Log in | Register

The effects of increasing effective airway diameter on weaning from mechanical ventilation in tracheostomized patients: a randomized controlled trial

Gonzalo Hernandez| Ana Pedrosa| Ramon Ortiz| Maria del Mar Cruz Accuaroni| Rafael Cuena| Concepción Vaquero Collado| Susana García Plaza| Paloma González Arenas| Rafael Fernandez
Original
Volume 39, Issue 6 / June , 2013

Pages 1063 - 1070

Abstract

Purpose

To determine the effects of deflating the tracheal cuff during disconnections from mechanical ventilation (MV) in tracheostomized patients.

Methods

This was a single-center, randomized trial conducted in a general ICU of a tertiary hospital with regional referral for trauma patients. Patients at high risk of aspiration based on the drink test were excluded. Critically ill tracheostomized patients were randomized to have the tracheal cuff deflated or not during spontaneous breathing trials. Weaning was protocolized on progressive T-tube trials, and patients were considered weaned after 24 consecutive hours disconnected from MV. The primary end point was time to definitive withdrawal of MV; secondary end points were ventilator-associated respiratory infection (pneumonia and/or tracheobronchitis) and swallowing function. Statistical analyses included Cox proportional risk models.

Results

We randomized 195 patients and 181 patients completed the study (94 patients with deflated cuff and 87 with inflated cuff). Variables independently related to weaning time in the multivariate analysis were tracheostomy-to-first MV disconnection time (HR 0.5, 95 % CI 0.3–0.8; p < 0.01) and cuff deflation (HR 2.2, 95 % CI 1.5–3; p < 0.01). Respiratory infection was lower in the deflated group (20 vs. 36 %; p = 0.02). Swallowing function improved more in the deflated group (31 vs. 22 %; p = 0.02).

Conclusion

Under the conditions of our protocol, deflating the tracheal cuff in tracheostomized patients shortens weaning, reduces respiratory infections, and probably improves swallowing.

