Review of Respiratory Medicine - Volumen 25, Número 1 - March 25

Review Article

Decannulation in a Tracheostomized Patient: Different Scenarios, Strategies, and Recommendations

Decanulación del paciente traqueostomizado: Diferentes escenarios, estrategias y recomendaciones

ABSTRACT

This review addresses the process of decannulation (removal of the cannula) in trache­ostomized patients, which is a complex, multifactorial event requiring a transdisciplinary approach. Currently, there are no recognized clinical practice guidelines or consensus recommending specific guidelines for decannulation. In order to initiate the process, it is necessary to identify patients that could potentially be decannulated, assessing three essential pillars: airway permeability, swallowing, and cough effectiveness. This article defines three different decannulation scenarios: simple, complex, and uncommon complex, each requiring different approaches for successful completion.

It is important to emphasize that rehabilitation strategies are often necessary to facilitate the process, requiring a multidisciplinary team for both evaluation and required treatment.

Key words: Decannulation, Upper airway permeability, Swallowing, Cough effectiveness

RESUMEN

Esta revisión aborda el proceso de decanulación (retiro de la cánula) del paciente traqueostomizado, un evento complejo, multifactorial y de abordaje transdisciplinario del cual no existen a la fecha guías de prácticas clínicas o consensos reconocidos que recomienden directrices al respecto. Se requiere para iniciar el proceso la identificación de pacientes potencialmente decanulables en los cuales se deben evaluar tres pilares esenciales; la permeabilidad de la vía aérea, la deglución y la efectividad de la tos. Definimos a la vez en este artículo tres escenarios distintos de decanulación: simple, compleja y compleja poco habitual en los cuales se requieren distintos abordajes para culminar con éxito el proceso.

Por último es importante recalcar que habitualmente se requerirá de estrategias de rehabilitación para favorecer el proceso necesitando un equipo multidisciplinario tanto para la evaluación como para el tratamiento necesario.

Palabras claves: Decanulación, Permeabilidad de vía aérea superior, Deglución, Efectividad de la tos.

Received: 12/09/2024

Accepted: 02/23/2025

INTRODUCTION

Currently, in Intensive care Units (ICUs) trache­ostomy (TQT) is one of the most common surgical interventions, although there is a wide range of incidence that goes from 5% to 54%, depending on the type of ICU and the timing of the procedure.¹ The development of percutaneous techniques has facilitated the procedure directly within the same intensive care unit.²

Main indications for tracheostomy include: weaning from prolonged invasive mechanical ventilation (IMV), altered neurological status, inability to manage secretions, and upper airway obstruction (UAO).³

Decannulation is the process of removing the tracheostomy cannula. The basic criteria for doing so include: resolution of the underlying condition, weaning from IMV, absence of organ failure, ab­sence of active sepsis, stable hemodynamics, and respiratory failure such as pulmonary infections in the process of being resolved.⁴ Despite the im­portance of decannulation in patient management, no widely accepted protocols have been set for its implementation. There is variability in the devel­opment of algorithms, lack of randomized studies, and ambiguity in the screening, technique, and monitoring of the decannulation process.⁵ For this reason, it is important to create clinical guidelines based on available evidence to be able to carry out this process as efficiently and safely as possible.

Most of the time, the decannulation process is slow and prolongs the patient’s ICU stay, and this increases the risk of nosocomial diseases and healthcare costs.⁶ In patients with good neurologi­cal status, the absence of decannulation in the ICU has been associated with a higher risk of death in the general ward.⁷ Therefore, trying to perform this procedure in the critical care unit is essential to facilitate the management of these patients, allowing for their transfer home or to less com­plex hospital units. Additionally, decannulation improves patient comfort, perception, and physical appearance.⁸

Kinesiologists and speech-language therapists in the intensive care unit play a crucial role in the early detection, evaluation, and rehabilitation of disorders that delay the decannulation process, aiming to prevent complications and improve the quality of life of critically ill patients through a multidisciplinary approach.⁹

The purpose of this article is to analyze the condi­tions necessary to achieve successful decannulation taking into account the high number of variables that affect its prognosis, as well as the different approaches to evaluation and decision-making. We provide a description of different scenarios within the process: simple decannulation, complex decan­nulation, and uncommon complex decannulation, outlining the procedure in each case. We also pro­pose an interdisciplinary management algorithm based on available evidence.

CONDITIONS THAT REQUIRE THE USE OF A TRACHEOSTOMY

It is important to differentiate the different types of tracheostomized patients according to the cause that led to the tracheostomy:

1) Patients that were tracheostomized to facilitate weaning (mostly involving simple decannulation based on clinical testing).

