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Article history: Background: Tracheostomy cuff deation is a necessary stage of the decannulation pathway, yet the
Received 28 August 2015 optimal clinical indicators to guide successful cuff deation are unknown.
Received in revised form 9 December 2015 Objectives: The study aims were to identify (1) the proportion of patients tolerating continuous cuff
Accepted 12 January 2016
deation at rst attempt; (2) the clinical observations associated with cuff deation success or failure,
including volume of above cuff secretions and (3) the predictive capacity of these observations within a
Keywords:
heterogeneous cohort.
Clinical indicators
Methods: A retrospective review of 113 acutely tracheostomised patients with a subglottic suction tube
Criteria
Cuff deation
in situ was conducted.
Decannulation Results: Ninety-ve percent of patients (n = 107) achieved continuous cuff deation on the rst attempt.
Subglottic suction The clinical observations recorded as present in the 24 h preceding cuff deation included: (1) medical
Tracheostomy stability, (2) respiratory stability, (3) fraction of inspired oxygen 0.4, (4) tracheal suction 12 hourly,
(5) sputum thin and easy to suction, (6) sputum clear or white, (7) moderate cough strength, (8) above
cuff secretions 1 ml per hour and (9) alertness eyes open to voice. Using the presence of all 9 indicators
as predictors of successful cuff deation tolerance, specicity and positive predictive value were 100%,
although sensitivity was only 77% and negative predictive value 19%. Renement to a set of 3 clinically
driven criteria (medical and respiratory stability, above cuff secretions 1 ml/h) provided high specicity
(100%), sensitivity (95%), positive predictive value (100%) and an improved negative predictive value
(55%).
Conclusions: Key criteria can help guide clinical decision-making on patient readiness for cuff deation.
Crown Copyright 2016 Published by Elsevier Ltd on behalf of Australian College of Critical Care
Nurses Ltd. All rights reserved.
1. Introduction
http://dx.doi.org/10.1016/j.aucc.2016.01.002
1036-7314/Crown Copyright 2016 Published by Elsevier Ltd on behalf of Australian College of Critical Care Nurses Ltd. All rights reserved.
L.N. Pryor et al. / Australian Critical Care 29 (2016) 132137 133
Table 1
focused on establishing indicators for decannulation4,5 as opposed
Patient factors commonly considered prior to cuff deation.
to key steps in the decannulation pathway, such as cuff deation
tolerance. Characteristics considered
Once the underlying reason for tracheostomy insertion has Medical status (stable or improving)
resolved and mechanical ventilation is no longer required, the fac- Respiratory status (stable or improving)
tors that have been put forward as inuencing decision-making Oxygenation (FiO2 0.4)a
Cough strength (moderate)
for tube removal include, a patients conscious state, oxygen lev-
Patient alertness (eyes open to voice)
els, cough effectiveness and both pulmonary and oral secretions.5,6 Sputum colour (clear or white)
The ability to tolerate prolonged occlusion of the tracheostomy Sputum nature (thin and easy to suction)
via capping or corking has been suggested as an indicator of suit- Tracheal suction frequency (12 hourly)
ability for decannulation.4,5 There is, however, a clinical debate Above cuff secretions (1 ml per hour)
Table 3
Presence of clinical indicators and proportion of cuff deation success within total group (n = 113).
Grouped indicators
Met all 9 indicators 82 (73) 82 (77) 0 (0)
Met 8 of the 9 indicators 25 (22) 24 (22) 1 (17)
Met 7 indicators 6 (5) 1 (1) 5 (83)
Met 3 indicators (1, 2 and 9) 102 (90) 102 (95) 0 (0)
Table 4
Predictive values of grouped clinical indicators: (a) set of 9 and (b) rened set of 3.
Positive Negative
Fig. 2. Above cuff secretions prior to initial cuff deation for the 3 patient groups indicators, was 100%. However the NPV was low (19%), reecting
(n = 113). Scatterplot demonstrating the accumulated secretions (ml) removed from that failure to meet the set of 9 indicators did not accurately predict
above the inated tracheostomy cuff for each patient in the 24 h prior to cuff a persons ability to tolerate cuff deation (Table 4a).
deation, with the cohort (n = 113) separated according to the reason for tra-
cheostomy insertion. S = tracheostomy as part of planned head and neck surgery.
The renement of the criteria to reect the 3 key indicators
V = tracheostomy for prolonged mechanical ventilation. A = tracheostomy for airway suggested in the clinical guidelines as important for cuff deation
protection +/ impaired conscious state. NB: grey diamond denotes two patients resulted in greater accuracy in clinical decisions (Table 3). This set
of criteria was both sensitive (95%) and specic (100%) with strong
deation on the rst trial: 77% met all of the 9 criteria; with an PPV (100%) (Table 4b). The NPV was 55%. Case examination revealed
additional 22% meeting 8 of the 9 criteria, and only 1% meeting 7 of all of the false negatives were patients for whom the tracheostomy
the 9 indicators (Table 3). There were 25 patients who did not meet was inserted during head and neck surgery.
