Tracheostomy decannulation protocol in patients with prolonged tracheostomy referred to a rehabilitation hospital: a prospective cohort study

Using ML techniques to predict extubation outcomes for patients with central nervous system injuries in the Yun-Gui Plateau

No predictive models have been reported for tracheostomy extubation success in plateau region rehabilitation departments. Hence, the primary objective of this retrospective study was to evaluate the predictive capabilities of different models for extubation outcomes in CNS injury patients in plateau rehabilitation departments, as well as investigate the influence of clinical features on these outcomes. Data were collected from 501 adult tracheostomy patients in the Department of Rehabilitation Medicine, including 196 successful extubations. Logistic regression was employed to identify the significant features linked to extubation outcomes from a pool of 31 variables. A total of eight independent models and a weighted posterior voting ensemble model were developed. Hyperparameter optimization and tenfold cross-validation were used to assist in choosing model parameters. Random forest (ACC = 84.15, AUC = 0.85), extra trees (83.17%, 0.87), K-NN (82.18%, 0.85), and gradient boosting (81.19%, 0.85) performed well. An ensemble model (85.15%, 0.87) combining random forest, Gaussian naive Bayes, and K-NN via the WPV method was developed. Dysphagia and low GCS scores have been linked to increased difficulty in extubation, as indicated by SHAP values and previous studies. Moreover, there could be a relationship between chronic inflammation and albumin levels in patients, which may collectively impact extubation success. This study evaluated the effectiveness of conventional models for predicting extubation outcomes and analyzed the factors influencing extubation results at high altitudes, laying the groundwork for clinical use and future research. Nevertheless, further research will see advantages in using multicentric approaches and broadening clinical indicators.

Optimizing tracheostomy weaning with PDCA cycles: a four-year multidisciplinary quality improvement initiative in Northeast Brazil

PURPOSE

We aimed to assess the impact of plan-do-check-act (PDCA) cycles on tracheostomy weaning in ICU patients from 2019 through 2023.

DESIGN/METHODOLOGY/APPROACH

A retrospective study was conducted at a private hospital, analyzing recorded data from two PDCA cycles that were implemented to reduce mean tracheostomy weaning times between 2019 and 2023. We further classified distinct timeframes for a separate analysis, including the baseline (April 2019-August 2020), the period post-PDCA cycle I (January 2021-April 2022) and the period post-PDCA cycle II (August 2022-December 2023).

FINDINGS

A total of 70 individuals completed the protocol (mean age ± SD, 60.51 ± 17.19 years; 31.4% female). One-way ANOVA revealed mean differences in weaning time compared to 2019 were significant: 2020-3.86 days (p = 0.02), 2021-6.56 days (p = 0.00), 2022-7.80 days (p = 0.00) and 2023-8.74 days (p = 0.00). Subgroup analysis also revealed significant differences in weaning time among baseline, post-first PDCA cycle and post-second PDCA cycle (F (2) = 20.15, p = 0.00, η2 = 0.51).

ORIGINALITY/VALUE

This management model underscores the benefits of consistently improving the quality management of physiotherapy, delivering value-based healthcare through the collaboration of a multidisciplinary team.

The Validation of the Italian Version of the Munich Swallowing Score (IT-MUCSS) Against the Fiberoptic Endoscopic Evaluation of Swallowing and Food Intake Modalities in Patients with Neurogenic Dysphagia: A Cross-Sectional Study

Background/Objectives: Oral intake and secretions need to be assessed separately, especially in patients with tracheal tubes, as they are vital for dysphagia treatment and may require different management strategies. This study aims to validate the Italian version of the Munich Swallowing Score (IT-MUCSS) by examining its content and construct validity in relation to the fiberoptic endoscopic evaluation of swallowing (FEES) and oral intake in adults with neurogenic dysphagia, as well as assessing intra- and inter-rater reliability. This tool is clinically and scientifically useful as it includes two subscales: IT-MUCSS-Saliva, which assesses saliva/secretion management and the presence of a tracheal tube, and IT-MUCSS-Alimentazione, which evaluates feeding methods. Methods: In this prospective cross-sectional study, a total of 50 dysphagic patients with a neurological diagnosis were recruited from a neuro-rehabilitation hospital and underwent both clinical and instrumental assessments. The main outcome measures included evaluating food and liquid intake using the Italian versions of the Functional Oral Intake Scale (FOIS-It) and the IT-MUCSS. Pharyngeal residues were assessed using the Yale Pharyngeal Residue Severity Rating Scale (IT-YPRSRS), and airway penetration/aspiration were evaluated using the Penetration-Aspiration Scale (PAS) during FEES. Results: The IT-MUCSS demonstrated excellent reproducibility (K = 0.91) and internal consistency (Cronbach's alpha = 0.72). Strong correlations were found between IT-MUCSS and the FOIS-It scale, indicating the effective assessment of dysphagia. Test-retest reliability was high (ICC = 0.96 for total score). Construct validity was confirmed through significant correlations with instrumental measures during FEES. Conclusions: The IT-MUCSS is a valid tool for assessing functional oral intake and the management of saliva/secretions, specifically in relation to the level of saliva/secretions management compared to FEES measures of swallowing safety and efficiency in patients with neurogenic dysphagia.