2) Patients that were tracheostomized with altered sensorium or neuromuscular involvement affecting swallowing and respiratory muscle strength, which leads to a more complex decannulation requiring objective evaluations and rehabilitation strategies.

3) Patients that were tracheostomized with pri­mary or secondary UAO requiring objective evaluation tests, medical-surgical interventions, and new rehabilitation strategies.

STATE OF THE ART IN DECANNULATION

The decannulation process should begin by identi­fying which are the patients that could potentially be decannulated, those of which shall meet a series of clinical conditions described in Table 1:⁴

A systematic review conducted by Singh5 about decannulation in adult patients (including stud­ies with low to moderate methodological quality) shows that preparation for decannulation is based mainly on qualitative and quantitative determi­nants of cough and swallowing. With regard to cough, the peak cough flow (PCF) and maximal expiratory pressure (MEP) were used as quantita­tive measures. Swallowing was evaluated mainly in a subjective way through the gag reflex and the Blue Dye Test¹⁰. Only one study considered the use of fiberoptic endoscopic evaluation of swallow­ing (FEES).¹¹ Some decannulation methods that have been reported involve replacing the cannula with one with a smaller lumen before completely removing it, whereas in other groups, decannula­tion was performed without changing the lumen size, leaving this decision to the criterion of each clinical center.^12-13

Another systematic review conducted by San­tus¹⁴ shows similar criteria for decannulation. The criteria include: adequate level of consciousness, effective cough showed by a PCF >160 L/min (measured at the mouth) or a MEP >40 cmH₂O, adequate swallowing, and the ability to tolerate cannula occlusion for 24 to 48 hours.

Taking into account both systematic reviews, we can establish three fundamental pillars to be assessed during the decannulation process: swal­lowing, upper airway permeability, and cough effectiveness.

The criterion for a successful decannulation doesn’t include the need to reinsert a tracheostomy cannula. The duration of a successful decannula­tion varies widely in the literature, ranging from 24-48 hours¹⁵ to 3-6 months.¹⁶ On the other hand, the decannulation failure rate reported in a mul­ticenter study was 3.1%¹⁷ and 4.8%¹⁸ in another single-center study, with no associated mortality. 62.5% of the patients who failed decannulation required a simple reinsertion of the cannula and didn’t need ICU readmission, while 37.5% required intubation and ICU admission. The main reason for failure was retention of the secretions; and most patients failed within the first 24 hours. This suggests the need for high levels of clinical surveillance

DECANNULATION SCENARIOS

Simple decannulation: in this case, ventilatory weaning is either consolidated or in the process of resolution, with safety and efficacy of the aerodi­gestive junction and adequate management of saliva (negative Blue Dye Test). In general, this type of procedure is carried out in the ICU or in the Intermediate Care Unit, through clinical testing. The permeability of the UAW is evaluated quan­titatively through manometry using a phonation valve (PV), and it is qualitatively evaluated using a phonendoscope and analyzing respiratory effort with an occluded cannula. On the other hand, swallowing is evaluated through simple clinical testing together with a Blue Dye Test. Generally, during these evaluations, there is no variation in respiratory effort or oxygen desaturation, and this frequently occurs in patients with no respiratory muscle weakness or ICU-acquired weakness.¹⁹ In such patients, cough effectiveness is objectively assessed through the PCF.

Complex decannulation: in this case, the aerodi­gestive junction is dysfunctional because of swal­lowing alterations (positive Blue Dye Test) or airway permeability issues which alter the transla­ryngeal airflow due to manometric pressures that aren’t adequate for tracheal sealing. Additionally, there are some patients with respiratory muscle weakness who require further monitoring beyond PCF, such as the evaluation of the maximal respi­ratory muscle strength, forced vital capacity, and diaphragmatic ultrasound, among others.

In this group, it is important to carry out an objective evaluation of the glottic function through an upper airway endoscopy, aiming to quantify any degree of dysphagia that could impact decannula­tion and identify possible structural alterations or dynamic dysfunctions. According to the findings of this study, the need to replace the TQT cannula must be determined, and rehabilitation strate­gies must be designed in line with the identified dysfunction.²⁰

Uncommon complex decannulation: it is pre­sented in situations where structural patholo­gies are found that can complicate the process of decannulation despite the use of rehabilitation strategies. These cases require airway endoscopy, imaging studies, and/or medical-surgical interven­tions to resolve the limiting condition preventing the decannulation process.

It is worth mentioning that this classification does not result from an isolated initiative but has emerged after years of discussion and consensus in various experts’ meetings, for the purpose of ad­dressing the unique challenges of decannulation in complex patients in a structured, effective manner.