all of the criteria yet still achieved successful cuff deation. The clin-
ical indicators which were not met by these individuals included 4. Discussion
alertness (n = 9), sputum colour (n = 5), above cuff aspirates (n = 5)
and cough strength (n = 4). The current study has provided initial evidence to support
Only 6 patients were unsuccessful on initial cuff deation. Of clinical indicators associated with successful tracheostomy cuff
these, 5 failed to meet multiple criteria prior to the attempt (Table 3) deation in patients weaned from mechanical ventilation. Almost
and all had above cuff aspirates exceeding 24 ml in the 24 h pre- all of the patients in our study tolerated continuous cuff deation
ceding deation (Fig. 2). These patients had tracheostomies for the at the rst attempt. Clinicians remain divided as to the ideal dura-
following reasons: (i) part of planned head and neck surgical pro- tion of the initial attempt for cuff deation: intermittent trials with
cedure (n = 2) or (ii) airway protection +/ conscious state (n = 4). planned reination; continuous cuff deation with reination only
These patients had an older median age than the successful group if not tolerated; or a mix of the two approaches depending on the
(67 years and 52 years respectively). Most failed immediately patient population have all been described.4,6,13 The current data
or within 30 min of the rst attempt (n = 4), which was charac- suggests that with use of key selection criteria, the majority of
terised by persistent coughing and an associated tachycardia. The patients can progress in a single step to continuous cuff deation,
remaining patients (n = 2) required cuff reination within 12 h due regardless of the reason for insertion.
to increased tracheal suction requirements overnight that was A core set of 9 clinical observations related to the factors
suggestive of aspiration. All 6 patients subsequently progressed previously highlighted in the literature as important precursors
to successful continuous cuff deation within 4 days of the rst to decannulation (including medical and respiratory stability,
attempt. oxygenation, consciousness, pulmonary and oral secretions, and
The sensitivity of all 9 grouped indicators for cuff deation to cough),5,6 were found to be indicative of patients likely to tol-
accurately identify those suitable for cuff deation, was 77%. Speci- erate an initial cuff deation trial. This was conrmed by high
city, which is the ability to correctly identify those who are likely positive predictive values. While these provide a starting point to
to fail, was 100%. The PPV, or the proportion of patients correctly further evaluate clinical observations that indicate suitability for
identied as passing their initial cuff deation trial using all 9 cuff deation, it should be noted that for almost a quarter of the
136 L.N. Pryor et al. / Australian Critical Care 29 (2016) 132137
cohort, strictly applying all of the 9 criteria would have unneces- 4.1. Summary and conclusions
sarily delayed cuff deation trials. As such, all the clinical factors
considered key at the end of the decannulation pathway, that is, This study has reported on cuff deation and clinical decision
prior to tube removal, may not be as important at the beginning. making processes for tracheostomised patients after weaning from
There will always be some exceptions to any prognostic criteria, and mechanical ventilation. Ninety-ve percent of patients successfully
in those cases contextual issues, such as the individuals diagnos- tolerated continuous cuff deation at the rst attempt. The use
tic group, will be important to consider. For example, some patient of the following 3 key indicators for readiness for cuff deation:
groups may never demonstrate cough adequacy (e.g. spinal cord medical stability, respiratory stability and the ability to control sec-
injury), or may never reach sufcient alertness (e.g. brain injury28 ), retions as quantied by removal of 24 ml above cuff secretions
yet may still tolerate cuff deation provided protective mecha- within a 24 h period, were supported. Our study describes the use
nisms are intact. Therefore, requiring all patients to meet all of the of a subglottic suctioning tracheostomy in monitoring the volume
9 criteria may not necessarily be appropriate. of upper airway secretions. This may aid identication of aspirat-
Rather than using the full set of 9 criteria, our data provides ing patients and, as such, contribute to improved clinical decision
empirical support for considering the medical and respiratory sta- making.
bility of the patient, as well as the ability to control oral secretions
prior to commencing cuff deation. These are consistent with Author contributions
current clinical guidelines.19,20 However, within the current data
we have further qualied these, providing an objective measure All authors made substantial contributions to the conception,
for the management of upper airway secretions, which had not design, analysis and interpretation of the data; and manuscript
previously been explored. Although it is acknowledged that the preparation and revisions. All authors have approved the nal ver-
maximum of 24 ml within a 24 h period (i.e. average of 1 ml sion and are accountable for the accuracy and integrity of the
per hour) followed within the current study may prove to be con- research.
servative for certain patient groups, in the current data set this
criteria assisted in correctly identifying the majority of patients Conict of interest
to be ready for continuous cuff deation. Only 5% of patients who
The authors declare no conicts of interest.
tolerated cuff deation failed to meet these 3 core criteria. With-
out exception, all had their tracheostomy inserted at the time of
Acknowledgements
head and neck surgery. This may suggest a greater tolerance for
larger volumes of upper airway secretions than other groups due
A grant from the Royal Adelaide Hospital Research Foundation
to clinically important differences in alertness, mobility and airway
funded employment of a research assistant for data collection.
clearance.
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