Decannulation Failure

Decannulation failure is defined as the need to replace the airway after the tube has been decannulated.  

This Australian study examined 981 ICU patients who received tracheostomies.  Seventy-seven percent of them were placed percutaneously and 23% were placed surgically.  The mean duration of placement was 16 days.  A total of 823 decisions to decannulate were made, and of these, there were 40 episodes of decannulation failure occurring in 35 patients.  Twenty-four episodes of decannulation failure (60%) occurred within 24 hours of tube removal, with 14 of these cases (58%) occurring within the first 4 hours.  Only two patients failed decannulation beyond 7 days, with one at 8 days and one at 10 days.

The reasons why patients failed decannulation included inability to expectorate secretions (52.8%) stridor, anatomical problems, and new sepsis.  Most stridor emerged within 4 hours of tube removal.  For the patients that failed decannulation multiple times, sputum retention was the primary reason.

In this study, there was no mortality associated with decannulation failure.  Most cases (62.5%) required simple recannulation of the stoma.  Translaryngeal intubation was required in 37.5% of cases.  The median duration between decannulation and reinsertion of a new artificial airway was 18 hours.

Source: Choate, K, Barbetti, J, Currey, J (2009). Tracheostomy decannulation failure rate following critical illness: A prospective descriptive study. Australian Crit Care, 22: 8-15.

10-Year Outcomes Study on Trachs

This was a 10-year study done at a tertiary care teaching hospital in Tanzania and included 214 patients. Male to female ratio was 3:1, with a mean age of 38 years.  In their study, the most common indication for tracheostomy was upper airway obstruction secondary to trauma or neoplastic causes. Eighty-six percent of tracheostomies were temporary, and 14% were permanent tracheostomies.  Most (80%) of these tracheotomies were performed as an emergency and the complication rate was higher in that group, compared to the overall complication rate (74% vs. 21.5%).   Twenty-two percent of complications occurred in the first  postoperative week, and 65% occurred after the first postoperative week. Of the patients who had a tracheostomy placed for prolonged mechanical ventilation, the duration of intubation before tracheostomy ranged from 4-62 days, with a median of 26 days.  Duration of cannulation was 8 days to 46 months, with a median duration of 4 months.  Decannulation was successful in 72% of patients who survived.  Mortality rate was 13.6% and was due to the underlying illness, not the tracheostomy itself.

As the authors stated, and I would agree, that the majority of the complications can be prevented by meticulous attention to technique and postoperative care.

Source: Gilyoma, J.,Balumuka, D, Chalya, P. (2011). Ten-year experiences with tracheostomy at a university teaching hospital in northwestern Tanzania: A retrospective review of 214 cases. World J Emerg Surg, 6:38.

Trach for Prolonged Mechanical Ventilation

A survey was done of intensive care units in Italy to learn about the clinical characteristics of patients with a tracheostomy, including types, complications, criteria for performing decannulation, and outcomes. They received responses from 22 intensive care units with 846 admissions of 719 patients. Reasons for admission included acute respiratory failure with underlying chronic co-morbidities (24.4%), exacerbation of COPD (34.4%), neuromuscular diseases (27.8%), surgical patients (10.7%), and obstructive sleep apnea (2.2%). They found a very low incidence of major complications (fistula or stenosis, 2%). Twenty-two percent of patients were decannulated prior to discharge; and 41% were discharged with home mechanical ventilation, while 26.5% maintained the tracheostomy despite being weaned from the ventilator, and 10% died or were lost (either transferred to other units or refused treatment). Those who maintained the trach without mechanical ventilation were either over age 70 or had co-morbidities, or both.
In this study, the criteria to indicate decannulation included: stable PaCO2, absence of swallowing problems, type and severity of disease, presence of effective cough, stability of respiratory parameters such as dyspnea, respiratory rate, SaO2, PaO2, PaCo2, pH, and successful capping.

Source: Marchese et al, (2010). Tracheostomy patients with long-term mechanical ventilation: A survey. Resp Med (104), 749-753.

First Trach Change

There is very little research regarding when it is safe to do the first tracheostomy tube change.  Commonly, the first tube change is done between post-op day 7-14. A study was just published in Critical Care Medicine and showed that it is safe to do the first tracheostomy change prior to post-op day 7.

The authors at Mass General in Boston enrolled 130 patients after a tracheostomy placement.  Thirty-eight patients received a trach change prior to Day 7 (early group) and 92 patients received a trach change after Day 7 (late group).  They found that the early group was more likely to be liberated from the ventilator on Day 7 (100% vs. 45%, p=0.0001), tolerate speaking valve earlier (7 vs. 12 days, p=0.001), more likely to tolerate earlier oral feeding (10 vs. 20 days, p=0.04), and had shorter length of stay (11 vs. 17 days, p=0.001).  There was no difference in mortality and no complications associated with the trach change.

