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Weaning from Tracheostomy in Subjects Undergoing Pulmonary

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Weaning from Tracheostomy in Subjects Undergoing Pulmonary Pasqua et al. Multidisciplinary Respiratory Medicine (2015) 10:35 DOI 10.1186/s40248-015-0032-1 ORIGINALRESEARCHARTICLE Open Access Weaning from tracheostomy in subjects undergoing pulmonary rehabilitation Franco Pasqua1,2*, Ilaria Nardi1, Alessia Provenzano1, Alessia Mari1 on behalf of the Lazio Regional Section, Italian Association of Hospital Pulmonologists (AIPO) Abstract Background: Weaning from tracheostomy has implications in management, quality of life, and costs of ventilated patients. Furthermore, endotracheal cannula removing needs further studies. Aim of this study was the validation of a protocol for weaning from tracheostomy and evaluation of predictor factors of decannulation. Methods: Medical records of 48 patients were retrospectively evaluated. Patients were decannulated in agreement with a decannulation protocol based on the evaluation of clinical stability, expiratory muscle strength, presence of tracheal stenosis/granulomas, deglutition function, partial pressure of CO2, and PaO2/FiO2 ratio. These variables, together with underlying disease, blood gas analysis parameters, time elapsed with cannula, comordibity, Barthel index, and the condition of ventilation, were evaluated in a logistic model as predictors of decannulation. Results: 63 % of patients were successfully decannulated in agreement with our protocol and no one needed to be re-cannulated. Three variables were significantly associated with the decannulation: no pulmonary underlying diseases (OR = 7.12; 95 % CI 1.2–42.2), no mechanical ventilation (OR = 9.55; 95 % CI 2.1–44.2) and period of tracheostomy ≤10 weeks (OR = 6.5; 95 % CI 1.6–27.5). Conclusions: The positive course of decannulated patients supports the suitability of the weaning protocol we propose here. The strong predictive role of three clinical variables gives premise for new studies testing simpler decannulation protocols. Keywords: Mechanical ventilation, Predictive models, Pulmonary rehabilitation, Tracheostomy, Weaning Background that prolonged endotracheal intubation (ETI) should be Tracheostomy is a common surgical procedure performed avoided as much as possible. Furthermore, tracheotomies to protect airways, to perform bronchial toilet and to wean lasting less than seven days have been associated to a from Intermittent Positive-Pressure Ventilation (IPPV) in shorter duration of mechanical ventilation and a shorter critically ill, ventilator-dependent patients [1–5]. This stay in the intensive care unit (ICU) [6, 7]. In contrast with practice has quickly gained success mostly because of the this evidence, an international multi-center survey carried development of the percutaneous dilational tracheostomy, out in 361 ICU patients revealed that the median length a technique which can be carried out at the bedside [4]. of stay of patients with tracheostomy in the intensive care Indications for tracheostomy generally include a respira- unit was 21 days, for a total of 36 days of hospitalization. tory failure due to a prolonged mechanical ventilation, the The authors of the survey concluded that tracheostomy is need to re-intubate the patient after a failed extubation, associated with a longer stay, and that the mortality of and the presence of neurological diseases [3]. No general these patients is similar to that of patients without consensus regarding the timing of tracheostomy has tracheostomy [3]. On the other hand, the benefits of been reached so far, although it is largely accepted tracheostomy compared to translaryngeal intubation are remarkable, particularly regarding the better com- * Correspondence: [email protected] fort for the patient, the greater ease of bronchial as- 1Pulmonary Medicine and Rehabilitation, Villa Delle Querce Hospital, Nemi, piration, the decreasing of resistance, the lower risk Rome, Italy of infection, and the easier oral communication and 2Pulmonary Rehabilitation, San Raffaele Hospital, Montecompatri, Rome, Italy © 2015 Pasqua et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Pasqua et al. Multidisciplinary Respiratory Medicine (2015) 10:35 Page 2 of 7 nutrition [8]. Finally, the easier weaning from mechanical Twenty-eight patients were admitted from intensive care ventilation facilitates patient’s transfer from ICU to a non- units (ICU), 14 from other clinical departments, and 6 intensive treatment [9]. came directly from home. To counterbalance the benefits mentioned