation [23] 3 step endoscopy of immediate 0: study Retrospective analysis may be a safer alternative Step 1—nasolaryngeal decannulation groups Clinical decisions based for weaning endoscopy confirming compared to traditional respectively on single person vocal cord mobility and decannulation opinion normal supraglottis Potential bias Step 2—TT removal Step 3—up and down look through TT stoma Control group: ↓TT or capping Abbreviations: NA not available, RR respiratory rate, SaO arterial oxygen saturation, TT tracheostomy tube, FOB fibre optic bronchoscope, MV mechanical ventilation, N normal, PaO partial pressure of 2 2 arterial oxygen, IV intravenous, IPPV intermittent positive pressure ventilation, MI–E mechanical insufflator–exsufflator, NIV non-invasive ventilation, PCF peak cough flow, PIF peak inspiratory flow, MEP maximum expiratory pressure, PaCO arterial partial pressure of carbondioxide, LOS length of stay, ICU intensive care unit, AECOPD acute exacerbation of chronic obstructive pulmonary disease, PCT per- cutaneous tracheostomy, LTAC long-term acute care, PMV prolonged mechanical ventilation, ARDS acute respiratory distress syndrome, GCS Glasgow coma scale, ICH intracranial haemorrhage, GBS Guil- lain–Barré syndrome, CSE clinical swallowing examination, FESS fibreoptic endoscopic evaluation of swallowing, SCI spinal cord injury, TR tracheostomy retainer, OSA obstructive sleep apnea syndrome, ILD interstitial lung disease, FiO fraction of inspired oxygen concentration 2 Singh et al. Journal of Intensive Care (2017) 5:38 Page 10 of 12 After this systematic review, we designed a protoco- practice) decannulation or comparing two different lized bedside decannulation algorithm for use in our decannulation protocols, is urgently needed. ICU (Fig. 2). This protocol is being currently studied in After ascertaining intactness of sensorium, further a prospective randomized manner to assess its feasibility identification of patient’s readiness to decannulate is in adult mechanically ventilated ICU patients. mostly based on the assessment of coughing and swal- lowing. More often than not these assessments are based on subjective clinical impression of the physician who Discussion may or may not be the most experienced one at the time Decannulation in tracheostomized patient is the final of decannulation. This is an avoidable lacuna in care of step towards liberation from MV. Despite its relevance, tracheostomized patients. Busy units and busy physicians lack of a universally accepted protocol for decannula- may devote minimal time for this transition. Protoco- tion continues to plague this vital transition. In order lized decannulation in our opinion may guarantee to focus attention on various practices of the process of consistency and objectivity of care. tracheostomy decannulation, we decided to do this sys- As is obvious from the studies included in our system- tematic review. The main finding from this review is atic review, assessments were mostly subjective, al- that there is no randomized controlled study on this though objective FEES [16] and of coughing with PCF critical issue. Several individualized, non-comparative [12] or PIF [18] have also been attempted. Endoscopic and non-validated decannulation protocols exist. How- evaluation of swallowing though technically demanding ever, a blinded randomized controlled study, either provides an objective assessment. However, studies in comparing protocolized and non-protocolized (usual support of this approach are limited. Only two studies Fig. 2 Decannulation algorithm Singh et al. Journal of Intensive Care (2017) 5:38 Page 11 of 12 [16, 23] out of 18 incorporated fibreoptic endoscopic studies in a concise tabular form. Our systematic review evaluation of vocal cords and/or swallowing prior to also incorporates the Q-Coh tool [10] to assess the meth- decannulation. Warnecke T et al. in their study per- odological quality of included cohort studies. As none of formed a mandatory step of FEES in their decannulation the studies included are of desired quality, the need for process [16]. In a recent retrospective study by Cohen et randomized controlled study on decannulation cannot be al., a three-step endoscopic confirmation of vocal cord over emphasized. However, our systematic review also has mobility and normal supraglottis was ascertained prior several limitations. We have not searched other databases to immediate decannulation [23]. He considered imme- like Google Scholar, Scopus or EMBASE and also not in- diate decannulation as a safer and shorter alternative for cluded non-English language articles. weaning in tracheostomized patients as compared to Our protocolized decannulation algorithm (Fig. 2) in- traditional decannulation. When so many decannula- corporates easy to use bed-side checklist for evaluation tions can happen without FEES, then what extra benefit of patients deemed fit for decannulation. The screening does this technically demanding step offer over clinical checklist includes assessment for intactness of sensor- swallowing evaluation (CSE) needs to be ascertained. ium, characteristics of secretions and need and fre- Graves et al. [11] also concluded about good success rate quency of suctioning, effectiveness of swallowing and without fibreoptic evaluation prior to decannulation of coughing, patency of airway and successfulness of a pro- long-term MV patients. Availability and technical ex- longed spontaneous breathing trial (SBT). The patient pertise of FEES needs to be ensured before including it should be conscious, oriented and be able to maintain a in any decannulation protocol. patent airway. Secretions should be easy to handle by Similarly, subjective assessment of coughing is the the patient and frequency of suctioning should be less usual norm. Only Bach et al. [12] in 1996, Ceriana et al. than 4 in the previous 24 hours. The patient must be [8] in 2003, Chan LYY et al. [15] in 2010 and Guerlain J able to swallow liquids/semisolids without risk of aspir- et al. [18] in 2015 used an objective measure of an ation, have adequate cough with good peak expiratory effective cough to decide about decannulation. PCF, MEP flow rate (PEFR) (>160 L/min) and be able to maintain a and PIF are all parameters used by these investigators as patent airway. Patency of the airway can be assessed measures of an effective cough. However, superiority of bedside by simply deflating the cuff and occluding the one over the other is undecided. TT with a gloved finger for testing phonation of the pa- The adopted method of decannulation is also variable. tient. In patients with prolonged MV of greater than While some authors preferred TT occlusion after down- 4 weeks, the duration of successful SBT should prefera- sizing to fenestrated or non-fenestrated tube [8, 11], bly be 48 hours or more. After the initial screening others straight away capped the TT without downsizing checklist, decision about the decannulation technique is [4, 13], while