Does a decannulation protocol exist in COVID-19 patients? The importance of working in a multiprofessional team

Abstract

As a Covid Hub in Emilia Romagna, we have experienced an increasing number of tracheostomized patients, prompting us to develop a standardized decannulation protocol for COVID-19 ARDS patients. Currently, there are no guidelines or protocols for decannulation in this population, and few studies have investigated the early outcomes of tracheostomy in COVID-19 patients, with no detailed analysis of the decannulation process. We recognized the importance of mutual reliance among our team members and the significant achievements we made compared to previous decannulation methods. Through the optimization of the decannulation process, we identified a clear, safe, and repeatable method based on clinical best practice and literature evidence. We decided to implement an existing standardized decannulation protocol, which was originally designed for severe brain-damaged patients, due to the growing number of COVID-19 patients with tracheostomy. This protocol was designed for daily practice and aimed to provide a uniform approach to using devices like fenestrated cannulas, speaking valves, and capping. The results of our implementation include: expanding the applicability of the protocol beyond severe brain-damaged patients to different populations and settings (in this case, patients subjected to a long period of sedation and invasive ventilation) early activation of speech therapy to facilitate weaning from the cannula and recovery of physiological swallowing and phonation early activation of otolaryngologist evaluation to identify organic problems related to prolonged intubation, tracheostomy, and ventilation and address proper speech therapy treatment activation of more fluid and effective management paths for decannulation with a multiprofessional team.

Atuação fonoaudiológica em pacientes traqueostomizados no contexto da COVID-19

“…Em relação à TQT, uma publicação científica prévia à pandemia descreveu como parâmetros considerados preditivos para o processo de decanulação a estabilidade clínica e hemodinâmica, condição funcional pulmonar favorável, bom gerenciamento de secreções e proteção de vias aéreas com tosse eficaz, tolerância ao cuff desinsuflado e à oclusão da TQT (16) . Contudo, ao verificar a falta de estudos sobre a análise detalhada do processo de decanulação de pacientes com TQT e COVID-19, pesquisadores criaram um protocolo, adaptado de outro existente e desenvolvido para pacientes com lesão cerebral adquirida grave, visando alcançar as melhores práticas em termos de segurança e prevenção de complicações da TQT (27) . Suas fases correspondem: 1) desinsuflação do cuff; 2) avaliação da gestão de secreções orofaríngeas (Blue Dye Test realizado pelo fonoaudiólogo); 3) avaliação com médico otorrinolaringologista para fibrobroncoscopia e troca da cânula de TQT (fenestrada ou não, com ou sem cuff); 4) teste de oclusão da TQT por cinco minutos (adaptação ou não de válvula de fala); 5) oclusão da TQT por 48-72 horas para decanulação.…”

Speech therapy performance in tracheostomized patients in the context of COVID-19

“…In relation to tracheostomy, a scientific publication prior to the pandemic described as parameters considered predictive for the decannulation process the clinical and hemodynamic stability, favorable pulmonary functional condition, good secretion management, airway protection with effective cough, tolerance to cuff deflation and tracheostomy occlusion (16) . However, after noting the lack of studies on the detailed analysis of the decannulation process of patients with tracheostomy and COVID-19, researchers created a protocol, adapted from an existing one and developed for patients with severe acquired brain injury, in order to achieve best practices in terms of safety and prevention of tracheostomy complications (27) . Its phases correspond to: 1) cuff deflation; 2) assessment of oropharyngeal secretion management (Blue Dye Test carried out by the speech therapist); 3) assessment with an otolaryngologist for fibrobronchoscopy and replacement of the tracheostomy tube (fenestrated or not, with or without cuff); 4) 5-minute tracheostomy occlusion test (adaptation or not of a speech valve); 5) tracheostomy occlusion for 48-72 hours for decannulation.…”