Suctioning frequency, high-flow oxygen can determine when to decannulate tracheostomy

A randomized trial in Spanish ICUs found that patients whose readiness for decannulation was determined by frequency of suctioning instead of a 24-hour capping trial had less time to decannulation and shorter length of stay.

Basing the decision to decannulate a tracheostomy tube on suctioning frequency plus continuous high-flow oxygen therapy rather than on the standard 24-hour capping trial reduced the time to decannulation without increasing failure rate, a study found.

Researchers enrolled conscious, critically ill adults who had a tracheostomy tube in five ICUs in Spain. Patients were eligible after weaning from mechanical ventilation. Patients were randomly assigned either to undergo a 24-hour capping trial plus intermittent high-flow oxygen therapy (control group; n=161) or to receive continuous high-flow oxygen therapy with frequency of suctioning being the indicator of readiness for decannulation (intervention group; n=169). Patients underwent decannulation when they had had no more than two aspirations every eight hours during a 24-hour period according to prespecified indications. Results were published Sept. 10 by the New England Journal of Medicine.

Commercial support came from the maker of the high-flow oxygen therapy device and interface for tracheostomy tubes, Fisher and Paykel Healthcare, which paid for writing assistance with the manuscript but had no role in the study's design or conduct or in the decision to submit the manuscript for publication.

The patients' mean age was 58.3 years; 68.2% were men. The primary outcome of time to decannulation was shorter in the intervention group than in the control group: median, 6 days (interquartile range, 5 to 7 days) versus 13 days (interquartile range, 11 to 14 days) (absolute difference, 7 days [95% CI, 5 to 9 days]).

Secondary outcomes included decannulation failure, weaning failure, respiratory infections, sepsis, multiorgan failure, durations of stay in the ICU and hospital, and deaths in the ICU and hospital. Pneumonia occurred in 16 patients (9.9%) in the control group and seven (4.1%) in the intervention group (difference, 5.8 percentage points; 95% CI, 0.2 to 11.8). Tracheobronchitis occurred in 47 patients (29.2%) in the control group and 32 (18.9%) in the intervention group (difference, 10.3 percentage points; 95% CI, 1.0 to 19.3). Median length of stay was 62 days (interquartile range, 38 to 105 days) in the control group and 48 days (interquartile range, 33 to 71 days) in the intervention group (absolute difference, 14 days; 95% CI, 9 to 33 days). Other secondary outcomes were similar between the two groups.

The authors concluded that this strategy of decannulation based on suctioning frequency plus the use of continuous high-flow oxygen therapy led to faster decannulation and no increase in decannulation failure compared to standard care. “The most plausible explanation for this result is that capping trials are highly demanding, thus delaying the time to decannulation as reflected by the high proportions of patients with capping trials that failed and of patients with weaning failure,” they wrote.

An editorial noted that in the U.S., patients are often transferred to post-acute care facilities for weaning from a mechanical ventilator and for decannulation. This trial took place in ICUs in Spain, where the ratio of nurses and respiratory therapists to patients probably differs. Also, patients in the intervention group spent more time receiving high-flow oxygen therapy than those in the control group, who received high-flow oxygen therapy when the tube was not capped. It is possible that the heated humidification of high-flow oxygen decreased the frequency of suctioning events, the editorial said.

“The authors have taken an important step in building an evidence base to improve care for patients with chronic critical illness,” the editorial stated. “The generation of new knowledge should not end when a patient has survived acute illness.”