some abruptly removed the TT [9, 14]. based on the duration of MV and presence of neuromus- The choice of the method is based on patient’s tolerabil- cular weakness. Patients with less than 4 weeks of MV ity of the procedure and also on the physician’s experi- and with no suspicion of neuromuscular weakness are ence. There exists no universally accepted method. subjected to a corking trial. This trial involves blocking Furthermore, discrepancy also exists in the period of the existing TT after cuff deflation followed by careful observation before which decannulation is deemed instructions to the bedside nurse/physician to re-inflate successful. Probably, a combination of factors like the the cuff in case of respiratory distress. Depending on the period of MV prior to decannulation, anticipation of tolerability and absence of any distress the TT is decan- neuromuscular fatigue on account of respiratory work- nulated. However, in case of a failed corking trial the TT load and protection of airway all play a role. can be downsized and blocked followed by a period of The self-confessed limitations of the included studies careful observation for few hours. If the observation were as depicted in Table 2. Specific illness group, small period is not associated with any respiratory distress sample size, retrospective design, and non-standardized, decannulation can then be performed. Patients who non-protocolized and non-validated method of decannu- failed the corking trail as well as downsizing & blocking lation are the major limitations of the included studies. and are in respiratory distress need immediate upsizing But above all, absence of a randomized controlled study in of the TT to resume ventilation. Further assessment this aspect of care is a major hurdle. The previously pub- warrants a FOB examination to explore the cause of fail- lished systematic review on tracheostomy decannulation ure. In patients with MV for more than 4 weeks and was by Santus P et al. [26] in 2014. Our systematic review with suspicion of neuromuscular weakness the decannu- has included 10 of these studies apart from addition of an- lation technique is that of downsizing and blocking. In other 8. While he compared primary and secondary out- case of failure and respiratory distress, approach remains comes of included studies, our review is much more same as above. This protocol is currently under evalu- exhaustive in that it incorporates the relevant details of 18 ation in our unit via a randomized study. Singh et al. Journal of Intensive Care (2017) 5:38 Page 12 of 12 Conclusions 5. Heffner JE, Hess D. Tracheostomy management in the chronically ventilated patient. Clin Chest Med. 2001;22(1):55–69. Decannulation is an essential step towards liberating a 6. Martinez GH, Fernandez R, Casado MS, Cuena R, Lopez-Reina P, Zamora S, tracheostomized patient from mechanical ventilation. et al. Tracheostomy tube in place at intensive care unit discharge is This transition is more often individualized than proto- associated with increased ward mortality. Respir Care. 2009;54(12):1644–52. 7. Fernandez R, Bacelar N, Hernandez G, Tubau I, Baigorri F, Gili G, et al. Ward colized. Universally accepted protocol is needed for mortality in patients discharged from the ICU with tracheostomy may better standardization. Randomized controlled studies in depend on patient’s vulnerability. Intensive Care Med. 2008;34(10):1878–82. this aspect of tracheostomy care can make it more 8. Ceriana P, Carlucci A, Navalesi P, Rampulla C, Delmastro M, Piaggi G, et al. Weaning from tracheotomy in long-term mechanically ventilated patients: evidence based. feasibility of a decisional flowchart and clinical outcome. Intensive Care Med. 2003;29(5):845–8. 9. Shrestha KK, Mohindra S, Mohindra S. How to decannulate tracheostomised Additional file severe head trauma patients: a comparison of gradual vs abrupt technique. Nepal Med Coll J. 2012;14(3):207–11. Additional file 1: Table S1. Quality of cohort studies as assessed by Q- 10. Jarde A, Losilla J, Vives J, Rodrigo MF. Q-Coh: a tool to screen the Coh tool. (DOCX 26 kb) methodological quality of cohort studies in systematic reviews and meta- analyses. Int J Clin Heal Psychol. 2013;13:138–46. 11. Rumbak MJ, Graves AE, Scott MP, Sporn GK, Walsh FW, Anderson WM, Abbreviations Goldman AL. Tracheostomy tube occlusion protoc predict success tracheal CSE: Clinical swallowing examination; FESS: Fibreoptic endoscopic evaluation decannulation follow long term mech vent. Crit Care Med. 1997;25(3):413–7. of swallowing; HDU: High dependency unit; ICU: Intensive care unit; 12. Bach JR, Saporito LR. Criteria for extubation and tracheostomy tube removal MEP: Maximum expiratory pressure; MV: Mechanical ventilation; NIV: Non- for patients with ventilatory failure: a different approach to weaning. Chest. invasive ventilation; PCDT: Percutaneous dilatational tracheostomy; PCF: Peak 1996;110(6):1566–71. cough flow; PIF: Peak inspiratory flow; TT: Tracheostomy tube 13. Tobin AE, Santamaria JD. An intensivist-led tracheostomy review team is associated with shorter decannulation time and length of stay: a Acknowledgements prospective cohort study. Crit Care. 2008;12(2):R48. Not applicable. 14. Choate K, Barbetti J, Currey J. Tracheostomy decannulation failure rate following critical illness: a prospective descriptive study. Aust Crit Care. 2009; Funding 22(1):8–15. The author(s) received no financial support this study. 15. Chan LYY, Jones AYM, Chung RCK, Hung KN. Peak flow rate during induced cough: a predictor of successful decannulation of a tracheotomy tube in Availability of data and materials neurosurgical patients. Am J Crit Care. 2010;19(3):278–84. Data sharing is not applicable to this article as no datasets were generated 16. Warnecke T, Suntrup S, Teismann IK, Hamacher C, Oelenberg S, Dziewas R. or analyzed during the current study. Standardized endoscopic swallowing evaluation for tracheostomy decannulation in critically ill neurologic patients. Crit Care Med. 2013;41(7):1728–32. 17. Pandian V, Miller CR, Schiavi AJ, Yarmus L, Contractor A, Haut ER, et al. Authors’ contributions Utilization of a standardized tracheostomy capping and decannulation RKS, SS and AKB contributed equally to the design, data acquisition and protocol to improve patient safety. Laryngoscope. 2014;124(8):1794–800. manuscript preparation. All authors read and approved the final manuscript. 18. Guerlain J, Guerrero JAS, Baujat B, St Guily JL, Périé S. Peak inspiratory flow is a simple means of predicting decannulation success following head and Competing interests neck cancer surgery: a prospective study of fifty-six patients. Laryngoscope. The author(s) declare that they have no competing interests. 2015;125(2):365–70. 19. Leung R, MacGregor L, Campbell D, Berkowitz RG. Decannulation and Consent for publication survival following tracheostomy in an intensive care unit. Ann Otol Rhinol Not applicable. Laryngol. 2003;112(10):853–8. 