PILLARS OF EVALUATION

Evaluation of upper airway permeability

Airway endoscopy is the best method for evaluating the permeability of the airway, but this procedure has to be performed by a trained professional.²¹ There are non-invasive clinical alternatives for tracheostomized patients, such as laryngotracheal auscultation performed during the occlusion of the TQT cannula with a deflated cuff used to analyze the translaryngeal airflow. Another alternative is the manometric evaluation of the TQT tube proposed by Johnson,²² using a one-way PV and an occlusion cap connected via a pressure line to a manometer. While the PV is being used, the ex­piratory occlusion pressure of the tracheostomy is measured, and also the inspiratory occlusion pres­sure is measured through cannula occlusion. This is a simple and safe practice (see Figure 1). In adult tracheostomized patients, expiratory occlusion pressure values measured over 3 minutes below 5 cmH₂O were associated with good tolerance to the one-way phonation valve; values between 5 and 10 cmH₂O were associated with intermittent toler­ance requiring supervision, and values of more than 10 cmH₂O were associated with significant dyspnea and intolerance to the one-way valve. Johnson’s research also showed that a reduction in the cannula lumen was associated with lower inspi­ratory and expiratory pressures, since it increases the tracheal lumen/cannula lumen ratio, and it is a good strategy when the values of expiratory occlusion pressure exceed 10 cmH₂O. However, if despite this modification high values persist, we suggest that the case be referred for endoscopic evaluation due to the possible presence of UAO.²² Johnson’s research also includes the measurement of inspiratory pressure during cannula occlusion. It was found that patients with pressures between 0 and -3 cmH₂0 were more tolerant to cannula occlusion. The author suggests that if inspiratory and expiratory occlusion pressures are adequate, the patient can simply use occlusion rather than a one-way valve to facilitate speech. But, in patients with inspiratory occlusion pressures lower than -3 (more respiratory effort), the author recommends a one-way valve rather than occlusion.

In order to carry out a clinical evaluation of the inspiratory dynamic collapse of the upper airway, a brief occlusion of the cannula with a deflated cuff is recommended, while checking the presence of inspiratory laryngeal stridor and signs of increased respiratory work, dyspnea or desaturation. If dur­ing this brief occlusion the patient shows intoler­ance with signs of respiratory distress or desatu­ration, an upper airway endoscopy is indicated to look for possible UAO.

Swallowing evaluation

Swallowing is defined as the activity of transport­ing solid and liquid substances and saliva from the mouth to the stomach. This transport mechanism can be achieved through forces, movements, and pressures inside the oropharyngeal-laryngeal com­plex.²³ The TQT cannula impacts on the structures and functions of the aerodigestive junction, modi­fying the efficacy and safety of swallowing. Such modifications associated with the use of the TQT include: absence of subglottic pressure (increas­ing the risk of stasis in the supraglottic region), reduced cough reflex (altering the protection of the airway), reduced vocal fold adductor reflex, and delayed oropharyngeal motor response.²⁴

The evaluation of swallowing should be per­formed through clinical methods and objective studies such as videofluoroscopy and FEES, which shall be used taking into account availability, pa­tient characteristics, and training level of profes­sionals in charge of the diagnosis and therapeutic process of decannulation.²⁵

The clinical evaluation should be performed daily and systematically, planning rehabilita­tion strategies in situations where clinical tests show swallowing issues in terms of efficacy or safety. First, the anatomy and functionality of the oropharyngeal structures are to be exam­ined. Next, the oropharyngeal motor response (OMR) has to be assessed, on spontaneous, voluntary, and reflexive actions (present in receptor areas such as the base of the tongue, anterior pillars or pharyngeal wall), noting whether they are present, reduced or absent. Then, the Blue Dye Test must be conducted, for the purpose of observing the management of saliva. This test involves placing blue dye inside the mouth cavity and observing if blue-stained secretions appear in the peristome, or aspirated through the subglottic catheter or during endotracheal aspiration.¹⁰

The result will be recorded as follows:

• Negative blue dye test (-): when endotracheal, subglottic, or peristome secretions don’t show blue staining over a 24-hour period, indicating absence of aspiration and good saliva manage­ment, thus allowing for the use of a PV during daytime, as tolerated.

• Positive blue dye test (+): when endotracheal, subglottic or peristome secretions are stained blue within the 24-hour observation period, in­dicating that the patient shows active aspiration of saliva, that is to say, severe dysphagia (altered efficacy and/or safety). The interdisciplinary team will use the rehabilitation strategy that is necessary to optimize the management of saliva, limiting the use of PV.