Nomograms for the prediction of decannulation in patients with neurological injury: a study based on clinical practice

BACKGROUND

Rational prediction of the probability of decannulation in tracheotomy patients is of great importance to clinicians and patients' families. This study aimed to develop a prediction model for decannulation in tracheotomized patients with neurological injury using routine clinical data and blood tests.

METHODS

We developed a prediction model based on 186 tracheotomized patients, and data were collected from January 2018 to March 2021. The least absolute shrinkage and selection operator (LASSO) regression model was used to optimize feature selection for the decannulation risk model. The performance of the prediction model was evaluated in terms of discrimination, calibration, and clinical utility using measures such as C-index, calibration plot, and decision curve analysis (DCA). Internal validation was performed through bootstrapping validation.

RESULTS

A total of 66.13% (123/186) of patients were decannulated. Predictors included in the prediction nomogram were age, gender, subtype of neurological injury, Glasgow Coma Scale (GCS) score, swallowing function, duration of tracheotomy, procalcitonin (PCT) level, white blood cell (WBC) count, and serum albumin (ALB) level. The predictive model showed good discrimination, with a C-index of 0.755 (95% confidence interval: 0.68-0.83). Internal validation also confirmed a satisfactory C-index of 0.690. The DCA indicated that the nomogram added substantial value in predicting decannulation risk for patients with threshold probabilities falling between >21% and <98% compared to the existing scheme.

CONCLUSIONS

This predictive model serves as a valuable instrument for clinicians to quantitatively assess the probability of decannulation in patients with neurological injury, aiding in informed decision-making and patient management.

The influencing factors for tracheostomy decannulation after traumatic cervical spinal cord injury: a retrospective study

STUDY DESIGN

Retrospective study.

OBJECTIVE

To investigate the outcomes and influencing factors of tracheostomy decannulation (TD) in persons with traumatic cervical spinal cord injury (SCI).

SETTING

China Rehabilitation Research Center (CRRC) in Beijing, China.

METHODS

From January 2017 to December 2021, 365 persons with traumatic cervical SCI were admitted to the China Rehabilitation Research Center. During hospitalization, tracheostomy patients were enrolled and divided into the TD group and non-TD group. Demographic and clinical data, as well as functional assessments, were collected and recorded for all persons. The factors influencing TD were analyzed using both univariate and multivariate logistic regression.

RESULTS

A total of 78 persons with traumatic cervical SCI from CRRC were enrolled in this study. Of these, 48 persons (61.5%) underwent successful decannulation, with a median time of 93.5 days (IQR: 62.0-143.8 days). Multivariate logistic regression revealed that AIS A (P = 0.021, OR: 5.378, 95% CI, 1.287-22.474) and Charlson comorbidity index (CCI) (P = 0.003, OR: 1.836, 95% CI, 1.230-2.740) were significant risk factors of reduced success in TD. PEF in the TD group was 145.44 ± 50.56 L/min. Middle-aged and young persons with traumatic cervical SCI at C3 to C5 neurological level did not satisfy the criterion of PEF (over 160 L/min), but they can still attempt tracheostomy decannulation.

CONCLUSION

AIS A and a high CCI will reduce the success rate of tracheostomy decannulation in persons suffering from traumatic cervical SCI.

Tracheostomy - A Comparative Study of Decannulation with Gradual Blocking of the Tube vs. Reduction of the Size of Tube - A Prospective Study

Background

Tracheostomy is one of the most common procedures done in intensive care unit (ICU) patients. Decannulation is the weaning off from tracheostomy to maintain spontaneous respiration and/or airway protection. However, this step needs a near perfect coordination of brain, swallowing, coughing, phonation, and respiratory muscles. However, despite its perceived importance, there is no universally accepted protocol for this vital transition. In this systematic review of decannulation we focus attention to this important aspect of tracheostomy care.

