2007 OPEN FORUM Abstracts
A NORTH AMERICAN SURVEY OF THE DETERMINANTS OF TRACHEOSTOMY DECANNULATION.
D. R. Hess1, 2, C. Crimi 3, L. Berra 3, A. Noto3, U. Schmidt3, 2, L. M. Bigatello3, 2, H. Stelfox4
Background. Little is known about how clinicians make decisions to decannulate patients with a tracheostomy. We conducted a survey of respiratory therapists (RTs) and physicians (MDs) to examine decannulation practices in North America. Methods. We constructed 2 medical and 2 surgical scenarios representative of patients treated in ICUs. Each included determinants of decannulation readiness that were randomly varied: age (45 vs. 75 yrs); co-morbidities (none vs. end-stage renal disease), etiology of respiratory failure (pneumonia vs. COPD); difficulty of intubation (easy vs. difficult); level of consciousness (alert vs. drowsy); ability to tolerate capping (24 vs. 72 hrs); cough effectiveness (strong vs. weak); secretions (scant thin vs. moderate thick); swallowing function (nothing-by-mouth vs. Jell-O and pudding); respiratory rate (18 vs. 28 breaths/min) and oxygenation (SpO2 95% with FIO2 0.3 vs. 0.5). Three scenarios were randomly selected for each survey and a decannulation recommendation (Yes or No) was requested for each. Respondents were also asked to rate the importance of each determinant of decannulation readiness on a Likert scale. The survey was conducted using a secure web-based questionnaire. Each respondent was asked to provide recommendations for additional experts to survey (snowball sampling technique).
Results. We received 154 responses (52 RTs, 102 MDs; 71% response rate). 83% of RTs and 62% of MDs reported >10 yrs experience caring for patients with tracheostomy. Tolerance of capping was rated the most important determinant of decannulation readiness. Decannulation was more likely (OR; 95% CI) for scenarios where patients had COPD (1.9; 1.2 - 3.0) compared to pneumonia, were alert (2.1; 1.0 - 4.4) compared to drowsy, had a strong cough (3.7; 2.4 - 5.7) compared to a weak cough, had scant thin secretions (2.7; 1.7 - 4.4) compared to moderate thick, and required FIO2 0.3 (2.5; 1.7 - 3.8) compared to 0.5. RTs were more likely to recommend decannulation than MDs (OR 1.8; 0.9 - 3.7) and RTs were more likely to recommend decannulation in a drowsy patient (OR 3.1; 1.2 - 7.8). Age, respiratory rate, ability to tolerate capping > 24 hrs, co-morbidity, difficulty of intubation, and swallowing function were not significant determinants of decannulation.
Conclusions. RTs were more likely to recommend decannulation than MDs, particularly in the drowsy patient. These data could serve as a basis for multidisciplinary decannulation guidelines.