20. Budweiser S, Baur T, Jörres RA, Kollert F, Pfeifer M, Heinemann F. Predictors Ethics approval and consent to participate of successful decannulation using a tracheostomy retainer in patients with Not applicable. prolonged weaning and persisting respiratory failure. Respiration. 2012;84(6): 469–76. 21. Byrd JK, Ranasinghe VJ, Day KE, Wolf BJ, Lentsch EJ. Predictors of clinical Publisher’sNote outcome after tracheotomy in critically ill obese patients. Laryngoscope. Springer Nature remains neutral with regard to jurisdictional claims in 2014;124(5):1118–22. published maps and institutional affiliations. 22. Pasqua F, Nardi I, Provenzano A, Mari A. Weaning from tracheostomy in subjects undergoing pulmonary rehabilitation. Multidiscip Respir Med. 2015; Received: 9 May 2017 Accepted: 14 June 2017 10(11):35. 23. Cohen O, Tzelnick S, Lahav Y, Stavi D, Shoffel-Havakuk H, Hain M, et al. Feasibility of a single-stage tracheostomy decannulation protocol with References endoscopy in adult patients. Laryngoscope. 2016;126(9):2057–62. 1. Esteban A, Anzueto A, Alía I, Gordo F, Apezteguía C, Pálizas F, et al. How is 24. Stelfox HT, Crimi C, Berra L, Noto A, Schmidt U, Bigatello LM, et al. mechanical ventilation employed in the intensive care unit? An international Determinants of tracheostomy decannulation: an international survey. Crit utilization review. Am J Respir Crit Care Med. 2000;161(5):1450–8. Care. 2008;12(1):R26. 2. Garuti G, Reverberi C, Briganti A, Massobrio M, Lombardi F, Lusuardi M. 25. Marchese S, Corrado A, Scala R, Corrao S, Ambrosino N. Tracheostomy in Swallowing disorders in tracheostomised patients: a multidisciplinary/ patients with long-term mechanical ventilation: a survey. Respir Med. 2010; multiprofessional approach in decannulation protocols. Multidiscip Respir 104(5):749–53. Med. 2014;9(1):36. 26. Santus P, Gramegna A, Radovanovic D, Raccanelli R, Valenti V, Rabbiosi D, et 3. Schmidt U, Hess D, Bittner E. To decannulate or not to decannulate: a al. A systematic review on tracheostomy decannulation: a proposal of a combination of readiness for the floor and floor readiness? Crit Care Med. quantitative semiquantitative clinical score. BMC Pulm Med. 2014;14:201. 2011;39(10):2360–1. 4. O ’connor HH, Kirby Ctr KJ, Terrin N, Hill NS, White AC. Decannulation following tracheostomy for prolonged mechanical ventilation. J Intensive Care Med. 2009;24(3):187–94. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Intensive Care Springer Journals

The practice of tracheostomy decannulation—a systematic review

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Springer Journals
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Copyright © 2017 by The Author(s).
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Medicine & Public Health; Intensive / Critical Care Medicine
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Abstract

Decannulation is an essential step towards liberating tracheostomized patients from mechanical ventilation. However, despite its perceived importance, there is no universally accepted protocol for this vital transition. Presence of an intact sensorium coordinated swallowing and protective coughing are often the minimum requirements for a successful decannulation. Objective criteria for each of these may help better the clinical judgement of decannulation. In this systematic review on decannulation, we focus attention to this important aspect of tracheostomy care. Keywords: Tracheostomy, Decannulation, Weaning Background Several studies have emphasized the importance of Tracheostomy is a common procedure in patients decannulation within the ICU due to better and requiring prolonged mechanical ventilation (MV) and focused care compared to HDU or ward [6, 7]. airway protection in intensive care unit (ICU) [1]. The Inspite of the relevance and importance of decannula- process of weaning from tracheostomy to maintenance tion, there is no universally accepted protocol for its of spontaneous respiration and/or airway protection is performance. Variability in existing algorithms [8], non- termed “decannulation”. This apparently simple step re- randomized study design [9] and ambiguity in the quires a near perfect coordination of brain, swallowing, screening, technique and monitoring of decannulation coughing, phonation and respiratory muscles [2]. limits our understanding in this important area of care. However, multifactorial aberrations in this complex In order to better understand the various practices of interplay can result in its failure. Moreover, inappropri- tracheostomy decannulation, we performed the present ate assessment of the above factors increases the risk of systematic review of the process of decannulation. aspiration during and after the decannulation process. Old age, obesity, poor neurological status, sepsis and Material and methods tenacious secretions are the predominant reasons of Criteria for including studies failed decannulation [3]. Case series, case–control, prospective, retrospective, ran- Inability to speak with tracheostomy tube (TT) in situ domized or non-randomized studies or surveys dealing results in significant anxiety and depression amongst with the process of decannulation were all included in patients [4]. More often than not, the process of decan- this systematic review. nulation is slow and prolonged leading to increased ICU stay, nosocomial infections and costs [5]. Provision of optimal tracheostomy care can help discharge these Patients patients with TT in situ to ward, high dependency unit Adult patients aged above 18 years and admitted in (HDU) and/or home. Repeat assessment and decannu- ward, operation theater, ICU or HDU were included. lation can then be performed during follow-up visits. Interventions * Correspondence: ratender@sgpgi.ac.in Patients with surgical or percutaneous dilatational Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute tracheostomy who were subjected to the process of of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow 226014, Uttar Pradesh, India decannulation during weaning from MV were included. © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. 