Table 2 Characteristics of included studies
From: The practice of tracheostomy decannulation—a systematic review
Author (Ref) | Method of decannulation | Primary outcome | Secondary outcome | Failure rate (%) | Time to recannulation | Limitations | Inference |
|---|---|---|---|---|---|---|---|
Graves A et al. [11] | TT occlusion protocol after downsizing to fenestrated cuffed 7/8 portex tube | Decannulation | Decannulation | 20 | NA | NA | Even without FOB decannulation can be done with good success rate following long term MV |
Bach et al. [12] | After measuring peak cough flow (PCF), switched to fenestrated cuffed TT that can be capped. Use of Nasal IPPV and MI–E, tube capped. If successful, TT removed, site closed, NIV and assisted coughing continued. | Decannulation | Factors predicting successful decannulation: Age Extent of pre-decannulation ventilator use Vital capacity Peak cough flow (PCF) | 32 | Within 3 days | Specific to neuromuscular and long-term MV pts NIV given to decannulated pts | Patients decannulated irrespective of their ventilator capacity. PCF >160 L/min predicted success Whereas <160 L/min predicted need to replace the tube |
Ceriana et al. [8] | TT downsized to 6 mm and capped for 3–4 days Clinical stability Absence of psychiatric disorders Effective cough (MEP ≥40 cmH2O). PaCO2 <60 mmHg Adequate swallowing (Gag reflex or blue dye test) No tracheal stenosis endoscopically Spontaneous breathing for ≥5 days | Decannulation | NA | 3.5 | Up to 3 and 6 months | NA | Large majority of patients with clinical stability can be decannulated with reintubation rate less than 3% after 3 months |
Leung et al. [19] | Not mentioned | Decannulation | Survival | 6 | During hospital stay. | Small sample size. Retrospective nature of the study. | ICU patients who require TT have high mortality (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. [13] | Tolerate capping >24 h Cough effective (No need of suctioning) Speech (Passey–Muir valve) | Decannulation time from ICU discharge | LOS hospital LOS after discharge from ICU | 13 | NA | Retrospective data collection Lack of similar care in wards | Intensivist-led TT team is associated with shorter decannulation time and length of stay. |
Stelfox et al. [24] | Tolerates TT capping (24 vs. 72 h) Effective cough (strong vs. weak) Secretions (thick vs. thin) Level of consciousness (alert vs. drowsy but arousable) | Which patient factors clinician’s rate as being important in the decision to decannulate? Which clinician and patient factors are associated with clinician’s recommendations to decannulate TT? Define decannulation failure. What do clinicians consider an acceptable rate of decannulation failure? | NA | 20.4 | Within 48 h (45% opinion) to 96 h (20% opinion) Acceptable rate of failure as 2–5%. | Only 73% responded to the questionnaire. | Patient’s level of consciousness, cough effectiveness, secretions, and oxygenation are all important determinants to decide decannulation. |
Choate et al. [14] | Cuffless then check airflow through upper airway followed by TT removal | TD practice and failure rates during 4-year and 10-month study period | NA | 5 | Until discharge from hospital | Single centre study High % of trauma and neurosurgical patients Descriptive data Decannulation criteria not specified | Old age, prolonged duration of TT and retention of sputum were risk factors for failure |
O Connor et al. [4] | TT occlusion with red cap/sleep apnea tube/Passy–Muir valve | Process of decannulation in patients of long-term acute care (LTAC) with prolonged MV (PMV) | NA | 19 | NA | Retrospective data collection | Decannulation was achieved in 35% of patients transferred to LTAC for weaning in patients with PMV |
Chan LYY et al. [15] | Amount of TT secretions at different time intervals (4 times; 2 h apart) in the same day followed by induced peak cough flow rate (PCFR) by suction catheter | Decannulation | NA | 6 | Within 72 h | Air leakage during PCF rate estimation as most of them were on uncuffed TT Single centre Small sample | Induced PCF rate: 42.6 L/min in successful vs. 29 L/min in unsuccessful, where 29 L/min may be considered as the determinant point |
