Weaning from tracheotomy in long-term mechanically ventilated patients: feasibility of a decisional flowchart and clinical outcome

To assess the feasibility of following a decisional flowchart to decide whether to remove tracheotomy in long-term mechanically ventilated patients. Prospective study in a respiratory intensive care unit, with beds dedicated to weaning from prolonged mechanical ventilation. 108 tracheotomized patients with respiratory failure of different causes (chronic obstructive pulmonary disease, postsurgical complications, recovery from hypoxemic respiratory failure, neuromuscular disorders), 36 of whom died or could not be weaned from mechanical ventilation. We applied a decisional flowchart based on some simple clinical and physiological parameters aimed at assessing the patient's ability to remove secretions, swallowing function, absence of psychiatric diseases, possibility of reaching spontaneous breathing, and amount of respiratory space. Following our flowchart 56 of the remaining patients were successfully weaned from the tracheotomy cannula, with a reintubation rate at 3 months of 3%. The main reasons for not proceeding to decannulation were inability to remove secretions and severe glottic stenosis. No statistical differences were found between patients who received a surgical or percutaneous tracheotomy. Using a simple decisional flowchart we were able to remove tracheotomy cannula in almost 80% of the patients with spontaneous breathing autonomy without major clinical complications. Further larger prospective studies are needed to confirm this clinical approach in larger and different populations.