Accelerating Weaning in Tracheostomized Critically-Ill Patients: Increasing Effective Airway Diameter
Mechanical ventilation (MV) is the main supportive treatment in patients with acute respiratory failure in Intensive Care Units, but most efforts are intended to restore spontaneous ventilation again, up to 40% of total time under MV (Epstein). Even so, close to 30% of patients become dependent on MV for prolonged weaning ventilation, according to the most recent series. Tracheostomy is frequently used in this subgroup of patients, as it improve patient comfort and communication, reduce sedative use and make easier airway management, but little evidence supports clinical decision making for weaning these patients.
Deflating the tracheal cuff is somehow an intermediate step not only to wean but also to decannulate the patient. Deflating the cuff impedes isolation of the lower airway, theoretically facilitating micro-aspirations and finally respiratory infections. Swallowing function is closely related to this risk and should always be evaluated before deflating the cuff. Considering that patient's collaboration is fundamental to perform the tests included in the decannulation protocols, we excluded from our population neuro-critical patients with deterioration of the level of consciousness, as they are the group at the highest risk for not tolerating decannulation.
Weaning time was 5 days shorter in the deflated group and fewer patients in the deflated group developed respiratory infections (15% less), both of them with significant statistical difference. In the deflated group, swallowing was better and improved more from baseline. We observed a trend toward lower weaning failure in the deflated group. Decannulation failure, defined as the need for a new cannula after protocolized decannulation, was 1% in the inflated group vs. 3% in the deflated group, but all patients with decannulation failure were eventually decannulated in the wards. It is worth notice that, in our study, the ventilator disconnection greater than 24 h was considered successful in weaning. Although it is possible to suppose that it is too short a period of time for patients with prolonged weaning, this does not invalidate the results considering that follow up was long enough to assure patients remained MV-free at ICU discharge.
The multivariate analysis confirmed that deflating the cuff is independently associated with a reduced weaning time and a decrease in respiratory infections.
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