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September - 2020

   

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High-Flow Oxygen with Capping or Suctioning for Tracheostomy Decannulation

G Hernandez Martinez, M-L Rodriguez, M-C Vaquero, et al New Eng J Med, 2020, 383:1009-1017

Comment

 This RCT of 330 patients performed in 5 Spanish ICUs is important as it provides a big step in the evidence for an area of intensive care that is arguably based on art more than science - how and when to decannulate a tracheostomy placed for weaning from mechanical ventilation. They compared “capping trial” to “suction frequency” in patients deemed “separated from mechanical ventilation” following 24-hrs of SBT. Of interest, there seems to be an assumption that cuff-down capping is standard of care, although I suspect this is highly geographic. 

The details;

  • 330 adults, average age 57-59 years, median of 13 days of MV before tracheostomy, over 50% indication was prolonged MV, 80% perc trach
  • To be included they had to meet criteria for “weaned from MV”. This meant freedom from MV for 24 hrs, following a weaning process of;
    • SBTs twice daily
    • minimum of 2-hrs rest between SBTs
    • Trial up to 12-hrs if no resp distress
    • If able to sustain SBTfor 12 hrs on 2 consecutive days, switched to HFO via trache.
    • Ready for capping trial if suction >4hrly
  • Randomised to;
    • Intervention group: No capping,  decannulated if suction maximum twice in 8-hr period for 24 hrs.
    • Standard care: 24-hour capping trial, described as cap over trache, cuff down, after performing 5-min tracheostomy tube occlusion test. 
  • Primary endpoint: Median time to decannulation;
    • time from completion of weaning from mechanical ventilation (24-hrs disconnected from ventilation) to actual decannulation
    • Shorter in intervention vs control group (6 days [IQR 5 to 7] vs. 13 days [IQR12 to 14]; abs diff, 7 days [95% CI, 5 to 9]
  • Secondary endpoint
    • Recannulation 2.4% intervention vs 5.6% control (diff 3.2%, 95% CI-1.2 to 8.1)
    • Weaning failure 6.5% intervention vs 16.7% control (diff 10.3%, 95% CI 3.4-17.4)
    • Pneumonia 4.1% vs 9.9%, (diff 5.8%, 95% CI 0.2-11.8)
    • Tracheobronchitis 18.9% vs 29.2% (diff 10.3%, 95% CI 1.0 -19.3)
    • Hospital LOS median days 48 vs 62 days (abs diff 14 days, 95% CI 9-33)

In summary, in this RCT of 330 patients with tracheostomy who had passed a hurdle of 24-hrs of separation from mechanical ventilation and were considered “weaned”, the decision to decannulate tracheostomy based on suction frequency was associated with improvement in primary and secondary outcomes, compared to use of a 24-hr tracheostomy capping trial. The outcomes include time to decannulation (7-day difference), recannulation, weaning failure, pneumonia, tracheobronchitis, and hospital LOS. This is clear, and suggest capping trials are associated with negative effects, possibly as they are highly demanding, they receive less continuous oxygen, and that failure may precede deterioration. It will be interesting to see how different regions of the world, with variation in practice, interpret this tria

 

Abstract

BACKGROUND

When patients with a tracheostomy tube reach a stage in their care at which decannulation appears to be possible, it is common practice to cap the tracheostomy tube for 24 hours to see whether they can breathe on their own. Whether this approach to establishing patient readiness for decannulation leads to better outcomes than one based on the frequency of airway suctioning is unclear.

METHODS

In five intensive care units (ICUs), we enrolled conscious, critically ill adults who had a tracheostomy tube; patients were eligible after weaning from mechanical ventilation. In this unblinded trial, patients were randomly assigned either to undergo a 24-hour capping trial plus intermittent high-flow oxygen therapy (control group) or to receive continuous high-flow oxygen therapy with frequency of suctioning being the indicator of readiness for decannulation (intervention group). The primary outcome was the time to decannulation, compared by means of the log-rank test. 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.

RESULTS

The trial included 330 patients; the mean (±SD) age of the patients was 58.3±15.1 years, and 68.2% of the patients were men. A total of 161 patients were assigned to the control group and 169 to the intervention group. The time to decannulation was shorter in the intervention group than in the control group (median, 6 days [interquartile range, 5 to 7] vs. 13 days [interquartile range, 11 to 14]; absolute difference, 7 days [95% confidence interval, 5 to 9]). The incidence of pneumonia and tracheobronchitis was lower, and the duration of stay in the hospital shorter, in the intervention group than in the control group. Other secondary outcomes were similar in the two groups.

CONCLUSIONS

Basing the decision to decannulate on suctioning frequency plus continuous high-flow oxygen therapy rather than on 24-hour capping trials plus intermittent high-flow oxygen therapy reduced the time to decannulation, with no evidence of a between-group difference in the incidence of decannulation failure

September


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