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. Singh et al. Journal of Intensive Care (2017) 5:38 Page 2 of 12 Outcome measures outcome measures, attrition, statistical analysis and the Primary outcome measure assessed was success of overall assessment of each study. weaning defined by a period of spontaneous breathing without having to resort to non-invasive ventilation Results (NIV) support or re-insertion of TT. Our PubMed database search yielded 62 articles pub- lished between January 1995 and December 2016. Four- teen articles were excluded as they were not related to Identification of studies the process of decannulation. Another 9 articles from Two independent reviewers searched the electronic paediatrics were also excluded. The remaining 39 articles database PubMed using mesh words “Tracheostomy”, included 24 observational studies, 5 case series, 1 case “Decannulation” and “Decannulation process” as title for report, 4 editorials and special comments, 2 question- the intervening period from 1995 to 2016 for identifica- naires or expert opinions and 1 systematic review. There tion of studies. The third independent reviewer then was no randomized controlled study. Six studies each screened the two lists, removed the duplicates, and then were further excluded owing to non-availability of data searched for the abstracts which fulfilled the inclusion and use of language other than English. The final num- criteria. Full texts of the selected abstracts were then re- ber of full-text studies thus included in our analysis was trieved. Studies which further detailed the aspects of the 18. The step-wise selection of studies along with reasons “process of decannulation” were included. References of for exclusion was as enumerated in Fig. 1. After analyz- the included studies were further searched for any add- ing the selected studies, we decided to perform a itional relevant studies not identified through our former systematic and critical review of the existing studies on search. decannulation due to lack of statistical requirements for a meta-analysis. Study selection The detailed characteristics of the finally included 18 Only studies wherein full texts were available were fi- studies were as depicted in the Tables 1 and 2. There nally included. In case full-text article was not available were 10 prospective [8, 9, 11–18], 6 retrospective studies for a selected study, the institutes e-library using [4, 19–23], and 2 questionnaire-based surveys [24, 25]. “ERMED consortium” and/or “Clinical key” were used There was no randomized controlled study. The 16 pro- for free access to journals. In the event free access to full spective and retrospective studies were all single centre, text was still not available then the authors were con- while both surveys were multicentre. Except one study tacted directly for copies. English language and full-text from India [9], all were from the developed world. In all, restriction were used for inclusion of relevant studies. a total of 3977 patients with age varying between 24 and 85 years were included in these studies. The largest Data extraction numbers of patients included were 981 in the prospect- Author (s), year of publication, country, type of study ive study by Choate et al. in 2009 from Australia [14]. (observational, cohort, case–control, randomized and or Majority of the studied tracheostomized patients had survey), characteristics of patients, nature and severity of illnesses chronic in nature [8, 11]. The clinical spectrum illness, site of care (ward, OT, HDU or ICU), method by included patients with stroke, quadriplegia, GBS, head which tracheostomy was performed [surgical or percu- trauma, acute exacerbations of chronic obstructive pul- taneous dilatational (PCD)], length of MV prior to monary disease, obstructive sleep apnea, restrictive lung decannulation, criteria and method of decannulation disorder, acute respiratory distress syndrome, cardiac used, outcomes in terms of success or failure of decan- failure, cancer and postoperative neurosurgical, cardio- nulation, definition of failed decannulation and limita- thoracic and abdominal patients. The study by Kenneth tions of study were all assessed. For completeness of B et al. specifically included critically ill obese patients data, any missing information was retrieved by directly with an average body mass index of 41.9 ± 14 [21]. Few contacting the respective authors. studies [8, 13, 20, 23] reported the severity of the illness of included patients. Quality assessment Ten out of 18 studies did not report whether the trache- The methodological quality of randomized controlled ostomy was performed by surgical or percutaneous tech- studies was assessed by Jadad scale while non-randomized nique. There were 2 studies each with tracheostomies studies were assessed using the “Q-Coh” tool for cohort performed by either surgical [8] or percutaneous [20] studies in systematic reviews and meta-analyses [10]. Q- technique, while 5 studies included patients with both Coh is a 9-point tool which incorporates the attributes of techniques [13, 14, 19, 21, 25]. design, representativeness, and comparability of groups, The duration of MV prior to decannulation was quite exposure measures, and maintenance of comparability, variable. It was lesser than 3 days in the study by Singh et al. Journal of Intensive Care (2017) 5:38 Page 3 of 12 Fig. 1 Flow diagram of selection of studies Guerlain J et al. [18] to as long as 2224 days with Bach While the primary outcome in most studies was a suc- et al. [12]. cessful decannulation, the secondary outcomes were While the inclusion criteria were distinctly spelled out quite variable. These secondary outcomes included sur- in 12 studies [8, 11–17, 20, 22], the exclusion criteria vival, length of stay, prediction factors for success, and were only mentioned in 6 [14, 15, 17, 21, 23]. utility of a particular assessment technique [16] or a Readiness to decannulate was assessed by qualitative screening tool [25]. In most studies, a successful decan- and quantitative determinants of coughing and swallow- nulation occurred when there was no need of reinsertion ing in different studies. Peak cough flow (PCF) [20] and of TT. However, the period of observation during which maximum expiratory pressure (MEP) [8] were used as re-insertion was averted varied widely from a minimum quantitative measures of coughing. Swallowing was of 24 h [18] to 3–6 months [8] and/or until discharge mostly assessed subjectively via gag reflex or dye test [2], from the unit or hospital [14, 19]. The success rate of except in the study by Wranecke et al. wherein fibreop- decannulation in the studies varied from as low of 23% tic endoscopic evaluation of swallowing (FEES) was used [25] to as high as 100% [23]. for objective assessment [23]. The authors concluded from the studies that identifi- Specific method of decannulation was mentioned in all cation of patients ready for decannulation via objective studies except two [19, 21]. Patients satisfying the criter- assessment of swallowing (FEES) [16], coughing [PCF or ion for decannulation were initially switched over to a peak [12, 18] inspiratory flow (PIF)] and use of a scoring smaller downsized fenestrated or non-fenestrated TT, (QsQ) system [26] performed by a multidisciplinary which was later uncuffed and/or capped for a variable decannulation team in ICU may prove to be more observation period before being finally removed. How- successful. ever, capping without downsizing [4, 13] and abrupt TT According to the Q-Coh tool [10] majority of the stud- removal was also reported [9]. While spontaneous re- ies were of low quality, except the study by Ceriana et al. spiratory workload post downsizing TT was monitored [8], Chaote et al. [14] and Wranecke et al. [13]. Details in most studies, Bach et al. used NIV