Keywords

References

  1. Ceriana P, Carlucci A, Navalesi P, Rampilla C, Delmastro M, Piaggi GC, De Mattia E, Nava S (2003) Weaning from tracheostomy in long-term mechanically ventilated patients: feasibility of a decisional flowchart and clinical outcome. Intensive Care Med 29:845–848
    • View reference on PubMed
  2. Hernández G, Ortiz R, Pedrosa A, Cuena R, Vaquero C, González P, García S, Canabal A, Fernández R (2012) The indication for tracheostomy is the main determinant in predicting timing for tracheostomy decannulation. Med Intensiva 36:531–539
    • View reference on PubMed
    • View reference on publisher's website
  3. Christopher KL (2005) Tracheostomy decannulation. Respir Care 50(4):538–541
    • View reference on PubMed
  4. Bach JR, Alba AS (1990) Tracheostomy ventilation. A study of efficacy with deflated cuffs and cuffless tubes. Chest 97:679–683
    • View reference on PubMed
    • View reference on publisher's website
  5. Hussey JD, Bishop MJ (1996) Pressures required to move gas through the native airway in the presence of a fenestrated vs a nonfenestrated tracheostomy tube. Chest 110:494–497
    • View reference on PubMed
    • View reference on publisher's website
  6. Cabello B, Thille AW, Roche-Campo F, Brochard L, Gomez FJ, Mancebo J (2010) Physiological comparison of three spontaneous breathing trials in difficult-to-wean patients. Intensive Care Med 36:1171–1179
  7. Emberger JS, Krauss E, Racine L, Brown JM (2009) Effect of deflated cuffs, fenestrations, speaking valves and capping on exhalation with a tracheostomy. 2009 OPEN FORUM Abstracts. http://www.rcjournal.com/abstracts/2009/?id=678230. Accessed 27 Feb 2013
  8. Boles JM, Bion J, Connors A, Herridge M, Marsh B, Melot C, Pearl R, Silverman H, Stanchina M (2007) Weaning from mechanical ventilation. Eur Respir J 29:1033–1056
    • View reference on PubMed
    • View reference on publisher's website
  9. Alves LM, Cassiani Rde A, Santos CM, Dantas RO (2007) Gender effect on the clinical measurements of swallowing. Arch Gastroenterol 44:227–229
    • View reference on publisher's website
  10. Romero CM, Marambio A, Larrondo J, Walker K, Lira MT, Tobar E, Cornejo R, Ruiz M (2010) Swallowing dysfunction in nonneurologic critically ill patients who require percutaneous dilatational tracheostomy. Chest 137:1278–1282
    • View reference on PubMed
    • View reference on publisher's website
  11. Rumbak MJ, Graves AE, Scott MP, Sporn GK, Walsh FW, Anderson WM, Goldman AL (1997) Tracheostomy tube occlusion protocol predicts significant tracheal obstruction to air flow in patients requiring prolonged mechanical ventilation. Crit Care Med 25:413–417
    • View reference on PubMed
    • View reference on publisher's website
  12. Ochoa ME, Marin MC, Frutos-Vivar F, Gordo F, Latour-Perez J, Calvo E, Esteban A (2009) Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis. Intensive Care Med 35:1171–1179
  13. Esteban A, Frutos F, Tobin MJ, Alia I, Solsona JF, Valverdu V, Fernández R, de la Cal MA, Benito S, Tomás R (1995) A comparison of four methods of weaning patients from mechanical ventilation. NEJM 332:345–350
    • View reference on PubMed
    • View reference on publisher's website
  14. Niederman MS, Craven DE, Bonten MJ (2005) American Thoracic Society and Infectious Diseases Society of America (ATS/IDSA). Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 171:388–416
    • View reference on publisher's website
  15. Craven DE, Chroneou A, Zias N, Hjalmarson KI (2009) Ventilator-associated tracheobronchitis. Chest 2009(135):521–528
    • View reference on publisher's website
  16. Bach JR, Saporito LR (1996) Criteria for extubation and tracheostomy tube removal for patients with ventilatory failure. A different approach to weaning. Chest 110:1566–1571
    • View reference on PubMed
    • View reference on publisher's website
  17. Terragni PP, Antonelli M, Fumagalli R, Faggiano C, Pallavicini FB, Miletto A, Mangione S, Sinardi AU, Pastorelli M, Vivaldi N, Pasetto A, Della Roca G, Urbino R, Filippini C, Evangelista A, Ciccone G, Mascia L, Ranieri VM (2010) Early vs late tracheostomy for prevention of pneumonia in mechanically ventilated adult ICU patients. A randomized controlled trial. JAMA 303:1483–1489
    • View reference on PubMed
    • View reference on publisher's website
  18. Rello J, Lorente C, Diaz E, Bodi M, Boque C, Sandiumenge A, Santamaria JM (2003) Incidence, etiology, and outcome of nosocomial pneumonia in ICU patients requiring percutaneous tracheostomy for mechanical ventilation. Chest 124:2239–2243
    • View reference on PubMed
    • View reference on publisher's website
  19. Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB (2004) A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 32:1689–1694
    • View reference on PubMed
    • View reference on publisher's website
  20. Ouanes I, Lyazidi A, Danin PE, Rana N, Di Bari A, Abroung F, Louis B, Brochard L (2001) Mechanical influences on fluid leakage past the tracheal tube cuff in a benchtop model. Intensive Care Med 37:695–700
  21. Amathieu R, Sauvat S, Reynaud P, Slavov V, Luis D, Dinca A (2012) Influence of the cuff pressure on the swallowing reflex in tracheostomized intensive care unit patients. Br J Anaesth 109(4):578–583
    • View reference on PubMed
    • View reference on publisher's website
  22. Jung SJ, Kim DY, Kim YW, Koh YW, Joo SY, Kim ES (2012) Effect of decannulation on pharyngeal and laryngeal movement in post-stroke tracheostomized patients. Ann Rehabil Med 36:356–364
    • View reference on PubMed
    • View reference on publisher's website
  23. Hales PA, Drinnan MJ, Wilson JA (2008) The added value of fibreoptic endoscopic evaluation of swallowing in tracheostomy weaning. Clin Otolaryngol 33:319–324
    • View reference on PubMed
    • View reference on publisher's website
  24. Tolep K, Getch CL, Criner GJ (1996) Swallowing dysfunction in patients receiving prolonged mechanical ventilation. Chest 109:167–172
    • View reference on PubMed
    • View reference on publisher's website

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement