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Correspondence: ABSTRACT
All correspondence and requests for McKim DA, Hendin A, LeBlanc C, King J, Brown CRL, Woolnough A:
reprints should be addressed to:
Tracheostomy decannulation and cough peak flows in patients with neuromuscular
Douglas A. McKim, MD, FRCPC, FCCP,
DABSM, Respiratory Rehabilitation weakness. Am J Phys Med Rehabil 2012;91:00Y00.
Services and The Ottawa Hospital Sleep Objective: The aim of this study was to examine the relationship between
Centre, Department of Medicine,
University of Ottawa, 505 Smyth Road, cough peak flows (CPFs) before and after tracheostomy tube removal (decan-
Ottawa, ON, Canada K1H 8M2. nulation) in patients with neuromuscular respiratory muscle weakness.
Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
A tracheostomy can be a life-saving procedure
for a patient who has severe upper airway obstruc-
sought to determine the relationship between CPF
values before and after decannulation.
2 McKim et al. Am. J. Phys. Med. Rehabil. & Vol. 91, No. 6, June 2012
Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
TABLE 1 Predecannulation and postdecannulation CPF
n Predecannulation Postdecannulation Difference P
CPFsp, l/min
All patients 26 146 T 78 181 T 82 35 G0.001
Nonfenestrated 21 141 T 79 184 T 89 43 G0.001
CPFLVR, l/min
All patients 22 229 T 83 263 T 83 34 0.0127
Nonfenestrated 17 225 T 79 261 T 81 36 0.0395
CPFLVR + MAC, l/min
All patients 19 291 T 109 333 T 96 42 0.0136
Nonfenestrated 14 285 T 105 337 T 84 52 0.0240
Data are presented as mean T SD. CPFsp refers to spontaneous CPF (no added LVR or MAC), CPFLVR refers to CPF with LVR, and
CPFLVR + MAC refers to CPF with LVR and the addition of MAC.
CPF, cough peak flow; LVR, lung volume recruitment; MAC, manually assisted cough.
lung volume as possible followed by a brief breath- postextubation CPFs. The analysis was performed
hold. The patient was then asked to produce a strong for all patients (n = 26). An additional subanalysis
cough timed with a manual abdominal thrust (MAC) was performed using only the patients with non-
or costal lateral compression just before glottic fenestrated tubes (n = 21) to remove the effect of
opening. The maximum values that were observed in diminished flow resistance of the fenestrated tra-
three attempts were recorded. There was no audible cheostomy tubes. Values are given as mean T SD.
or visible leak around the occluded tracheostomy Tests of significance were two sided. All P values
tube, although a small leak could not be excluded. G0.05 were considered to be statistically significant.
Predecannulation CPFs were measured at the This study was approved by the Ottawa Hospital
mouth within 24 hrs before decannulation with Research Ethics Board.
the tracheostomy tube capped or with a Passy-Muir
valve in place. Postdecannulation CPFs were mea- RESULTS
sured through the mouth within 24 hrs of decan- The CPFsp, CPFLVR, and CPFLVR + MAC are noted
nulation, wherever possible or once the stoma had in Table 1 and Figure 1. Seven of the 26 patients
completely closed (range, 1Y15 days; median, 2 (27%) did not demonstrate an increase in CPFsp
days). Any stoma leaks were controlled by pressure after decannulation. This result is surprising be-
dressings for the patients who used nocturnal non- cause removing this obstruction can only be ex-
invasive mechanical ventilation. pected to increase expiratory flows. An additional
Data analysis was conducted using Microsoft subanalysis was performed after removing the data
Excel 2003 and SPSS Version 18.0 for Windows. A of these seven patients.. The average CPFsp of the
paired t test was used to compare preextubation and remaining subgroup (n = 19) before and after decan-
FIGURE 1 Relationship between predecannulation and postdecannulation for all patients and for each condition
(CPFsp, CPFLVR, and CPFLVR + MAC). *Significant differences (P G 0.05) under each condition, between
predecannulation and postdecannulation. CPF, cough peak flow; LVR, lung volume recruitment; MAC,
manually assisted cough.
Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
nulation was 129 T 78 and 181 T 92 l/min, respectively nificantly higher than spontaneous CPF after de-
(P G 0.001). The difference between predecannulation cannulation. As such, LVR with the tracheostomy
and postdecannulation was 53 l/min. Of the seven tube in place is more effective than decannulation
patients removed from this analysis, five had SCI (C4- alone in improving CPF. Combined, LVR and MAC
C5), one patient who suffered a stroke could not techniques further increase CPF, thereby improv-
perform LVR, and one patient experienced postoper- ing airway clearance and increasing chances for
ative respiratory failure from intensive care unit successful decannulation as previously reported.15
myoneuropathy. Four of the seven patients had non- The average CPFsp in the subjects in our study
fenestrated tracheostomy tubes. was 146 T 78 l/min, low enough to question the
ability to clear secretions if decannulated. On av-
erage, the patients were able to achieve CPFs above
DISCUSSION 270 l/min with a combination of LVR and MAC,16
This study demonstrates a significant increase whether tracheostomized (291 T 109 l/min) or
in CPF after tracheostomy tube decannulation. The decannulated (333 T 96 l/min). All patients were
improvement in CPF for the patients with nonfene- decannulated successfully.
strated tracheostomy tubes alone was consistently
greater than that of the entire group (Table 1). Be- ACKNOWLEDGMENTS
cause the data were all collected during clinical care, We thank Carolyn Cook from the Institute
not all patients received an abdominal thrust and for Rehabilitation Research Development, who pro-
LVR before and after decannulation; all 26 had vided assistance with the illustrations.
CPFssp, 22 had CPFLVR, and 19 had CPFLVR + MAC
measures (Fig. 1).
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Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.