support to de- of all attributes of the Q-Coh tool were as depicted in crease the breathing workload [12]. the Additional file 1: Table S1. Singh et al. Journal of Intensive Care (2017) 5:38 Page 4 of 12 Table 1 Characteristics of included studies Author Country Year of Type of study Category of patients Number Age Duration of MV (days) Surgical/PCT Inclusion criteria Exclusion criteria publication of patients (years) prior to decannulation Graves A USA 1995 Prospective Chronic neurological 20 58 44–54 NA 1. Ventilation for 4 weeks NA et al. [11] single centre illness 2. Successfully weaned off for 48 h 3. Minute ventilation <10 L/min 4. RR <12 5. SaO >90% (0.4 FiO2) Bach et al. USA 1996 Prospective Chronic neurological 49 24–62 287–2224 NA Medically stable NA [12] single centre illness Afebrile N WBC counts Not receiving IV antibiotics Cognitively intact Not on narcotics/sedation Peak cough flow (PCF) PaO >60 mmHg SaO2 >92% N PaCO ± ventilation and use of manually/mechanically assisted coughing Ceriana Italy 2003 Prospective Non-respiratory, 58% 72 59–77 8–72 Mainly Clinical stability NA et al. [8] single centre Chronic respiratory surgical Absence of psychiatric disorders failure, 40% Effective cough (MEP ≥40 cmH O) PaCO <60 mmHg Adequate swallowing (evaluated by gag reflex or blue dye test) No tracheal stenosis endoscopically Spontaneous breathing ≥5 days. Leung Australia 2003 Retrospective Respiratory, 35% 100 65 25 Surgical, 47 Not mentioned NA et al. [19] single centre Neurological, 35% PCT, 53 Trauma, 17% Tobin et al. Australia 2008 Prospective Medical, 40% 280 61.8 NA Surgical, 15 Tolerate capping >24 h NA [13] single centre Surgical, 14% However, 58 pts PCT, 85 Cough effective Cardiothoracic, 25% on prolonged MV (No need of suctioning). Neurosurgical, 23% Speech (with Passey–Muir valve). Stelfox USA 2008 Questionnaire- Stroke, 166(24) 675 case NA NA NA NA NA et al. [24] based study Respiratory failure, scenarios However, majority Multicentre 159(23) physicians were (118 centres) Trauma, 168(24) from acute care. Abdominal aortic aneurysm, 182(27) Choate Australia 2009 Prospective Medical, 190 981 35–77 9–25 Surgical, 77% Weaned from ventilator Tracheotomies et al. [14] single centre Surgical, 362 PCT, 23% Normal gag reflex by ENT surgeons Trauma, 429 Effective cough were excluded Reason for TT resolved Ability to swallow own secretions SaO >90% 2 Singh et al. Journal of Intensive Care (2017) 5:38 Page 5 of 12 Table 1 Characteristics of included studies (Continued) O Connor USA 2009 Retrospective Pneumonia, 25 135 74(36–91) 45 NA NA NA et al. [4] single centre Aspiration pneumonia or pneumonitis, 25 AECOPD, 25 Septic shock, 25 Chan LYY Hong 2010 Prospective Neurosurgical 32 49–80 13.32 NA Hemodynamically stable Full ventilator et al. [15] Kong single centre patients Body temp <38 °C support Inspired O ≤4 L/min Upper airway SpO >90% obstruction Inability to produce confirmed by FOB voluntary cough on Fully alert and command producing voluntary cough on command Fenestrated TT in place Marchese Italy 2010 Retrospective Acute respiratory 719 50–78 Not mentioned. Surgical, 34% NA NA et al. [25] questionnaire failure, 24 Majority patients with PCT, 66% based COPD, 34 chronic diseases Multicentre study Neuromuscular (22 centres) diseases, 28 Surgical, 11 Thoracic dysmorphism, 4 OSAS, 2 Budviewser Germany 2011 Retrospective AECOPD, 63 384 60–74 38 PCT, 100% Tolerates TT capping >24–48 h NA et al. [20] single centre Pneumonia, 38 Tracheostomy retainer (TR) Cardiac failure, 18 successfully inserted ≥1h Sepsis, 8 ARDS, 7 Shrestha KK India 2012 Prospective Severe head trauma 118 NA NA NA. NA et al. [9] single centre (GCS <8) Gradual vs. abrupt decannulation compared Warnecke T Germany 2013 Prospective Neurologically ill 100 7–33 NA Weaned off ventilator NA et al. [16] single centre patients, like stroke, Assessment by CSE which includes: ICH, GBS, Patient’s vigilance and compliance, meningoencephalitis cough, swallowing assessed by fibreoptic endoscopic evaluation (FESS) with FEES protocol steps. Each step to be passed for decannulation to be considered, like secretions, spontaneous swallows, cough, puree consistency and fluids. Kenneth B USA 2014 Retrospective Critically ill obese 102 NA Surgical, 74% NA Malignancy or et al. [21] single centre BMI 41.9 ± 14.3 PCT, 26% tracheostomies performed outside Singh et al. Journal of Intensive Care (2017) 5:38 Page 6 of 12 Table 1 Characteristics of included studies (Continued) Data missing—2 Pandain V USA 2014 Prospective NA 57 21 NA 1.TT size ≤4 preferably cuffless Not satisfying et al. [17] single centre 2. Breathes comfortably with inclusion criteria continuous finger occlusion of TT >1 min without trapping air, tolerate speaking valve during waking hours without distress, mobilize secretions 3. Suction frequency less than every 4 h 4. No sedation during capping Guerlain J France 2015 Prospective Postoperative head 56 Short-term (<3 days) Surgical, NA NA et al. [18] single centre and neck cancer 100% patients Pasqua Italy 2015 Retrospective Respiratory (COPD, 48 91.61–215.5 NA Clinical and hemodynamic NA et al. [22] single centre ILD, OSAS), 33 stability Cardiac, 10 No evidence of sepsis Abdominal surgery, 4 Expiratory muscle strength Orthopaedic, 1 (MEP >50 cm H O) Absence of tracheal stenosis/ granuloma Normal deglutition PaCO <50 mm Hg PaO /FiO >200 2 2 Absence of nocturnal oxyhemoglobin desaturation Patient consent Cohen Israel 2016 Retrospective Patients with ≥3 49 10 PCT, 100% Maturation of TT stoma Age <18 years et al. [23] single centre co-morbidities, 35% Normal vital signs Complications Effective coughing during initial TT Normal swallowing placement Positive leak test Decannulation process completed outside institute Singh et al. Journal of Intensive Care (2017) 5:38 Page 7 of 12 Table 2 Characteristics of included studies Author (Ref) Method of decannulation Primary outcome Secondary Failure rate (%) Time to Limitations Inference outcome recannulation Graves A et TT occlusion protocol after Decannulation Decannulation 20 NA NA Even without FOB al. [11] downsizing to fenestrated decannulation can be cuffed 7/8 portex tube done with good success rate following long term MV Bach et al. After measuring peak cough Decannulation Factors predicting 32 Within 3 days Specific to Patients decannulated [12] flow (PCF), switched to successful decannulation: neuromuscular and irrespective of their fenestrated cuffed TT that Age long-term MV pts ventilator capacity. can be capped. Extent of pre-decannulation NIV given to PCF >160 L/min Use of Nasal IPPV and MI–E, ventilator use decannulated pts predicted success tube capped. Vital capacity Whereas <160 L/min If successful, TT removed, Peak cough flow (PCF) predicted need to replace site closed, NIV and assisted the tube coughing continued. Ceriana et TT downsized to 6 mm and Decannulation NA 3.5 Up to 3 and 6 months NA Large majority of patients al. [8] capped for 3–4 days with clinical stability can Clinical