It is important to emphasize that this test has high specificity but low sensitivity to detect the risk of aspiration, so there is a high percentage of false negatives.²⁶

If the test is considered positive and the reha­bilitation strategies are not functioning, it will be necessary to study the aerodigestive junction in an objective manner, evaluating the structures that make up that area (sensitivity, muscle action, and airway reflexes). The most suitable procedure for this condition will be the FEES.²⁵

There are some structural and anatomical al­terations that can compromise the decannulation process. These alterations are rare (they fall under the category of uncommon complex decannula­tion), but they can alter the passage of the food bolus (for example, cervical indentations impairing the opening of the upper esophageal sphincter and tracheoesophageal fistulas that can be detected through videofluoroscopy). In this regard, the study by Cortes et al¹⁹ shows that one of the fac­tors limiting decannulation was severe dysphagia in 72% of the patients. The following therapeutic strategies were used: translaryngeal airflow, pho­nation valve, respiratory muscle training, vocal exercises, and stimulation of swallowing exercises, achieving decannulation in 83% of the patients after implementing a rehabilitation program.¹⁹

Evaluation of cough effectiveness

Cough effectiveness is an important element to consider, because it depends on adequate per­formance of the respiratory muscles and on an airway that is free of collapse. It gives the patient independence to maintain airway permeability against possible secretions, also contributing to an adequate bronchial hygiene. The PCF mea­surement establishes ranges of ineffective cough for values <160 L/pm.²⁷ These values also apply to tracheostomized patients whose measurement has been taken orally with a deflated cuff, occluded cannula and nasal clip (Figure 2a). If the patient has difficulty to achieve a proper lip seal for the PCF measurement, resulting in air leakage, we suggest that the mouthpiece is replaced with an oronasal mask (Figure 2b). If the patient can’t cooperate because of their cognitive status, the measurement shall be taken directly through the TQT cannula with an inflated cuff, performing tracheal mechanical stimulation through an as­piration catheter without negative pressure, and the measurement shall be recorded in a flowmeter connected to a closed suction system (Figure 2C). In this situation, the cutoff value will be >60 L/min to classify the coughing as the minimum necessary for decannulation.²⁸ If the respiratory values are lower than the ones previously mentioned, and the patient is cooperative, they should begin with respiratory muscle training and complement the evaluation with the measurement of both maxi­mal inspiratory and expiratory pressures (Pimax/ Pemax).

There may be some conditions in which upper or lower airway collapse is responsible for a reduced PCF.^29-30 In those cases, the condition must be ad­dressed in order to favor cough effectiveness. On the other hand, we recommend that in cases where the PCF is below the suggested values for decan­nulation, it should be complemented with Pimax and Pemax measurements in order to determine if the responsibility relies on the respiratory muscles or the airway. Obtaining these values will also help in the decision-making process whether or not to proceed with decannulation.

REHABILITATION STRATEGIES TO FAVOR THE PROCESS OF COMPLEX DECANNULATION

The reason for which a patient is tracheostomized, the underlying conditions, and the different types of TQT cannulas determine the behavior of every tracheostomized patient. So, rehabilitation strate­gies are to be organized from two different points of view: structural (tracheostomy cannula) and clini­cal (dysfunction at the aerodigestive junction).²⁵

Strategies to facilitate decannulation should be implemented as soon as the decision to perform a tracheostomy is made, taking into account which is the adequate type of cannula and making bedside decisions following an efficient scheme. This is a dynamic process based on daily evaluation and planning.

Table 3 shows some of the most frequently used rehabilitation strategies in the process of decan­nulation.

Recommendations for the use of rehabilitation strategies

Restoration of the translaryngeal airflow begins with the application of air through the subglottic catheter once the stoma has healed (avoiding the risk of subcutaneous emphysema).³¹ Air stimula­tion via the subglottic catheter has to be used when clinical tests show inadequate management of sa­liva (positive Blue Dye Test). This strategy allows for an increased cough response to the pooling of laryngeal secretions and an improved swallowing response, thus favoring airway protection and reducing the risk of aspiration.³²

With tracheal pressures within the normal lim­its, it may even be possible to progress early to the occlusion of the TQT cannula. However, if there is inspiratory collapse of the UAW or if negative pressures are high, we recommend that a PV be used initially (monitoring translaryngeal airflow via auscultation). In cases of high tracheal pres­sures, we recommend that the TQT cannula diam­eter be reduced, and if pressures remain high, an endoscopic evaluation should be done looking for structural obstruction or dynamic dysfunctions.²¹

Stimulation can even be started early through leak ventilation in patients who are on continuous mechanical ventilation by deflating the cuff (after the subglottic aspiration of the oropharyngeal and laryngeal material and ensuring proper oral hygiene).

