Decannulation
(Tracheostomy Tube Removal)
WHY DECANNULATE TO NONINVASIVE VENTILATORY SUPPORT?
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Once tracheostomy tubes are placed for continuous tracheostomy mechanical ventilation (CTMV), 4 out of 5 patients may eventually die due to complications of the tubes (JBCV63).
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Hospitalizations and respiratory complications are far more frequent for TMV users than for people managed by continuous noninvasive ventilatory support (CNVS).
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No one prefers to have tracheostomy tubes for CTMV rather than use CNVS unless they were never properly managed by NVS and mechanical insufflation-exsufflation (MIE).
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TMV necessitates either a lifetime of nursing home institutionalization or return home with 16-24 hours per day of nursing care at costs of up to $380,000 per year, whereas nursing care is usually not necessary for people using CNVS because they have no invasive airway interfaces.
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CNVS users with Duchenne muscular dystrophy survive 10 years longer than CTMV users.
DECANNULATION OF ADULTS
Make an outpatient appointment at a "Center for Noninvasive Respiratory Management" for decannulation. The center will determine the assisted cough peak flow (CPF). If the assisted CPF exceeds 120 L/min, then the tube can be removed irrespective of the extent of ventilator dependence (even for those who are 24 hours a day). Lower flows indicate that the upper airway may not be sufficiently open to permit MIE to expulse airway secretions after decannulation, so an otolaryngologist (ENT doctor) evaluation of the upper airway is needed for potentially reversible obstructing lesions such as granulation tissue before decannulation. Often, after placing a cuffless fenestrated tracheostomy tube, adjusting the ventilator settings, and practicing NVS for days to months, the tracheostomy tube can be removed in the outpatient department (without need for hospital admission).
DECANNULATION OF INFANTS AND SMALL CHILDREN
Although we can routinely decannulate adolescents and adults even when CTMV dependent, small children who require CTMV are too frightened to cooperate with decannulation, so we often wait until they are at least adolescents and hope that the tube will not have caused too much damage to the airways by that time to prevent decannulation. However, if the child only needs TMV during sleep and can cooperate with transition to nasal NVS with a cuffless fenestrated tracheostomy tube, then they can be safely decannulated as outpatients.
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