Aim

To compare the two methods of decannulation, with gradual blocking of the tube and reducing the size of the tube and also study and compare the incidental complications associated with both methods.

Methodology

This longitudinal, open label, randomized, observational study of 50 patients who were tracheostomized for more than 7 days was carried out in a tertiary health care Centre in central India. Over the course of 2 years demographic data, clinical information was collected and patients divided into 2 groups according to the method of decannulation done by a simple randomization method. The outcomes and the complications associated with the two techniques in the study groups were also be noted down and then compared.

Results

Maximum number of patients in both the study groups were males (56% in group with tube blocking, and 52% in group with tube size reduction). 48% cases in group with tube blocking, and 60% in group with tube size reduction were noted to be between 51 and 70 years' age group. The mean duration between tracheostomy and decannulation in group with tube blocking was 16.63 + 8.44 days, and while it was 16.71 + 8.79 days in group with tube size reduction. 36% patients in group with tube blocking had tracheostomy tube number 7.5, while 32% had tube number 8. 36% in group with tube size reduction had tube number 7.5 while 32% had tube size 7. 4 patients in group with tube blocking, and 3 patients in group with tube size reduction required reinsertion of tube. 40% patients in group with tube blocking, and 44% in group with tube size reduction underwent tracheostomy following prolonged intubation. 4 patients in group with tube blocking, and 3 patients in group with tube size reduction required reinsertion of tube. 1 patient in group with tube blocking had trachea-esophageal fistula as post decannulation complication. 1 patient each in group with tube size reduction had granule formation over stoma and tracheal stenosis as complications.

Conclusion

The two decannulation methods, viz., gradual blocking of tube and reduction of tube size, showed comparable outcomes in terms of tube reinsertion rate, mechanical ventilation rate after decannulation, successful decannulation, and complications.

Single-Stage Bronchoscopy-Guided Protocol for Tracheostomy Decannulation in Adult Patients

INTRODUCTION

Tracheostomy decannulation is a routine procedure in airway management. There is no standard decannulation method; however, the two commonly practiced approaches are tracheostomy downsizing and intermittent capping, which are both accompanied by multiple visits to the clinic and increase patient discomfort. Herein, we explore fiberoptic bronchoscopy application in a novel single-stage decannulation protocol.

METHODS

We conducted a retrospective study on tracheostomy patients eligible for decannulation. Fiberoptic bronchoscopy was performed on patients with spontaneous ventilation for ≥48 h, age ≥18, hemodynamic stability, normal chest X-ray, adequate swallowing, effective cough, adequate consciousness, patent speaking valve, and absent history of recurrent aspiration. Tracheostomy removal occurred after evaluating the airway and ruling out tracheomalacia, tracheitis with stenosis, obstructive granulation tissue, and moderate-to-severe stenosis. We documented patients' demographic and clinical information, along with details of their post-decannulation course.

RESULTS

Out of 58 patients admitted for tracheostomy removal, we excluded six patients (10.3%) from the study because, despite clinical indications for successful weaning, they exhibited abnormalities that interrupted the decannulation process. Of the remaining 52 patients, 50 (96.1%) were successfully weaned off, while two needed reinsertion during their hospital course. Bronchoscopy findings were unremarkable in 33 (63.5%) patients, and the most frequently observed abnormalities were paucity of vocal cord movement in 5 (9.6%) patients and granulation tissue formation in 5 (9.6%) patients. No further airway management was necessary after discharge.

CONCLUSIONS

Our study introduces the innovative approach of single-stage bronchoscopic decannulation as a potentially beneficial tool for immediate decannulation. Based on our experience, we achieved a relatively satisfactory outcome following single-stage tracheostomy decannulation with bronchoscopy. The approach shows promise in providing valuable airway insights and predicting possible decannulation failures. Further research is needed to evaluate its impact on stress reduction for patients and surgeons, its superiority compared to traditional techniques, its long-term effects on healthcare, and its potential cost-effectiveness.

Prognostic factors for tracheostomy early decannulation in acquired brain injury patients

