Patterns of return to oral intake and decannulation post-tracheostomy across clinical populations in an acute inpatient setting.

BACKGROUND: Dysphagia is often a comorbidity in patients who require a tracheostomy, yet little is known about patterns of oral intake commencement in tracheostomized patients, or how patterns may vary depending on the clinical population and/or reason for tracheostomy insertion. AIMS: To document patterns of clinical management around the commencement of oral intake throughout hospital admission and along the decannulation pathway in patients with a new tracheostomy, and to examine the nature of variability across multiple clinical populations. METHODS & PROCEDURES: A 12-month retrospective review of 126 patients who had undergone an acute tracheostomy was conducted. Within the cohort, patients were further classified into eight clinical populations representing specialty areas within the tertiary referral centre. Data were collected on timing of milestones and patterns of clinical management related to oral and enteral feeding and decannulation. Relationships between temporal variables were calculated, in addition to descriptive analysis of the overall cohort and by clinical population. OUTCOMES & RESULTS: Median temporal markers of patient progression post-tracheostomy insertion for the cohort were: continuous cuff deflation after 7.5 days, commencement of oral intake after 10.5 days, decannulation after 15 days and cessation of enteral nutrition (EN) after 17 days. However, considerable individual variation and differences between clinical populations was observed. Overall, 86% of the cohort returned to oral intake, although 25% were discharged with EN via a gastrostomy. A total of 86% of the group were decannulated by hospital discharge. Oral intake was introduced at every stage of the decannulation pathway, including prior to cuff deflation, but the majority of patients commenced diet/fluids following cuff deflation or with an uncuffed tube in situ, and most patients who ceased EN did so following decannulation. Commencement of oral intake was evenly split between the intensive care unit (ICU) and the wards. Increased time to commencement of oral intake correlated with increased time to decannulation (r = .805, p = .001), and increased time to decannulation correlated with increased hospital length of stay (r = .687, p = .006). Whilst cohort patterns were observed within the heterogeneous group, sub-analysis revealed distinct patterns of oral intake management across the different clinical populations. CONCLUSIONS & IMPLICATIONS: The data provide benchmarks enabling comparison by overall cohort as well as by specialist clinical populations, each with differing reasons for tracheostomy insertion. The data would suggest that tracheostomy patients should not be looked upon as a singular cohort; rather, evaluation of factors with specific attention made to underlying aetiology and individual clinical presentation is essential.

Clinical indicators associated with successful tracheostomy cuff deflation.

BACKGROUND: Tracheostomy cuff deflation is a necessary stage of the decannulation pathway, yet the optimal clinical indicators to guide successful cuff deflation are unknown. OBJECTIVES: The study aims were to identify (1) the proportion of patients tolerating continuous cuff deflation at first attempt; (2) the clinical observations associated with cuff deflation success or failure, including volume of above cuff secretions and (3) the predictive capacity of these observations within a heterogeneous cohort. METHODS: A retrospective review of 113 acutely tracheostomised patients with a subglottic suction tube in situ was conducted. RESULTS: Ninety-five percent of patients (n=107) achieved continuous cuff deflation on the first attempt. The clinical observations recorded as present in the 24h preceding cuff deflation included: (1) medical stability, (2) respiratory stability, (3) fraction of inspired oxygen ≤0.4, (4) tracheal suction ≤1-2 hourly, (5) sputum thin and easy to suction, (6) sputum clear or white, (7) ≥moderate cough strength, (8) above cuff secretions ≤1ml per hour and (9) alertness≥eyes open to voice. Using the presence of all 9 indicators as predictors of successful cuff deflation tolerance, specificity and positive predictive value were 100%, although sensitivity was only 77% and negative predictive value 19%. Refinement to a set of 3 clinically driven criteria (medical and respiratory stability, above cuff secretions ≤1ml/h) provided high specificity (100%), sensitivity (95%), positive predictive value (100%) and an improved negative predictive value (55%). CONCLUSIONS: Key criteria can help guide clinical decision-making on patient readiness for cuff deflation.

Outcomes of percutaneous versus surgical tracheostomy in an Australian Quaternary Intensive Care Unit: An entropy-balanced retrospective study.