A British survey conducted by McGowan et al reported that rehabilitation in a tracheostomized patient is based on cuff deflation protocols using a phonation valve to restore the airflow towards the upper airway and improve sensation, taste, smell, voice and coughing, thereby reducing secretions.³³ The study by Carmona et al³⁴ compared the use versus the non-use of a phonation valve in a decan­nulation protocol including a population of 19 patients. It was observed that the group using the PV had fewer respiratory infectious complications (18% vs. 37%), and shorter decannulation time (4.4 vs. 6 days). It is important to highlight that the use of the PV should not exceed daytime use, since it doesn’t allow conditioning of inspired air (humidification/warming and filtering), which may lead to mucous plugs and cannula obstruction. If inefficient humidification results in the formation of mucous plugs, active thermal humidification of inspired air through a high-flow cannula can be used, in combination with a one-way valve to allow phonation.³⁵

The type of TQT cannula being used plays an important role in the development of rehabilita­tion strategies. Sometimes it may be necessary to transition to an alternative model with different characteristics in order to achieve lower resistance in the upper airway, prevent respiratory distress and ensure an adequate translaryngeal airflow.³⁶ Special cannulas are used in patients with func­tional/structural alterations of the airway in com­bination with rehabilitation strategies so that they can facilitate the decannulation process.

Once the patient is already using a PV or occlu­sion cap, it is possible to begin with the strategies that are focused on phonation, coughing, and the increase of lung volumes. These strategies can be optimized through incentive spirometry, increas­ing lung volumes and capacities (while maintain­ing subglottic pressure within optimal values)³⁷ and through RMT of the inspiratory muscles which enhances cough effectiveness.

The strategy of using positive pressure will be implemented when the patient shows dynamic airway collapse, acting as a pneumatic stent.

Most studies related to decannulation state that the swallowing of saliva must be normal, or that there should only be mild to moderate dysphagia.³⁸ Among the strategies used to optimize swallowing efficiency, the isometric tongue exercises and the stimulation of swallowing valves are used to im­prove strength, mobility, and coordination of the speech and swallowing muscles.

Thermotactile stimulation provides sensory in­formation to increase the activation and frequency of the OMR. On the other hand, strengthening of the suprahyoid muscles and stimulation of laryn­geal elevation improve hyolaryngeal excursion.

In cases of airway conditions requiring surgi­cal intervention, it is necessary to ensure airway permeability after said surgery, for which a Mont­gomery tube is used. In conditions requiring the stoma to be preserved, a stent retainer is used. Other patients who also require stoma preserva­tion include those who need ventilatory support³⁹ due to sleep apnea, neuromuscular disorders, or advanced COPD (chronic obstructive pulmonary disease)⁴⁰, where decannulation requires a thor­ough examination of the underlying disease, and where it is necessary to maintain the stoma in order to avoid new airway interventions. These conditions fall under the group of complex and uncommon decannulations.

Finally, it is important to consider that physi­ological changes occur after removing the TQT cannula, when the natural airway is restored, due to an increase in the dead space that can lead to increased respiratory effort in patients with respiratory muscle weakness, producing a com­pensatory effect in tidal volume by integrating the anatomical dead space.⁴¹ These changes must also be considered in complex and uncommon decan­nulation, where the increase in airway resistance can be more relevant.⁴²

Most of the protocols that use TQT cannula oc­clusion have occlusion times ranging from 24 ^4-43 to 48 hours.^44-45 In simple decannulation, the PV could be used as an alternative to the occlusion cap, as shown in the study by Zhou, obtaining good results.⁴⁶

Lastly, in cases of complex and uncommon decannulation, it is very important to understand that the process is not limited only to cannula removal. These patients often show associated factors that require a comprehensive approach to physical and cognitive rehabilitation, as decan­nulation failure is related to a series of complex conditions that impact recovery.

CONCLUSION

The continued presence of a tracheostomy can in­crease hospital stay and healthcare costs and may induce or worsen some complications, for example tracheal stenosis, dysphagia, and granulomas. In light of the above, it is necessary to attempt the removal of tracheostomy cannulas once the underlying cause that led to their placement has been resolved.

The evaluation of the three pillars: upper airway permeability, adequate saliva swallowing, and ef­fective coughing is essential for the development of an effective and safe decannulation process.

More complex studies are necessary to deter­mine which is the best strategy for decannulation, however, basing on current available evidence we propose an evaluation and intervention plan to achieve successful decannulation. Protocol stan­dardization and training of healthcare profession­als are crucial in this process.

Conflict of interest

The authors have no conflicts of interest to declare.

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