above, posi- The most frequent underlying diseases leading to tioning the endotracheal cannula may induce periopera- tracheostomy were: COPD (n = 23), ischemic cardiopa- tive bleeding, pneumothorax, dislocation, and cannula thy requiring surgical treatment (n = 8), respiratory fail- aspiration. Although complications related to tracheal ure following fibrothorax (n = 4), and pneumonia (n =2) cannula positioning have been greatly reduced by the (Table 1). Subjects affected by neuromuscular diseases latest development of the techniques, late side effects, were excluded from the study for the technical difficulty such as nosocomial infection of tracheal stenosis, and of decannulation in these patients. The study was deglutition defects, may occur [10, 11]. approved by the local Ethical Committee. In addition, the return to residence of tracheotomised patients is undoubtedly more difficult for caregiver(s), Study design and the survival of these patients has been found to be The following data were collected at admission: underlying worse when compared to decannulated patients [12]. disease, haemogasanalysis parameters (pH, PaO2,PaCO2, Removing tracheostomy is an essential step in rehabili- PaO2/FiO2; Novamedical equipment), time from the trache- tating patients recovering from critical illness. This ostomy (expressed in days), comorbidity (assessed by the achievement is also of considerable importance for the Charlson index (CI)), degree of disability (assessed by the quality of life and for the reduction of the associated Barthel index (BI)), and the presence of mechanical ventila- costs [13]. Although, at present, no randomised studies tion (yes or not). Ventilated patients were weaned from the have been published on validating criteria for undergo- ventilator before undergoing to decannulation protocol. ing tracheotomies, a large consensus exists on clinical The rehabilitative programme included: active mobil- conditions requiring this procedure, and several reports isation of the limbs, electro-stimulation of the quadriceps, are available [14–18]. On the contrary, only very few abdominal muscle reinforcement, respiratory muscle studies have been published on the clinical criteria re- training, strength retraining via ergometric cycle for the quired for the removal of the endotracheal cannula, lower limbs and arm ergometer for the upper limbs, bron- many of which based on experts’ opinions [19, 20]. A re- chial clearing techniques. The protocol for weaning from cent survey carried out on 32 Italian Respiratory Inten- sive Care Unit (RICU) showed that the proportion of Table 1 Distribution of underlying diseases cause of tracheostomy patients decannulated is rather low (22 %), and that Underlying diseases Number Percent there is a notable portion of subjects (26 %) who, even Pulmonary though weaned from mechanical ventilation, were dis- COPD 23 47.9 charged with the tracheotomy tube still applied [21]. Fibrothorax 4 8.3 Given the evident benefits of tracheostomy in com- parison with translaryngeal intubation, and considering Pneumonia 2 4.1 the lack of general consensus regarding the timing and Obstruction Sleep Apnoea Syndrome, 4 8.4 Lung cancer, Emopneumothorax, conditions for removal, a new decannulation protocol Pulmonary fibrosis has been developed by the multidisciplinary team of the Total 33 68.7 Unit of Pulmonary Medicine and Rehabilitation of San Raffaele Montecompatri (Rome) and Pulmonary Medi- Cardiac cine and Rehabilitation, Villa Delle Querce Hospital, Cardiac surgery (By-pass) 4 8.3 Nemi, (Rome, Italy) on tracheotomised patients admitted Heart failure, Cardiac surgery 3 6.3 to the units [6–9]. Therefore, aim of this study was the (thoracic-abdominal aneurysm), Cardiac tamponade evaluation of the efficacy of that protocol and to analyze factors that could predict the success of decannulation. Cardiac surgery (valvulopathy) 3 6.3 Total 10 20.9 Abdominal Surgery Methods Acute pancreatitis, septic shock, stomach 4 8.4 Study subjects cancer, bowel stroke, peritonitis We retrospectively analyzed 48 medical records of consecu- Total 4 8.4 tive patients admitted to the Unit of Pulmonary Medicine Other and Rehabilitation of San Raffaele Montecompatri (Rome) Orthopedic complications 1 2.1 and Pulmonary Medicine and Rehabilitation, Villa Delle Total 48 100.0 Querce Hospital, Nemi, (Rome, Italy) from 2009 to 2014. Pasqua et al. Multidisciplinary Respiratory Medicine (2015) 10:35 Page 3 of 7 tracheostomy was designed to choose the best moment of In regard to covariates included in the analysis, the decannulation. The following criteria
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