Retrospective review of complex tracheostomy ward round in determining barriers to decannulation in acquired and traumatic brain injured patients.

Purpose

To identify most common barriers to decannulation in complex neurosurgical patients and explore therapy options to overcome these and reduce time with tracheostomy in situ.

Out of the 8 patients
meeting the inclusion criteria,
50%
struggled to manage oral secretions,
50%
were complicated by infection,
25%
had complex airway issues such as trachitis or vocal cord palsy...
...and 25%
had evidence of/ diagnosed with PSH at some point.

Approach

Retrospective review of complex patients reviewed on TWR over 3 month period.  

 

Inclusion:

Brain injury requiring surgical intervention, LOS >6/52, reviewed at least twice on TWR.  

 

Excluded:

3 patients (1. Initial injury in 2016, recent deterioration resulting in tracheostomy. 2. Awaiting further surgery so not decannulated although appropriate. 3. Clotting issues, airway remains in situ although appropriate for decannulation)

 

Barriers to decannulation: 

B1 - Inability to manage oral secretions

B2 - Infection / medical instability

B3 - Airway issues

B4 - Paroxysmal sympathetic hyperactivity (PSH)  

 

Patients:

  1. SAH 22/09/18. Tracheostomy 08/10/18. Not decannulated due to oral secretions and medical instability. B1+2.
  2. TBI 06/12/18. Tracheostomy 21/12/18. Decannulated 10/01/19. B1+4.
  3. SAH 15/12/18. Tracheostomy 27/12/18. Decannulated 11/01/19. B2.
  4. Hypoxic brain injury (cardiac arrest) 22/01/19. Tracheostomy 31/01/19. Not decannulated due to oral secretions. B1+4.
  5. ICH 21/01/19. Tracheostomy 06/02/19. Decannulated - 27/03/19. B3.
  6. Encephalitis 13/01/19. Tracheostomy 05/02/19. Not decannulated due to oral secretions. B1.
  7. Polytrauma (TBI) 13/01/19. Tracheostomy 17/01/19. Not decannulated due to vocal cord palsy. B2+3.
  8. ICH 13/03/19.Tracheostomy 28/03/19. Not decannulated as medically unwell. B2.

Outcomes

Out of the 8 patients meeting the inclusion criteria, 50% struggled to manage oral secretions, 50% were complicated by infection, 25% had complex airway issues such as trachitis or vocal cord palsy and 25% had evidence of/ diagnosed with PSH at some point.

Currently 3 out of 8 have been decannulated (37.5%). The average number of days with a tracheostomy in situ for these patients was 28 days. All patients remain in an inpatient setting therefore unable to determine LOS.

NB. Only 1 out of the 4 patients with difficulty managing oral secretions had been decannulated.

Implications

  • Could Above cuff vocalisation be utilised as a treatment option to improve airflow over vocal cords, improving sensation and promoting swallow in conjunction with medical management and appropriate cuff deflation trials?
  • Is PSH recognised early enough as a non-infective complication which should not stop weaning? Could a tool such as the PSH-AM be utilised routinely to identify these patients?
  • Would it be beneficial for a Senior Practitioner to review these patients throughout their journey (ICU-NHDU- Neurosurgical wards) in order to improve consistency with weaning these complex patients?

Top three learning points

  1. The benefit of MDT working in managing complex tracheostomy patients and how this can enhance patient care, outcomes and reduce length of stay.
  2. Medical management of saliva is not always appropriate in complex tracheostomy weans; providing an awareness of other adjuncts / therapies which can be utilised.

Additional notes

This work was presented at Physiotherapy UK 2019

Please see the attached Innovations poster below.

For further information about this work please contact Elizabeth Starbuck.

 

With special thanks to Dr Walton (Neurorehabilitation Consultant), Rebecca Twigden (Neurosurgery team lead), Lindsay Sudell (Neurosurgery team lead), Jennifer Lee (Senior Speech & language therapist), Aaron Ramchurn (Neurorehabilitation Co-ordinator).

 

Reference(s):

De Mestral, C., Iqbal, S., Fong, N., LeBlanc, J., Fata, P., Razek, T., Khwaja, K. (2011). Impact of a specialized multidisciplinary tracheostomy team on tracheostomy care in critically ill patients. Canadian Journal of Surgery, 54 (3), pp167-172.

Checklin, M., Etty-Leal, M., Iseli, T.A., Potter, N., Fisher, S., Chapman, L. (2015). Saliva management options for difficult-to-wean people with tracheostomy following severe acquired brain injury (ABI): A review of the literature. Brain Injury. 29(1), 1-10.

McGrath, B.A., Lynch, J., Bonvento, B., Wallace, S., Poole, V., Farrell, A., Diaz, C., Khwaja, S., Robertson, D.W., (2017). Evaluating the quality improvement impact of the Global Tracheostomy Collaborative in four diverse NHS hospitals. BMJ quality improvement report. 6(1).

Mitton, K., Walton, K., Sivan, M. (2017). Tracheostomy weaning outcomes in relation to the site of acquired brain injury: A retrospective case series. Brain Injury. 31(2).

McGrath, B.A., Wallace, S., Wilson, M., Nicholson, L., Felton, T., Bowyer, C. and Bentley, A.M., 2019. Safety and feasibility of above cuff vocalisation for ventilator-dependant patients with tracheostomies. Journal of the Intensive Care Society, 20(1), pp.59-65.

 

Garuti, G., Reverberi, C., Briganti, A., Massobrio, M., Lombardi, F. and Lusuardi, M., 2014. Swallowing disorders in tracheostomised patients: a multidisciplinary/ multiprofessional approach in decannulation protocols. Multidisciplinary respiratory medicine, 9(1), p.36.

 

Kothari, M., Bjerrum, K., Nielsen, L.H., Jensen, J. and Nielsen, J.F., 2017. Influence of External Subglottic Air Flow on Dysphagic Tracheotomized Patients With Severe Brain Injury: Preliminary Findings. Annals of Otology, Rhinology & Laryngology, 126(3), pp.199-204.

 

Bonvento, B., Wallace, S., Lynch, J., Coe, B. and McGrath, B.A., 2017. Role of the multidisciplinary team in the care of the tracheostomy patient. Journal of multidisciplinary healthcare, 10, p.391.