Pediatric tracheostomy decannulation: Post implementation of tracheostomy team and decannulation protocol

Abstract

Background: Historically, the Royal Children’s Hospital tracheostomy service relied upon senior airway clinician decision-making regarding decannulation. In March 2016 we established a formal Tracheostomy multidisciplinary team (MDT) which now meets on a weekly basis. Simultaneously, we devised a Tracheostomy Decannulation protocol to be used to guide management and treatment decision-making around timing of tracheostomy decannulation. Methods: The tracheostomy decannulation outcomes at a large tertiary pediatric Hospital were reviewed for the period spanning 2003 until 2018. The primary outcome measure was decannulation success. Secondary outcome measures were timing of failure (early ≤28 days, or late >28 days) and mortality. Decannulation results before and after the tracheostomy MDT were compared, along with other variables which could influence decannulation success including indication for tracheostomy, significant comorbidities, cyanotic heart disease, simple or major airway reconstruction, peri-decannulation steps and timing of decannulation. Results: Fifty-two children underwent a total of 68 decannulation attempts across the 15-year study period. Involvement of the tracheostomy MDT correlated with improved likelihood of decannulation success (P=0.007). Additional variables which also strongly correlated with decannulation success included indication for tracheostomy (P=0.048), major airway reconstruction (P=0.031), normal overnight oximetry (P=0.003), and timing of the decannulation (P=0.002). Conclusions: Tracheostomy multidisciplinary teams and protocol-guided decannulation pathways should recognise the need for appropriate pre-attempt multidisciplinary work-up, good oxygen saturations before attempts and well-supported appropriately-timed decannulations. Due to the medical complexity of these patients, protocol-based decision-making is useful as a guide to management, but care should be individualised in order to maximise successful outcomes.