Decannulation of patients with long-term tracheostomies

In neurosurgical rehabilitation, few patients require a tracheostomy for purely respiratory purposes. Management of respiratory secretions and swallowing problems are the primary reasons for intubation (insertion of the tube).

Once a patient is intubated, a pattern of dependency follows and removal of the tracheostomy tube should be considered as soon as possible.

For early decannulation (removal of the tracheostomy tube) to occur a patient must:

- Be medically stable;

- Have adequate respiratory function;

- Have an adequate swallow and cough reflex for airway protection;

- Have the ability to swallow their oral secretions without drooling or dribbling;

- Have reasonable levels of alertness (be able to interact with the environment and obey simple commands).

Problems with long-term intubation
Prolonged tracheostomy intubation can result in tethering of the larynx to the tracheostomy tube, causing decreased elevation and closure time of the vocal cords.

This leads to an increased risk of aspiration (Shaker et al, 1995). The stoma (artificial opening in the trachea) creates aerodynamic changes including poor subglottic pressure required for control of the base of the tongue. This results in poor initiation and coordination of the swallowing reflex. It is therefore vital to identify whether the patient requires a tracheostomy because her or his swallowing reflex is poor or whether the swallow reflex is poor because of the presence of the tracheostomy.

Development of granulomas (a mass of inflammatory tissue that forms in response to the tube) and other pathologies can also impact on both respiratory and swallowing function.

We have found that some patients require a longer time to achieve decannulation due to psychological dependence. An anxious patient can take as long to decannulate as one with a poor swallowing function.

Management of patients who are not suitable for early decannulation
At the Acquired Brain Injury Unit (ABIU) at the Royal Perth Hospital (RPH), Australia, we care for patients who do not meet the criteria for early decannulation. This is the only specialist unit of its kind in Western Australia. A survey of national neurosurgical rehabilitation facilities in 1994 found that up to 60 per cent refused to admit patients with tracheostomies. This was due to the high levels of nursing care required and a view at the time that rehabilitation programmes were unsuitable for this group of patients.

An audit of our tracheostomy decannulation figures in 1994 revealed that 20 per cent of patients (five) failed our standard decuffing protocol each year. Decuffing involves deflating the cuff on the tracheostomy tube. When the cuff is inflated it prevents fluid and secretions from reaching the lungs. Decuffing allows the patient to practice swallowing before decannulation and allows health professionals to assess the effectiveness of the swallow.

Failing to decannulate had a negative impact on the patient's quality of life, limited the options for long-term care and resulted in blocking of acute care beds. However, nurses and physiotherapists had no formal, systematic patient assessment protocol for decannulation and there was little input from the speech therapists who were primarily involved in the assessment and treatment of communication problems. Junior staff in particular reported that they lacked the skills needed to carry out the protracted decuffing process.

We designed an evidence-based, multidisciplinary assessment tool for decannulation. We piloted this, which confirmed the advantage of consolidating a multidisciplinary team approach and developing a best-practice protocol to improve decannulation rates. The Shenton Park three-track decannulation protocol was developed locally and audited over the first three years.

The Shenton Park three-track decannulation protocol
The protocol allows for variations in an individual patient's management based on a clinical assessment. The patient is assessed over a 24-hour period either on admission to the ABIU or when she or he has become medically stable (Box 1). The patient is then assigned to a fast-track, standard-track or slow-track decannulation protocol (Box 2).

Audit results
From 1994 to 1997, 60 patients were treated on the ABIU with the Shenton Park protocol. Of these, only four failed to meet the criteria for any decannulation regimen (three needed ear, nose and throat management; a fourth was medically unstable). The other 56 patients were assigned to the following protocols:

- Fast track (eight patients);

- Standard track (31);

- Slow track (14);

- Failed to decannulate (3).

Of the three patients who we failed to decannulate: one had severe and unmanageable gastric reflux with aspiration; another had difficulty managing changes in position when the tracheostomy tube cuff was deflated and eventually had the tube removed in a long-term care facility; and the third had a stenosis of trachea.

Other audit findings Seventeen patients were intubated for more than 30 days before beginning our protocol. Of these, one was fast tracked, six used the standard track and eight required slow tracking. We failed to decannulate two patients. It appears there is a correlation between the duration of intubation and subsequent need for a slower decuffing regimen.

Four patients were intubated for less than five days, one was fast tracked and three required a standard-track approach. This suggests the shorter the intubation period the faster the tracheostomy can be removed.

The slow-track regimen demands an extremely flexible multidisciplinary team approach to care, and great sensitivity to the patient's needs.

Most of our patients can have their tracheostomy tubes removed, and the process has aided team-building and multidisciplinary management.

Follow-up audit
The protocol is continually being developed and we are keen to improve the care and management of our patients. A follow-up audit from April 2001 to December 2003 identified that 68 patients were admitted with tracheostomy tubes to the ABIU. Of these:

- Eight were decannulated using a fast-track regimen;

- 37 successfully completed the standard track;

- 23 were eligible for a slow-track regimen.

All but two of the slow-track group were decannulated on the ABIU: one was transferred to another hospital before the regimen ended, and completed decannulation there; the second had bilateral vocal-cord paralysis and could not maintain an airway without a tracheostomy.

Conclusion
The Shenton Park protocol was adopted across the hospital this year. It has also been adopted by several long-term care facilities across Perth. We have found that patients once thought incapable of permanent decannulation are now achieving this goal.

Our evidence shows that an individualised decuffing regimen has reduced the number of patients failing decannulation from 20 per cent to two per cent in the past decade. Nurses should not assume that severe swallowing problems automatically condemn patients to a permanent tracheostomy.

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