Background: Studies comparing percutaneous tracheostomy (PT) and surgical tracheostomy (ST) complications in the critically ill patient population with high acuity, complexity, and severity of illness are sparse. This study evaluated the outcomes of elective PT versus ST in such patients managed at a quaternary referral center. Aims: The primary aim was to detect a difference in hospital mortality between the two techniques. The secondary aims were to compare Intensive Care Unit (ICU) mortality, complications (including stoma site, tracheostomy-related, and decannulation complications), ICU and hospital length of stay, and time to decannulation. Methods: This was a single-center retrospective observational study of ICU admission from August 2018 to August 2021. Patients were included if an elective tracheostomy was performed during their ICU admission. Patients with a pre-existing tracheostomy and those who underwent an obligatory tracheostomy requirement (e.g. total laryngectomy) were excluded. Cohorts were matched using Hainmueller's entropy balancing. Binary data were evaluated using logistic regression and continuous data with ordinary least squares regression. Results: 349 patients with a tracheostomy were managed in the ICU during the observation period. They were predominantly males (75% in PT; 67% in ST), with a mean age in the PT and ST group of (47; SD = 18) and (55; SD = 16), respectively. After exclusion, 135 patients remained, with 63 in the PT group and 72 in the ST group. Patients receiving ST were significantly older with a higher Body Mass Index (BMI) than the PT group. There were no significant differences in gender, Acute Physiological And Chronic Health Evaluation (APACHE) III, and the Australian and New Zealand Risk Of Death (ANZROD) between the two groups. There was no difference in hospital mortality between groups (OR 0.91, CI 0.26-3.18, p = 0.88). There were also no differences in ICU mortality, ICU and hospital length of stay, and time to decannulation. PT was associated with a greater likelihood of complications (OR 4.19; 95% CI 1.73-10.13; p < 0.01). PT was associated with a greater risk of complications in those who had this performed early (<10 days of intubation) as well as late (>10 days of intubation). Conclusions: Percutaneous tracheostomy was associated with higher complications compared to surgical tracheostomy. They were related to tracheostomy cuff deflation, stomal site bleeding and infection, sputum plugging, and accidental and failed decannulation. These findings have identified opportunities to improve patient outcomes.

Tracheostomy Tube Type and Inner Cannula Selection Impact Pressure and Resistance to Air Flow.

BACKGROUND: Advancements in tracheostomy tube design now provide clinicians with a range of options to facilitate communication for individuals receiving ventilator assistance through a cuffed tube. Little is known about the impact of these modern design features on resistance to air flow. METHODS: We undertook a bench model test to measure pressure-flow characteristics and resistance of a range of tubes of similar outer diameter, including those enabling subglottic suction and speech. A constant inspiratory ± expiratory air flow was generated at increasing flows up to 150 L/min through each tube (with or without optional, mandatory, or interchangeable inner cannula). Driving pressures were measured, and resistance was calculated (cm H2O/L/s). RESULTS: Pressures changed with increasing flow (P < .001) and tube type (P < .001), with differing patterns of pressure change according to the type of tube (P < .001) and direction of air flow. The single-lumen reference tube encountered the lowest inspiratory and expiratory pressures compared with all double-lumen tubes (P < .001); placement of an optional inner cannula increased bidirectional tube resistance by a factor of 3. For a tube with interchangeable inner cannulas, the type of cannula altered pressure and resistance differently (P < .001); the speech cannula in particular amplified pressure-flow changes and increased tube resistance by more than a factor of 4. CONCLUSIONS: Tracheostomy tube type and inner cannula selection imposed differing pressures and resistance to air flow during inspiration and expiration. These differences may be important when selecting airway equipment or when setting parameters for monitoring, particularly for patients receiving supported ventilation or during the weaning process.

Impact of nasogastric tubes on swallowing physiology in older, healthy subjects: A randomized controlled crossover trial.

BACKGROUND & AIMS: The presence of a nasogastric tube (NGT) affects swallowing physiology but not function in healthy young adults. The swallowing mechanism changes with increasing age, therefore the impact of a NGT on swallowing in elderly individuals is likely to be different but is not yet known. The aims of this study were to determine the effects of NGTs of different diameter on (1) airway penetration-aspiration, (2) pharyngeal residue, and (3) pharyngeal transit, in older healthy subjects. METHODS: Randomized controlled crossover design. Healthy elderly volunteers underwent 3 modified barium swallow studies in which multiple diet and fluid consistencies were swallowed under the following conditions: (A) no NGT (control), (B) fine bore NGT, and (C) wide bore NGT. The control condition was assessed first to establish baseline swallowing function, then NGT order was randomly allocated. RESULTS: Of the 15 volunteers (median age 65 years, range 60-81) complete data sets were obtained for 9 (4 with allocation order ABC; 5 with ACB). Wide bore NGT data could not be obtained for 6 volunteers mainly due to tube intolerance. The presence of a NGT was associated with: (i) an increase in airway penetration-aspiration (fine bore NGT with serial liquid swallows and puree) (p < 0.01); (ii) increased pharyngeal residue (p < 0.05) in the pyriform sinus (fine bore NGT with puree); and in the valleculae (both fine and wide bore NGT with soft solids); and (iii) an increase in pharyngeal transit duration regardless of consistency (p < 0.01), with longest swallowing durations with the widest tube. CONCLUSIONS: NGT presence increases airway penetration-aspiration, pharyngeal residue and prolongs transit through the pharynx in older healthy individuals. Consideration of NGT impact on swallowing during concurrent oral and enteral feeding is recommended, with further systematic investigation required in elderly patients recovering from critical illness. Clinical trial registry Australia & New Zealand Clinical Trials Registry (ACTRN12613000577718).