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Authors:

Douglas A. McKim, MD,


FRCPC, FCCP, DABSM Pulmonary
Ariel Hendin, BSc
Carole LeBlanc, RRT
Judy King, PT, PhD
Catherine R.L. Brown, BSc
Andrew Woolnough, MSc
ORIGINAL RESEARCH ARTICLE
Affiliations:
From the University of Ottawa
(DAM, AH, JK), Ottawa, ON, Canada;
The Ottawa Hospital Rehabilitation Tracheostomy Decannulation and
Centre (DAM, CL, AW), Ottawa, ON,
Canada; The Institute for Rehabilitation
Research and Development (DAM, AW),
Cough Peak Flows in Patients with
Ottawa, ON, Canada; and Dalhousie
University (CRLB), Halifax, Nova
Neuromuscular Weakness
Scotia, Canada.

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.

Disclosures: Design: For 26 patients with occluded tracheostomies (capped or Passy-


Financial disclosure statements have Muir valve), spontaneous CPF (CPFsp ), CPF after lung volume recruitment
been obtained, and no conflicts of (CPFLVR ), and CPF after lung volume recruitment and a manually assisted cough
interest have been reported by the (CPFLVR + MAC ) were measured before and after decannulation.
authors or by any individuals in control
of the content of this article. Results: Decannulation resulted in a significant increase (P G 0.001) in CPF of
0894-9115/12/9106-0000/0
35.6, 34.5, and 42.6 l/min for CPFsp, CPFLVR, and CPFLVR + MAC, respectively.
American Journal of Physical In addition, CPFLVR or CPFLVR + MAC with a capped tracheostomy in place were
Medicine & Rehabilitation greater than spontaneous CPF with the tracheostomy tube removed.
Copyright * 2012 by Lippincott
Williams & Wilkins Conclusions: Our study suggests that assisted coughing with a capped tra-
cheostomy tube in place can result in higher flows than removing the tube and
DOI: 10.1097/PHM.0b013e31825597b8 relying on spontaneous cough alone. Postdecannulation CPF measured at the
mouth can be predicted to be at least 34.5 l/min greater than predecannulation
values, which may thereby lower the threshold of the CPF indicated for safe
decannulation.
Key Words: Decannulation, Neuromuscular Disease, Cough Peak Flows, Airway
Clearance Techniques

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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.

tion or who cannot maintain oxyhemoglobin satu-


ration (SpO2) greater than 94% because of severe MATERIALS AND METHODS
bulbar-innervated muscle impairment, whether This study was conducted at a tertiary rehabili-
the patient requires ventilatory support or not.1 tation facility. Data were collected by a single respi-
Nevertheless, if the reason for tracheostomy has ratory therapist. Patients were included if they were
resolved, it is preferable practice to decannulate decannulated during an inpatient admission between
regardless of the need for ongoing mechanical ven- June 1998 and June 2008. The exclusion criteria in-
tilation. Patients continuing to require ventilatory cluded having an unassisted predecannulation CPFsp
assistance can be transitioned to noninvasive me- greater than 350 l/min.
chanical ventilation before and after decannulation. Twenty-six patients with tracheostomies cap-
Decannulation is indicated because of the long-term ped to receive regular LVR and MAC were included
risks of tracheostomy, including tube displacement, in the study. Of the 26 patients, 16 had had a high-
hemorrhage, tracheal stenosis, tracheomalacia, and level spinal cord injury (SCI); the other 10 had a
patient preference for noninvasive management to variety of diagnoses that included aortic repair with
improve his/her quality of life.2 In addition, invasive left hemidiaphragm paralysis and paraplegia, cen-
mechanical ventilation poses several risks, such as tral cord syndrome with left hemidiaphragm pa-
ventilator-associated pneumonia and upper airway ralysis, Guillain Barre syndrome, multiple sclerosis,
injury.3 Aside from these risks, Engoren et al.4 have myasthenia post-thymectomy, pneumonectomy,
observed that patients who can wean from trache- stroke, syringomyelia, and two patients with re-
ostomy support have an improved survival rate. strictive syndromes and critical illness myoneuro-
Patients with Duchenne muscular dystrophy who pathy. The tracheostomy tubes were all cuffed,
are ventilator dependent have also been demon- except for one, and included 10 Bivona Tight-to-
strated to have significantly longer survival without, Shaft, 8 Portex, 7 Shiley, and 1 Jackson (cuffless).
rather than with, tracheotomy tubes.5 Aside from The median inner diameter was 7.0 mm (range,
improving quality of life for patients, decannulation 5.0Y7.0 mm); the median outer diameter was 10.0
can result in decreased costs and better potential mm (range, 8.2Y10.8 mm). Twenty-one patients
for community-based care rather than institutional used nonfenestrated and 5 used fenestrated tra-
management.6 In addition, ventilator-dependent cheostomy tubes. Six patients used nocturnal non-
patients with vital capacities greater than 250 ml invasive mechanical ventilation only, and one
and who have tracheostomy tubes removed tend to patient used full-time noninvasive mechanical
wean from daytime ventilator support whereas ventilation with daytime mouthpiece ventilation.
those who are not decannulated do not wean.7 For the latter patient, the resuscitation bag was
Criteria for decannulation include the ability used, as in other subjects, to stack breaths to obtain
to attain a cough peak flow (CPF), whether assisted CPF measurements. The patient used tidal ventila-
or not, of greater than 160 l/min with the tracheos- tor breaths from the mouthpiece as required.
tomy capped7Y9 However, no one has yet described With a Passy-Muir valve or cap applied to the
changes in CPF before and after decannulation, the tracheostomy, the patient was instructed to cough
importance of which cannot be overstated for facili- as forcefully as possible, and these unassisted CPFssp
tating airway secretion removal and maintaining air- were measured via a peak flow meter (Mini Wright,
way patency.7,10,11 Patients with neuromuscular Clement Clarke Instrument, England) at the mouth.
disease may have reduced CPFs because of inspira- To measure CPF after LVR (CPFLVR), breaths were
tory and expiratory muscle weakness, impaired bulbar stacked to approximate the maximum insufflation
function, and diminished vital capacity. Delivering capacity.14 To achieve a maximum insufflation ca-
maximal insufflations with lung volume recruitment pacity, the patient was instructed to inhale fully,
(LVR) and manual thrust to the abdomen (manually hold his/her breath, and then place the lips tightly
assisted coughing [MAC]) can improve CPFs and around a mouthpiece through which consecutive
improve airway secretion clearance.12,13 volumes of air were delivered using a manual re-
The ability to predict postdecannulation CPF suscitation bag and held by a closed glottis. The
is important in evaluating a patients candidacy for patient was then asked to cough and the flows were
decannulation. Because most clinical assessments measured. To measure a manually assisted CPF
are based on predecannulation CPF only, this study (CPFLVR + MAC), LVR was used to achieve as large a

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.

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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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