stability be decannulated with Absence of psychiatric reintubation rate less disorders than 3% after 3 months Effective cough (MEP ≥40 cmH O). PaCO <60 mmHg Adequate swallowing (Gag reflex or blue dye test) No tracheal stenosis endoscopically Spontaneous breathing for ≥5 days Leung et al. Not mentioned Decannulation Survival 6 During hospital stay. Small sample size. ICU patients who require [19] Retrospective nature TT have high mortality of the study. (37%). All surviving patients were decannulated within 25 days. Patients with unstable or obstructed airway had shorter cannulation time compared to patients with chronic illness. Tobin et al. Tolerate capping >24 h Decannulation time from ICU LOS hospital 13 NA Retrospective data Intensivist-led TT team [13] Cough effective discharge LOS after discharge collection is associated with shorter (No need of suctioning) from ICU Lack of similar care decannulation time and Speech (Passey–Muir valve) in wards length of stay. Stelfox et Tolerates TT capping (24 vs. 72 h) Which patient factors NA 20.4 Within 48 h Only 73% responded Patient’s level of al. [24] Effective cough (strong vs. weak) clinician’s rate as being (45% opinion) to the questionnaire. consciousness, cough Secretions (thick vs. thin) important in the decision to to 96 h (20% effectiveness, secretions, Level of consciousness (alert decannulate? opinion) and oxygenation are all vs. drowsy but arousable) Which clinician and patient Acceptable rate important determinants factors are associated with of failure as 2–5%. to decide decannulation. Singh et al. Journal of Intensive Care (2017) 5:38 Page 8 of 12 Table 2 Characteristics of included studies (Continued) clinician’s recommendations to decannulate TT? Define decannulation failure. What do clinicians consider an acceptable rate of decannulation failure? Choate et Cuffless then check airflow TD practice and failure rates NA 5 Until discharge Single centre study Old age, prolonged duration al. [14] through upper airway during 4-year and 10-month from hospital High % of trauma and of TT and retention of sputum followed by TT removal study period neurosurgical patients were risk factors for failure Descriptive data Decannulation criteria not specified O Connor TT occlusion with red cap/ Process of decannulation in NA 19 NA Retrospective data Decannulation was achieved et al. [4] sleep apnea tube/Passy– patients of long-term acute collection in 35% of patients transferred Muir valve care (LTAC) with prolonged to LTAC for weaning in MV (PMV) patients with PMV Chan LYY Amount of TT secretions Decannulation NA 6 Within 72 h Air leakage during PCF Induced PCF rate: 42.6 L/min et al. [15] at different time intervals rate estimation as most in successful vs. 29 L/min in (4 times; 2 h apart) in the of them were on unsuccessful, where 29 L/min same day followed by uncuffed TT may be considered as the induced peak cough Single centre determinant point flow rate (PCFR) by Small sample suction catheter Marchese Scores for specific action Decannulation Calculus score 77 NA NA Substantial % maintained TT et al. [25] Capping, 92/110 Each parameter score—0 despite no requirement of MV Tracheoscopy, 79/110 to 5 (max score–110) No consensus on indications Tracheostomy button, 1: Difficult intubation and systems for closure of TT 60/110 2: 1+ H/O Chronic Downsizing, 44/110 respiratory failure 3: Home ventilation 4: 3+ ventilation hrs/day 5: PaCO in stable state 6: Impaired swallowing 7: Underlying disease 8: Cough effectiveness 9: Relapse rate last year Budviewser In patients with adequate Decannulation NA 28 Entire period of Did not measure PCF Feasibility, efficacy and safety of et al. [20] cough and swallowing, the hospital stay TR in patients with prolonged disc tracheostomy retainer weaning with high risk for (TR) is cut as per size of TT. recurrent or persistent Then inserted in a manner hypercapnic respiratory that it touches the ventral failure part of the trachea, thereby completely sealing the TT channel. Shrestha KK Abrupt: TT removal Decannulation Factors enhancing Gradual NA NA Factors associated with success et al. [9] instantaneously. successful decannulation (G)—1.5 were cough reflex, number of Gradual: Downsizing TT Abrupt(A)—6 suctioning required per day, followed by strapping over S (G)—98.5 standard X-ray and use of the tube followed by S (A)—94 antibiotics ≥7 days strapping over the stoma. Singh et al. Journal of Intensive Care (2017) 5:38 Page 9 of 12 Table 2 Characteristics of included studies (Continued) Gradual (68) vs. Abrupt (50) Warnecke T Clinical swallowing assessment Decannulation based To compare how many 1.9 Till discharge from Small % with FEES is an efficient, reliable, et al. [16] (CSE) followed by fibreoptic on FEES could have been hospital neuromuscular bedside tool, performed safely endoscopic evaluation of decannulated without weakness in tracheostomized critically ill swallowing (FEES) with decision FEES neurologic patients to guide to decannulate based only on decannulation. FEES Kenneth B Not mentioned Tracheostomy type and Patient factors associated 49 NA Retrospective data Increased tracheostomy et al. [21] patient outcome in with outcomes collection. dependence in OSA, and terms of dependence, Variability in co- surgical tracheostomy decannulation and morbidities(incomplete/ death. incorrect medical records) Pandain V Capping Quality improvement NA 1.7 Tolerates capping 12– Small sample size Multidisciplinary protocol for et al. [17] project to develop a 24 h Non-randomized determining readiness to standardized protocol No ↑ FiO >40%, Labour-intensive capping trial prior to for TT capping and shortness of breath, protocol decannulation decannulation process suction requirement, hemodynamic instability is defined as success Guerlain J Peak inspiratory flow (PIF) Minimum peak NA 13 Within 24 h NA PIF improves quality of care et al. [18] assessment through oral inspiratory flow (PIF) and optimizes outcomes cavity after blocking TT required for successful following decannulation cannula decannulation Pasqua et Insertion of a fenestrated Evaluate efficacy of NA 37 NA NA Using specific protocol, al. [22] cannula in the TT followed protocol to analyze decannulation can be done. by its closure with a cap for factors that could However, larger prospective progressively longer periods predict successful studies required. up to 48 h decannulation Cohen et al. Study group: Safety and feasibility NA 20: control Single centre Immediate decannulation [23] 3 step endoscopy of immediate 0: study Retrospective analysis may be a safer alternative Step 1—nasolaryngeal decannulation groups Clinical decisions based for weaning endoscopy confirming compared to traditional respectively on single person vocal cord mobility and decannulation opinion normal supraglottis Potential bias Step 2—TT removal Step 3—up and down look through TT stoma Control group: ↓TT or capping Abbreviations: NA not available, RR respiratory rate, SaO arterial oxygen