What is the comparison between decannulation trial and suction frequency in patients with tracheostomy (tracheostomy tube)?

From the Guidelines

Decannulation trials should be prioritized over suction frequency when assessing a patient's readiness to have their tracheostomy tube removed. A patient is typically ready for decannulation when they can tolerate capping of their tracheostomy tube for 24-48 hours without respiratory distress, maintain adequate oxygen saturation (>92% on room air), effectively clear secretions through coughing, and demonstrate stable respiratory status. Suction frequency, while important for assessing secretion management, should decrease to less than once every 4-6 hours before considering decannulation, as indicated by the American Thoracic Society's guidelines 1.

Key Considerations for Decannulation

• The decannulation process often involves progressively downsizing the tracheostomy tube, followed by capping trials, before complete removal, as outlined in the care of children with chronic tracheostomy 1.
• After decannulation, the stoma is covered with an occlusive dressing and typically closes within 5-7 days.
• The approach prioritizes the patient's physiological readiness to breathe independently rather than relying solely on the frequency of suctioning needed, as decreased suction requirements are just one indicator of readiness among several critical factors that must be considered, including assessment of tracheostomy patency 1.

Suction Frequency and Tracheostomy Care

• Routine suctioning is performed according to a set schedule or as needed, based on assessment of the patient, with the frequency varying on the basis of individual characteristics, including age, muscular and neurological status, activity level, ability to generate an effective cough, viscosity and quantity of mucus, and maturity of the stoma 1.
• Suctioning allows the caregiver to assess tube patency, which is important because tubes can become obstructed without clinical symptoms, highlighting the need for regular assessment and maintenance of the tracheostomy tube 1.

Prioritizing Decannulation Trials

Given the importance of assessing a patient's readiness for decannulation based on their physiological ability to breathe independently, decannulation trials should take precedence over suction frequency in the evaluation process, as supported by the guidelines for the management of tracheostomy and laryngectomy airway emergencies 1. This approach ensures that the decision to remove the tracheostomy tube is based on a comprehensive assessment of the patient's respiratory status and ability to manage secretions effectively, rather than solely on the frequency of suctioning required.

From the Research

Comparison of Decannulation Trial and Suction Frequency

• The study 2 compared the time to decannulation between patients who underwent a 24-hour capping trial plus intermittent high-flow oxygen therapy and those who received continuous high-flow oxygen therapy with frequency of suctioning as the indicator of readiness for decannulation.
• The results showed that the time to decannulation was shorter in the intervention group (median, 6 days) than in the control group (median, 13 days).
• The incidence of pneumonia and tracheobronchitis was lower, and the duration of stay in the hospital was shorter, in the intervention group than in the control group.
• Another study 3 surveyed clinicians and found that patient level of consciousness, ability to tolerate tracheostomy tube capping, cough effectiveness, and secretions were the most important factors in the decision to decannulate a patient.
• The study 4 compared gradual vs abrupt techniques for decannulation in tracheostomized severe head trauma patients and found that the success or failure of decannulation was independent of the mode of decannulation.
• A prospective study 5 compared two methods of decannulation, gradual blocking of the tube and reduction of the size of the tube, and found that the two methods showed comparable outcomes in terms of tube reinsertion rate, mechanical ventilation rate after decannulation, successful decannulation, and complications.
• A retrospective study 6 found that early rehabilitation reduced the time to decannulation in patients with severe acquired brain injury, with a shorter tracheostomy duration and a higher probability of occurrence of decannulation in the early rehabilitation group.

Factors Influencing Decannulation

• Patient level of consciousness, cough effectiveness, secretions, and oxygenation are important determinants of clinicians' tracheostomy decannulation opinions 3.
• The ability to tolerate tracheostomy tube capping and the frequency of suctioning are also important factors in the decision to decannulate a patient 2, 3.
• The mode of decannulation, whether gradual or abrupt, does not appear to affect the success or failure of decannulation 4.
• Early rehabilitation has been shown to reduce the time to decannulation in patients with severe acquired brain injury 6.

Suction Frequency

• The frequency of suctioning is an important factor in the decision to decannulate a patient, with patients who require less frequent suctioning being more likely to be decannulated 2, 3.
• The study 2 found that basing the decision to decannulate on suctioning frequency plus continuous high-flow oxygen therapy reduced the time to decannulation, with no evidence of a between-group difference in the incidence of decannulation failure.
• Another study 4 found that the number of suctioning required per day was a statistically significant factor in the success or failure of decannulation.