An Interdisciplinary Approach to the Management of Individuals With Tracheostomy

Methods

This retrospective cohort study was approved by the institutional review board of the King Abdullah International Medical Research Center. Due to the study's retrospective design, informed consent was not required. All adult tracheostomy subjects admitted between January 2016 and December 2018 were included. Long-term tracheostomy patients with recurrent admissions and compromised airway and patients with neck tumors obstructing the airway were excluded.

An interdisciplinary tracheostomy team followed all subjects. To identify variables that could predict decannulation protocol outcomes, subjects who were successfully capped and decannulated were compared to those who failed capping and did not progress to decannulation.

We retrieved data on the subjects’ age, sex, comorbidities, Glasgow coma score (GCS), feeding, tracheotomy date, ICU discharge date, decannulation date, and outcome.^7,8 Comorbidities included diseases commonly encountered in tracheostomy patients (traumatic brain injury, stroke, brain tumors, pneumonia, COPD, heart failure, ischemic heart disease, and end-stage renal disease on dialysis).

The interdisciplinary tracheostomy team consisted of a respiratory therapist; a speech and swallowing clinician; an ear, nose, and throat (ENT) specialist; a rehabilitation medicine specialist; and a tracheostomy resource nurse. The respiratory therapist performed daily tracheostomy tube care; the speech and swallowing clinician performed endoscopic airway assessment and clinical and endoscopic swallowing assessments; the ENT specialist diagnosed and managed airway complications; the rehabilitation medicine specialist evaluated the subjects’ cognition and medical comorbidities; and the tracheostomy resource nurse ensured that subjects’ needs, regarding caregiver education, training, home supply, and equipment, were met. The team was notified as soon as the tracheostomy subjects were discharged from the ICU or admitted to a general unit. Tracheostomy subjects were discussed during weekly clinical rounds, and management decisions were based on the tracheostomy decannulation protocol (Fig. 1).^8-10

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Fig. 1.

Tracheostomy decannulation protocol. GCS = Glasgow coma score.

Tracheostomy tube with inflated cuff is needed to maintain positive-pressure ventilation; however, after extubation cuff, deflation is needed to progress toward decannulation. Subjects who were vitally stable underwent suctioning and monitoring before and during the trial of tracheostomy cuff deflation.

On the initial assessment by the tracheostomy team (after ICU discharge), most of the subjects had already deflated cuffs. Dried secretions may obstruct the tracheostomy tube and cause respiratory distress; therefore, air humidification is an essential component of care for tracheostomy patients. A heat and moisture exchanger was used for air humidification for tracheostomy subjects in this cohort. In addition, inner-tube care was performed (1–2 times per shift) for double lumen tracheostomy tubes to prevent tracheostomy tube obstruction due to dried/thick secretions. Subjects who were medically stable, emerged out of coma, had strong cough, and minimal secretions underwent endoscopic airway and swallowing evaluation by the speech and language pathologist. Then, subjects with compromised airway had tracheostomy tube (cuff deflated) changed to cuffless nonfenestrated. On the other hand, subjects with good airway assessment had tracheostomy tube (cuff deflated) change to a cuffless fenestrated tube and progressed to a capping trial. The endoscopic airway evaluation is an anatomical assessment, and the capping trial is a functional/physiological assessment for the airway. Subsequently, subjects who had successful capping progressed to decannulation. Capping failure was defined as respiratory distress and/or the inability to maintain oxygen saturation during a 72-h trial of tracheostomy tube capping.¹¹ When subjects failed the capping trial, further capping was delayed; and reassessment of the decannulation protocol steps regarding suctioning/secretions management, medical stability, tube type/size, and airway assessment for granulomas/obstructive lesions was repeated. If the reason for capping failure remained unknown, a computed tomography for neck and chest was done to rule out subglottic stenosis, tracheal stenosis, tracheomalacia, and/or tracheoesophageal fistula. Subjects who failed repeated capping trials did not progress to decannulation and were labeled long-term tracheostomy.

The objective of swallowing evaluation was to ensure safe feeding, and the recommended feeding modality did not impact decannulation protocol. Tube-fed subjects who had successful capping underwent a repeated swallowing evaluation after decannulation because normalization of subglottic pressure and laryngeal mobility could improve dysphagia.

Decannulation failure was defined as the need for stoma recannulation or oral intubation due to respiratory distress and/or the inability to maintain oxygen saturation 48–96 h after decannulation.^12,13 Based on a small pilot study, the proportion of patients with failed capping was estimated to be approximately 50%. The subjects’ electronic medical records were checked for data availability. Sample size calculation was performed using the formula n = 10 K/P, where K is the number of predictors needed in the model and P is the smallest proportion among positive or negative cases.¹⁴ The nQuery program was used for sample size sensitivity analysis. After accounting for missing data, the estimated sample size for a power of 80% and a 2-sided alpha level of 0.05% was 140 subjects. Data analysis was done using IBM SPSS Statistics Version 26 (IBM, Armonk, New York).