Failure of standard tracheostomy decannulation criteria to detect suprastomal pathology

Abstract

Meeting established criteria for tracheostomy decannulation should improve success, although there will be a small proportion of patients with a tracheostomy who fail decannulation. Failure rates depend on patient characteristics and disparity between institutional practices and expert opinion. However, there are no widely accepted published failure rates, or agreement on the time-point at which failure is assessed. We present a patient who had evidence of readiness for decannulation, but had immediate failure due to extrinsic tracheal compression, which proved difficult to diagnose and required surgery to resolve. Capping the tracheostomy before decannulation may or may not have given rise to suspicion of potential failure and this practice requires further evaluation as it is not without risk. For subglottic, but suprastomal lesions, nasendoscopy is not of value. It is important to decannulate patients in a safe environment, preferably early in the day to allow post decannulation observations and interventions should they become necessary, and with the close involvement of the multi-professional team. This report illustrates the failure of our standard Tracheostomy decannulation criteria, and direct upper airway view to identify suprastomal tracheal pathology, and we discuss the potential for additional criteria which may have identified the issue before decannulation attempts.

A Simplified Protocol for Tracheostomy Decannulation in Patients Weaned off Prolonged Mechanical Ventilation

“…Moreover, performing the retrograde and antegrade tracheoscopy after removing the tube could also aid in unmasking the underlying tracheomalacia, which can be observed in many patients with long-standing tracheostomy dependence. 1 The assessment of the airway by flexible tracheoscopy is dependent on the observer. 19 In the present study, although eight consultant otolaryngologists were involved in the airway assessment, an evaluation of the interobserver variability was not possible due to the retrospective nature of the study.…”

“…Although the procedure itself may sound simple, the implications of improperly-performed and abrupt decannulation can be catastrophic at times. 1,2 To be eligible for decannulation, a patient with a tracheostomy should have a reasonable neurological status, with a good swallowing function, an adequate airway, and a satisfactory pulmonary function. [3][4][5][6] To elaborate, as for the neurological status, the patient should be conscious and alert, and have a good cough reflex to clear the secretions from the lower airway.…”

Tracheostomy healing time after decannulation

“…A recent study including 50 patients demonstrated a similar rate [ 11 ]. The wide variation in failure rates may be due to a lack of agreement on the time-point for assessing failure [ 23 ]. A previous study reported failure rates between 3.5% and 32% with registration of recannulation within 1-60 days [ 5 ].…”

Identification of Laryngotracheal Stenosis During Weaning from Tracheostomy – A Clinical Conundrum

“…These inspiratory negative pressures may be sufficient to overcome the structural integrity of incompetent or narrowed supra-stomal segments due to the collapsing pressures generated. Inability to tolerate capping may be indicative of laryngotracheal pathology although the tracheostomy tube itself may "splint" the suprastomal tracheal segment during these negative pressure swings and mask potential complications [4]. While "capping" is discussed in the literature, the purpose, timing and duration of applying a tracheostomy cap lacks consensus and guidelines.…”

“…

These criteria can be insufficient to detect the presence of suprastomal pathology as described previously [4], although this complication occurs infrequently compared to the number of patients who can be successfully decannulated using recognized decannulation criteria [5]. This narrative explores the rationale underlying the components

…”