After severe brain injuries, a tracheostomy tube is usually inserted for respiratory support. This study aimed to clarify the prognostic factors for tracheostomy early decannulation in patients with acquired brain injuries. We retrospectively reviewed the medical records of inpatients with acquired brain injuries who underwent successful tracheostomy decannulation between March 2021 and June 2022. Fifty-six patients were included; median age was 68 (59-72) years; 28 (50%) were men; 28 (50%) underwent tracheostomy due to stroke. The median time to decannulation was 47 days. The patients were divided into the early and the late decannulation groups based on the median time, and compared. In univariate analysis, the early decannulation group had a higher BMI, peak cough flow, and acquired brain injuries due to trauma, and a lower penetration-aspiration scale score, duration of antibiotic use, and duration of oxygen use. Multivariate Cox regression analysis revealed that a higher initial peak cough flow [hazard ratio (HR) 1.142; 95% confidence interval (CI) 0.912-0.954; P  < 0.001] and lower duration of oxygen use (HR 0.930; 95% CI 0.502-0.864; P  = 0.016) were independent factors for early tracheostomy decannulation, with each unit increase in peak cough flow corresponding to a 14.2% increase and each additional day of duration of oxygen use corresponding to a 7.0% decrease in the likelihood of early decannulation. In conclusion, key prognostic factors for early tracheostomy decannulation were identified as the initial cough strength and duration of oxygen use. These results could play important role in decannulation plans for patients with tracheostomy tube.

Cough flows as a criterion for decannulation of autonomously breathing patients with tracheostomy tubes

BACKGROUND

Adequate cough or exsufflation flow can indicate an option for safe tracheostomy decannulation to noninvasive management. Cough peak flow via the upper airways with the tube capped is an outcome predictor for decannulation readiness in patients with neuromuscular impairment. However, this threshold value is typically measured with tracheotomy tube removed, which is not acceptable culturally in China. The aim of this study was to assess the feasibility and safety of using cough flow measured with tracheostomy tube and speaking valve (CFSV) > 100 L/min as a cutoff value for decannulation.

STUDY DESIGN

Prospective observational study conducted between January 2019 and September 2022 in a tertiary rehabilitation hospital.

METHODS

Patients with prolonged tracheostomy tube placement were referred for screening. Each patient was assessed using a standardized tracheostomy decannulation protocol, in which CFSV greater than 100 L/min indicated that the patients' cough ability was sufficient for decannulation. Patients whose CFSV matched the threshold value and other protocol criteria were decannulated, and the reintubation and mortality rates were followed-up for 6 months.

RESULTS

A total of 218 patients were screened and 193 patients were included. A total of 105 patients underwent decannulation, 103 patients were decannulated successfully, and 2 patients decannulated failure, required reinsertion of the tracheostomy tube within 48 h (failure rate 1.9%). Three patients required reinsertion or translaryngeal intubation within 6 months.

CONCLUSIONS

CFSV greater than 100 L/min could be a reliable threshold value for successful decannulation in patients with various primary diseases with a tracheostomy tube.

TRIAL REGISTRATION

This observational study was not registered online.

Predictors of long-term decannulation in patients with disorders of consciousness

Purpose

The predictors of tracheostomy decannulation in patients with disorders of consciousness (DOC) are not comprehensively understood, making prognosis difficult. The primary objective of this study was to identify predictors of tracheostomy decannulation in patients with disorders of consciousness (DOC). The secondary aim was to evaluate the feasibility and safety of the modified Evans blue dye test (MEBDT) in tracheostomized DOC patients.

Methods

This retrospective study included all patients with disorders of consciousness (DOC) who underwent tracheostomy and were admitted between January 2016 and September 2022. Age, sex, etiology, initial Glasgow coma scale (GCS), initial Coma Recovery Scale-Revised (CRS-R), diagnosis of unresponsive wakefulness syndrome (UWS) or minimal consciousness state (MCS), MEBDT, initial modified Rankin scale (mRS), and initial Functional Oral Intake Scale (FOIS) were collected upon study enrollment. The relationship between clinical characteristics and cannulation status was investigated through a Cox regression model.

Results

A total of 141 patients were included in the study. The average age of these patients was 52.5 ± 16.7 years, with 42 (29.8%) being women. During the study period, 86 subjects (61%) underwent successful decannulation. Univariate analysis revealed that decannulated patients exhibited a significantly better conscious state compared to those without decannulation (CRS-R: p < 0.001; GCS: p = 0.023; MCS vs. UWS: p < 0.001). Additionally, a negative modified Evans blue dye test (MEBDT) result was significantly associated with tracheostomy decannulation (p < 0.001). In the multivariate analysis, successful decannulation was associated with a higher level of consciousness (MCS vs. UWS, p < 0.001, HR = 6.694) and a negative MEBDT result (negative vs. positive, p = 0.006, HR = 1.873). The Kaplan-Meier analysis further demonstrated that MEBDT-negative patients and those in the MCS category had a higher probability of decannulation at 12 months (p < 0.001).

Conclusion

The findings of this study indicate that a negative MEBDT result and a higher level of consciousness can serve as predictive factors for successful tracheostomy decannulation in DOC patients.