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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
  1. Abbreviations: NA not available, RR respiratory rate, SaO 2 arterial oxygen saturation, TT tracheostomy tube, FOB fibre optic bronchoscope, MV mechanical ventilation, N normal, PaO 2 partial pressure of 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 2 arterial partial pressure of carbondioxide, LOS length of stay, ICU intensive care unit, AECOPD acute exacerbation of chronic obstructive pulmonary disease, PCT percutaneous tracheostomy, LTAC long-term acute care, PMV prolonged mechanical ventilation, ARDS acute respiratory distress syndrome, GCS Glasgow coma scale, ICH intracranial haemorrhage, GBS Guillain–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 2 fraction of inspired oxygen concentration