Marchese et al. [25] | Scores for specific action Capping, 92/110 Tracheoscopy, 79/110 Tracheostomy button, 60/110 Downsizing, 44/110 | Decannulation | Calculus score Each parameter score—0 to 5 (max score–110) 1: Difficult intubation 2: 1+ H/O Chronic respiratory failure 3: Home ventilation 4: 3+ ventilation hrs/day 5: PaCO2 in stable state 6: Impaired swallowing 7: Underlying disease 8: Cough effectiveness 9: Relapse rate last year | 77 | NA | NA | Substantial % maintained TT despite no requirement of MV No consensus on indications and systems for closure of TT |
Budviewser et al. [20] | In patients with adequate cough and swallowing, the disc tracheostomy retainer (TR) is cut as per size of TT. Then inserted in a manner that it touches the ventral part of the trachea, thereby completely sealing the TT channel. | Decannulation | NA | 28 | Entire period of hospital stay | Did not measure PCF | Feasibility, efficacy and safety of TR in patients with prolonged weaning with high risk for recurrent or persistent hypercapnic respiratory failure |
Shrestha KK et al. [9] | Abrupt: TT removal instantaneously. Gradual: Downsizing TT followed by strapping over the tube followed by strapping over the stoma. Gradual (68) vs. Abrupt (50) | Decannulation | Factors enhancing successful decannulation | Gradual (G)—1.5 Abrupt(A)—6 S (G)—98.5 S (A)—94 | NA | NA | Factors associated with success were cough reflex, number of suctioning required per day, standard X-ray and use of antibiotics ≥7 days |
Warnecke T et al. [16] | Clinical swallowing assessment (CSE) followed by fibreoptic endoscopic evaluation of swallowing (FEES) with decision to decannulate based only on FEES | Decannulation based on FEES | To compare how many could have been decannulated without FEES | 1.9 | Till discharge from hospital | Small % with neuromuscular weakness | FEES is an efficient, reliable, bedside tool, performed safely in tracheostomized critically ill neurologic patients to guide decannulation. |
Kenneth B et al. [21] | Not mentioned | Tracheostomy type and patient outcome in terms of dependence, decannulation and death. | Patient factors associated with outcomes | 49 | NA | Retrospective data collection. Variability in co-morbidities(incomplete/incorrect medical records) | Increased tracheostomy dependence in OSA, and surgical tracheostomy |
Pandain V et al. [17] | Capping | Quality improvement project to develop a standardized protocol for TT capping and decannulation process | NA | 1.7 | Tolerates capping 12–24 h No ↑ FiO2 >40%, shortness of breath, suction requirement, hemodynamic instability is defined as success | Small sample size Non-randomized Labour-intensive protocol | Multidisciplinary protocol for determining readiness to capping trial prior to decannulation |
Guerlain J et al. [18] | Peak inspiratory flow (PIF) assessment through oral cavity after blocking TT cannula | Minimum peak inspiratory flow (PIF) required for successful decannulation | NA | 13 | Within 24 h | NA | PIF improves quality of care and optimizes outcomes following decannulation |
Pasqua et al. [22] | Insertion of a fenestrated cannula in the TT followed by its closure with a cap for progressively longer periods up to 48 h | Evaluate efficacy of protocol to analyze factors that could predict successful decannulation | NA | 37 | NA | NA | Using specific protocol, decannulation can be done. However, larger prospective studies required. |
Cohen et al. [23] | Study group: 3 step endoscopy Step 1—nasolaryngeal endoscopy confirming vocal cord mobility and normal supraglottis Step 2—TT removal Step 3—up and down look through TT stoma Control group: ↓TT or capping | Safety and feasibility of immediate decannulation compared to traditional decannulation | NA | 20: control 0: study groups respectively | Single centre Retrospective analysis Clinical decisions based on single person opinion Potential bias | Immediate decannulation may be a safer alternative for weaning |