Source: Abstract: Fisher et al., (2011). Early tracheostomy change is associated with earlier use of speaking valve and earlier oral intake, Crit Care Med, 39(12), 515.

Air Transport with Trachs

R.H. asks, "We have a tracheostomy patient who is being airlifted to a different facility in another state.  Should we have any concerns with air transport?"

Answer: The biggest concerns with transport of any kind is dislodgement.  So the usual precautions for ensuring tube security should be in place.  These include ensuring snugness of the trach ties and limiting traction against the tube.  However, air transport poses additional concerns with cuffed tracheostomy tubes.  Boyle's law states that a fixed volume of gas will expand as pressure decreases.  So when the cuff is inflated with air, barometric pressure will decrease with altitude, and cuff pressure will rise as the cuff expands.  Studies have measured cuff pressures of well over 200 cm water pressure during air transport!

The usual clinical methods of ensuring safe cuff pressure--namely, minimal occlusive volume and minimal leak technique, are ineffective in air transport because the noise level is too high.  Some recommend using saline to inflate the cuff, but there are no devices currently on the market that will continuously monitor and automatically adjust cuff pressure.

For a detailed discussion on this topic, see Chapter 5 in Tracheostomies: The Complete Guide.

Home Supplies

Dr. C.R. asks, "What kind of home supplies do my tracheostomy patients need?"

Answer: Patients need many supplies to manage their tracheostomy.  They need plenty of suction catheters, suction machine, tubing, inner cannulas (if disposable), tracheostomy cleaning kits, trach holders, and an extra trach of the same size, and one size smaller.  It is essential that these supplies are delivered to the patients home before the patient is discharged. 

Keep in mind that Medicare and most insurance companies provide a cap on the number of supplies.  For example, the maximum allowance for suction catheters is 90 per month.  The patient can use the same suction catheter all day by rinsing it completely and allowing it to dry between uses.  But this may not be optimal, especially if the patient is prone to frequent infections.  In that case, it would be wise to write a letter of medical necessity so that they can receive more than the usual maximum number of supplies.

Maximum monthly allowance for other tracheostomy supplies are as follows: one new tracheostomy tube, 12 rigid Yankauer suction catheters, 30 disposable inner cannulas, 30 tracheostomy holders, and 30 cleaning kits per month. 

Patients need to be taught how to use these supplies before they are discharged from the hospital so that they are comfortable with the basic care of the tracheostomy.  This includes suctioning, changing or cleaning the inner cannula, care of the stoma, and managing the cuff (when present).  They also need to know how to identify the signs of infection and how to manage an emergency, such as a mucus plug.

Tracheal Bleeding

W.C. asks, "I've noticed a small amount of bleeding from my trach recently. Should I be worried?"

Answer: The two most frequent causes of tracheal bleeding are due to frequent suctioning and lack of humidity.  Regarding frequent suctioning, one should not decrease the frequency of suctioning just because of the appearance of some blood.  Rather, this should be a cue to switch to softer suction catheters.  I usually recommend red rubber catheters, which are not suction catheters, but are actually they are urinary catheters, technically called "coude" catheters.  These are especially helpful because the tip is closed, rather than open, so there is less trauma to the tissue with the use of these catheters.  Because the tip is closed, they may not be quite as effective as the standard suction catheters, but complete healing of tracheal tissue has been observed in as little as 24 hours after the switch, so this is an option.  Please note: Red rubber catheters cannot be used in the patient with a latex allergy.

The other frequent cause of tracheal bleeding is lack of proper humidity.  This is especially true in the fall and winter in colder climates....or other places that have low humidity (like hospitals!).  This dried blood can collect within the tracheostomy tube and begin to occlude the airway.  In fact, one patient had no trouble at home, but came to the hospital and required almost daily trach changes because of the accumulation of dried blood within his tracheostomy.  The problem resolved as soon as humidity was added to his ventilator circuit.

Now that fall and winter is approaching, you may need some extra help with humidity.  This can include room humidifiers, soaking a gauze in water or saline and placing lightly over your trach, using an HME (heat moisture exhanger), spritzing some atomized saline (Ocean nasal spray) into the trach and mucous membranes, increasing water intake, and more frequent changes.

If there is a large amount of bleeding, contact your health care provider for further evaluation.