saturation, TT tracheostomy tube, FOB fibre optic bronchoscope, MV mechanical ventilation, N normal, PaO partial pressure of 2 2 arterial oxygen, IV intravenous, IPPV intermittent positive pressure ventilation, MI–E mechanical insufflator–exsufflator, NIV non-invasive ventilation, PCF peak cough flow, PIF peak inspiratory flow, MEP maximum expiratory pressure, PaCO arterial partial pressure of carbondioxide, LOS length of stay, ICU intensive care unit, AECOPD acute exacerbation of chronic obstructive pulmonary disease, PCT per- cutaneous tracheostomy, LTAC long-term acute care, PMV prolonged mechanical ventilation, ARDS acute respiratory distress syndrome, GCS Glasgow coma scale, ICH intracranial haemorrhage, GBS Guil- lain–Barré syndrome, CSE clinical swallowing examination, FESS fibreoptic endoscopic evaluation of swallowing, SCI spinal cord injury, TR tracheostomy retainer, OSA obstructive sleep apnea syndrome, ILD interstitial lung disease, FiO fraction of inspired oxygen concentration 2 Singh et al. Journal of Intensive Care (2017) 5:38 Page 10 of 12 After this systematic review, we designed a protoco- practice) decannulation or comparing two different lized bedside decannulation algorithm for use in our decannulation protocols, is urgently needed. ICU (Fig. 2). This protocol is being currently studied in After ascertaining intactness of sensorium, further a prospective randomized manner to assess its feasibility identification of patient’s readiness to decannulate is in adult mechanically ventilated ICU patients. mostly based on the assessment of coughing and swal- lowing. More often than not these assessments are based on subjective clinical impression of the physician who Discussion may or may not be the most experienced one at the time Decannulation in tracheostomized patient is the final of decannulation. This is an avoidable lacuna in care of step towards liberation from MV. Despite its relevance, tracheostomized patients. Busy units and busy physicians lack of a universally accepted protocol for decannula- may devote minimal time for this transition. Protoco- tion continues to plague this vital transition. In order lized decannulation in our opinion may guarantee to focus attention on various practices of the process of consistency and objectivity of care. tracheostomy decannulation, we decided to do this sys- As is obvious from the studies included in our system- tematic review. The main finding from this review is atic review, assessments were mostly subjective, al- that there is no randomized controlled study on this though objective FEES [16] and of coughing with PCF critical issue. Several individualized, non-comparative [12] or PIF [18] have also been attempted. Endoscopic and non-validated decannulation protocols exist. How- evaluation of swallowing though technically demanding ever, a blinded randomized controlled study, either provides an objective assessment. However, studies in comparing protocolized and non-protocolized (usual support of this approach are limited. Only two studies Fig. 2 Decannulation algorithm Singh et al. Journal of Intensive Care (2017) 5:38 Page 11 of 12 [16, 23] out of 18 incorporated fibreoptic endoscopic studies in a concise tabular form. Our systematic review evaluation of vocal cords and/or swallowing prior to also incorporates the Q-Coh tool [10] to assess the meth- decannulation. Warnecke T et al. in their study per- odological quality of included cohort studies. As none of formed a mandatory step of FEES in their decannulation the studies included are of desired quality, the need for process [16]. In a recent retrospective study by Cohen et randomized controlled study on decannulation cannot be al., a three-step endoscopic confirmation of vocal cord over emphasized. However, our systematic review also has mobility and normal supraglottis was ascertained prior several limitations. We have not searched other databases to immediate decannulation [23]. He considered imme- like Google Scholar, Scopus or EMBASE and also not in- diate decannulation as a safer and shorter alternative for cluded non-English language articles. weaning in tracheostomized patients as compared to Our protocolized decannulation algorithm (Fig. 2) in- traditional decannulation. When so many decannula- corporates easy to use bed-side checklist for evaluation tions can happen without FEES, then what extra benefit of patients deemed fit for decannulation. The screening does this technically demanding step offer over clinical checklist includes assessment for intactness of sensor- swallowing evaluation (CSE) needs to be ascertained. ium, characteristics of secretions and need and fre- Graves et al. [11] also concluded about good success rate quency of suctioning, effectiveness of swallowing and without fibreoptic evaluation prior to decannulation of coughing, patency of airway and successfulness of a pro- long-term MV patients. Availability and technical ex- longed spontaneous breathing trial (SBT). The patient pertise of FEES needs to be ensured before including it should be conscious, oriented and be able to maintain a in any decannulation protocol. patent airway. Secretions should be easy to handle by Similarly, subjective assessment of coughing is the the patient and frequency of suctioning should be less usual norm. Only Bach et al. [12] in 1996, Ceriana et al. than 4 in the previous 24 hours. The patient must be [8] in 2003, Chan LYY et al. [15] in 2010 and Guerlain J able to swallow liquids/semisolids without risk of aspir- et al. [18] in 2015 used an objective measure of an ation, have adequate cough with good peak expiratory effective cough to decide about decannulation. PCF, MEP flow rate (PEFR) (>160 L/min) and be able to maintain a and PIF are all parameters used by these investigators as patent airway. Patency of the airway can be assessed measures of an effective cough. However, superiority of bedside by simply deflating the cuff and occluding the one over the other is undecided. TT with a gloved finger for testing phonation of the pa- The adopted method of decannulation is also variable. tient. In patients with prolonged MV of greater than While some authors preferred TT occlusion after down- 4 weeks, the duration of successful SBT should prefera- sizing to fenestrated or non-fenestrated tube [8, 11], bly be 48 hours or more. After the initial screening others straight away capped the TT without downsizing checklist, decision about the decannulation technique is [4, 13], while some abruptly removed the TT [9, 14]. based on the duration of MV and presence of neuromus- The choice of the method is based on patient’s tolerabil- cular weakness. Patients with less than 4 weeks of MV ity of the procedure and also on the physician’s experi- and with no suspicion of neuromuscular weakness are ence. There exists no universally accepted method. subjected to a corking trial. This trial involves blocking Furthermore, discrepancy also exists in the period of the existing TT after cuff deflation followed by careful observation before which decannulation is deemed instructions to the bedside nurse/physician to re-inflate successful. Probably, a combination of factors like the the cuff in case of respiratory distress. Depending on the period of MV prior to decannulation, anticipation of tolerability and absence of any distress the TT is decan- neuromuscular fatigue on account of respiratory work- nulated. However, in case of a failed corking trial the TT load and protection of airway all play a role. can be downsized and blocked followed by a period of The self-confessed limitations of the included studies careful observation for few hours. If the observation were as depicted in Table 2. Specific illness group, small period is not associated with any respiratory distress sample size, retrospective design, and non-standardized, decannulation can then be performed. Patients who non-protocolized and non-validated method of decannu- failed the corking trail as well as downsizing & blocking lation are the major limitations of the included studies. and are in respiratory distress need immediate upsizing But above all, absence of a randomized controlled study in of the TT to resume ventilation. Further assessment this aspect of care is a major hurdle. The previously pub- warrants a FOB examination to explore the cause of fail- lished systematic review on tracheostomy decannulation ure. In patients with MV for more than 4 weeks and was by Santus P et al. [26] in 2014. Our systematic review with suspicion of neuromuscular weakness the decannu- has included 10 of these studies apart from addition of an- lation technique is that of downsizing and blocking. In other 8. While he compared primary and secondary out- case of failure and respiratory distress, approach remains comes of included studies, our review is much more same as above. This protocol is currently under evalu- exhaustive in that it incorporates the relevant details of 18 ation in our unit via a randomized study. Singh et al. Journal of Intensive Care (2017) 5:38 Page 12 of 12 Conclusions 5. Heffner JE, Hess D. Tracheostomy management in the chronically ventilated patient. Clin Chest Med. 2001;22(1):55–69. Decannulation is an essential step towards liberating a 6. Martinez GH, Fernandez R, Casado MS, Cuena R, Lopez-Reina P, Zamora S, tracheostomized patient from mechanical ventilation. et al. Tracheostomy tube in place at intensive care unit discharge is This transition is more often individualized than proto- associated with increased ward mortality. Respir Care. 2009;54(12):1644–52. 7. Fernandez R, Bacelar N, Hernandez G, Tubau I, Baigorri F, Gili G, et al. Ward colized. Universally accepted protocol is needed for mortality in patients discharged from the ICU with tracheostomy may better standardization. Randomized controlled studies in depend on patient’s vulnerability. Intensive Care Med. 2008;34(10):1878–82. this aspect of tracheostomy care can make it more 8. Ceriana P, Carlucci A, Navalesi P, Rampulla C, Delmastro M, Piaggi G, et al. Weaning from tracheotomy in long-term mechanically ventilated patients: evidence based. feasibility of a decisional flowchart and clinical outcome. Intensive Care Med. 2003;29(5):845–8. 9. Shrestha KK, Mohindra S, Mohindra S. How to decannulate tracheostomised Additional file severe head trauma patients: a comparison of gradual vs abrupt technique. Nepal Med Coll J. 2012;14(3):207–11. Additional file 1: Table S1. Quality of cohort studies as assessed by Q- 10. Jarde A, Losilla J, Vives J, Rodrigo MF. Q-Coh: a tool to screen the Coh tool. (DOCX 26 kb) methodological quality of cohort studies in systematic reviews and meta- analyses. Int J Clin Heal Psychol. 2013;13:138–46. 11. Rumbak MJ, Graves AE, Scott MP, Sporn GK, Walsh FW, Anderson WM, Abbreviations Goldman AL. Tracheostomy tube occlusion protoc predict success tracheal CSE: Clinical swallowing examination; FESS: Fibreoptic endoscopic evaluation decannulation follow long term mech vent. Crit Care Med. 1997;25(3):413–7. of swallowing; HDU: High dependency unit; ICU: Intensive care unit; 12. Bach JR, Saporito LR. Criteria for extubation and tracheostomy tube removal MEP: Maximum expiratory pressure; MV: Mechanical ventilation; NIV: Non- for patients with ventilatory failure: a different approach to weaning. Chest. invasive ventilation; PCDT: Percutaneous dilatational tracheostomy; PCF: Peak 1996;110(6):1566–71. cough flow; PIF: Peak inspiratory flow; TT: Tracheostomy tube 13. Tobin AE, Santamaria JD. An intensivist-led tracheostomy review team is associated with shorter decannulation time and length of stay: a Acknowledgements prospective cohort study. Crit Care. 2008;12(2):R48. Not applicable. 14. Choate K, Barbetti J, Currey J. Tracheostomy decannulation failure rate following critical illness: a prospective descriptive study. Aust Crit Care. 2009; Funding 22(1):8–15. The author(s) received no financial support this study. 15. Chan LYY, Jones AYM, Chung RCK, Hung KN. Peak flow rate during induced cough: a predictor of successful decannulation of a tracheotomy tube in Availability of data and materials neurosurgical patients. Am J Crit Care. 2010;19(3):278–84. Data sharing is not applicable to this article as no datasets were generated 16. Warnecke T, Suntrup S, Teismann IK, Hamacher C, Oelenberg S, Dziewas R. or analyzed during the current study. Standardized endoscopic swallowing evaluation for tracheostomy decannulation in critically ill neurologic patients. Crit Care Med. 2013;41(7):1728–32. 17. Pandian V, Miller CR, Schiavi AJ, Yarmus L, Contractor A, Haut ER, et al. Authors’ contributions Utilization of a standardized tracheostomy capping and decannulation RKS, SS and AKB contributed equally to the design, data acquisition and protocol to improve patient safety. Laryngoscope. 2014;124(8):1794–800. manuscript preparation. All authors read and approved the final manuscript. 18. Guerlain J, Guerrero JAS, Baujat B, St Guily JL, Périé S. Peak inspiratory flow is a simple means of predicting decannulation success following head and Competing interests neck cancer surgery: a prospective study of fifty-six patients. Laryngoscope. The author(s) declare that they have no competing interests. 2015;125(2):365–70. 19. Leung R, MacGregor L, Campbell D, Berkowitz RG. Decannulation and Consent for publication survival following tracheostomy in an intensive care unit. Ann Otol Rhinol Not applicable. Laryngol. 2003;112(10):853–8. 20. Budweiser S, Baur T, Jörres RA, Kollert F, Pfeifer M, Heinemann F. Predictors Ethics approval and consent to participate of successful decannulation using a tracheostomy retainer in patients with Not applicable. prolonged weaning and persisting respiratory failure. Respiration. 2012;84(6): 469–76. 21. Byrd JK, Ranasinghe VJ, Day KE, Wolf BJ, Lentsch EJ. Predictors of clinical Publisher’sNote outcome after tracheotomy in critically ill obese patients. Laryngoscope. 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