Decannulation following tracheostomy is an important transition. Subcutaneous emphysema (SE) following decannulation has been rarely reported. We, herein, report a case of massive subcutaneous emphysema following decannulation of a short-term tracheostomy, discuss the various decannulation methods and causes of SE. We report and hypothesize the tight occlusive dressing method for tracheostomy decannulation to be the possible cause of SE in the present case.

BACKGROUND: Clinical blood resources are scarce and autologous blood transfusion for extracorporeal membrane oxygenation (ECMO) withdrawal is less studied.
OBJECTIVE: To assess the use of staged autotransfusion during ECMO decannulation.
METHODS: The study included ECMO withdrawal patients. Patients in the autologous transfusion group underwent staged transfusion during ECMO withdrawal, while those in the control group received 2.0 units of allogeneic packed red blood cells (RBCs) to increase hemoglobin (Hb). Parameters such as Hb, hematocrit (Hct), adverse events, decannulation success rate, volume of allogeneic RBC transfusions, and transfusion costs were compared.
RESULTS: A total of 82 Chinese patients were enrolled, with a mean age of 46 years, 27 were female, and the top three primary diagnoses were cardiac arrest, acute myocarditis, and severe pneumonia. There were 41 individuals in the autologous blood transfusion group and 41 in the control group. No significant differences were observed in Hb, Hct, adverse events, and the success rate for decannulation between the two groups (all P > 0.05). Compared with the control group, the volume of allogeneic RBC transfusions [0 (0∼1.50) U vs. 3.5 (1.88∼40) U, P < 0.001] and the total cost [130 (130∼390) Chinese Yuan (CNY) vs. 910 (487.50, 1040) CNY, P = 0.002] were lower in the autologous transfusion group.
CONCLUSIONS: In comparison with allogeneic RBC transfusion, staged autotransfusion during ECMO decannulation not only effectively maintained Hb levels but also reduced the requirement for allogeneic RBC transfusions. In addition, this approach decreased the associated costs and did not increase the risk of clinical adverse events.

UNASSIGNED: Tracheostomy is a life-saving surgical intervention commonly performed in patients requiring prolonged mechanical ventilation. However, the decannulation process is associated with various complications that can affect patient outcomes. This study aimed to assess complications and their management during decannulation in a cohort of tracheostomy patients at a tertiary care hospital, considering the complexities introduced by prior intubation.
UNASSIGNED: A retrospective cohort study was conducted involving 450 patients who underwent tracheostomy during a stipulated timeframe. Data regarding demographic characteristics, complications, and management strategies during decannulation were analysed. Special attention was given to distinguishing between complications directly related to the tracheostomy procedure and those potentially influenced by previous intubation.
UNASSIGNED: Out of the 450 patients, 250 experienced minor complications such as localized bleeding, oxygen desaturation, and minor infections. Another 40 faced major complications including severe haemorrhage, tracheal damage, and stenosis. Increasing age and tracheostomy duration were identified as significant predictors of complications. Pharmacological treatments, surgical interventions, and respiratory therapy were among the management strategies employed. The differentiation between complications arising from tracheostomy and prior intubation highlighted the need for comprehensive patient evaluation.
UNASSIGNED: Complications associated with decannulation occur frequently with varying severity. Efficient recognition and management of these complications are vital for improving patient outcomes. The study provides important insights into the challenges experienced during the decannulation process and highlights the necessity of considering prior intubation history in the management of tracheostomy decannulation to refine patient care protocols.

BACKGROUND: Tracheostomy decannulation is a routine procedure in airway management. There is no standard decannulation method; however, the two commonly practiced approaches are tracheostomy downsizing and intermittent capping, which are both accompanied by multiple visits to the clinic and increase patient discomfort. Herein, we explore fiberoptic bronchoscopy application in a novel single-stage decannulation protocol.
METHODS: We conducted a retrospective study on tracheostomy patients eligible for decannulation. Fiberoptic bronchoscopy was performed on patients with spontaneous ventilation for ≥48 h, age ≥18, hemodynamic stability, normal chest X-ray, adequate swallowing, effective cough, adequate consciousness, patent speaking valve, and absent history of recurrent aspiration. Tracheostomy removal occurred after evaluating the airway and ruling out tracheomalacia, tracheitis with stenosis, obstructive granulation tissue, and moderate-to-severe stenosis. We documented patients\' demographic and clinical information, along with details of their post-decannulation course.
RESULTS: Out of 58 patients admitted for tracheostomy removal, we excluded six patients (10.3%) from the study because, despite clinical indications for successful weaning, they exhibited abnormalities that interrupted the decannulation process. Of the remaining 52 patients, 50 (96.1%) were successfully weaned off, while two needed reinsertion during their hospital course. Bronchoscopy findings were unremarkable in 33 (63.5%) patients, and the most frequently observed abnormalities were paucity of vocal cord movement in 5 (9.6%) patients and granulation tissue formation in 5 (9.6%) patients. No further airway management was necessary after discharge.
CONCLUSIONS: Our study introduces the innovative approach of single-stage bronchoscopic decannulation as a potentially beneficial tool for immediate decannulation. Based on our experience, we achieved a relatively satisfactory outcome following single-stage tracheostomy decannulation with bronchoscopy. The approach shows promise in providing valuable airway insights and predicting possible decannulation failures. Further research is needed to evaluate its impact on stress reduction for patients and surgeons, its superiority compared to traditional techniques, its long-term effects on healthcare, and its potential cost-effectiveness.

BACKGROUND: Decannulation for people in a persistent vegetative state (PVS) is challenging and relevant predictors of successful decannulation have yet to be identified.
OBJECTIVE: This study aimed to explore the predictors of tracheostomy decannulation outcomes in individuals in PVS and to develop a nomogram.
METHODS: In 2022, 872 people with tracheostomy in PVS were retrospectively enrolled and their data was randomly divided into a training set and a validation set in a 7:3 ratio. Univariate and multivariate regression analyses were performed on the training set to explore the influencing factors for decannulation and nomogram development. Internal validation was performed using 5-fold cross-validation. External validation was performed using receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA) on both the training and validation sets.
RESULTS: Data from 610 to 262 individuals were used for the training and validation sets, respectively. The multivariate regression analysis found that duration of tracheostomy tube placement≥30 days (Odds Ratio [OR] 0.216, 95 % CI 0.151-0.310), pulmonary infection (OR 0.528, 95 %CI 0.366-0.761), hypoproteinemia (OR 0.669, 95 % CI 0.463-0.967), no passive standing training (OR 0.372, 95 % CI 0.253-0.547), abnormal swallowing reflex (OR 0.276, 95 % CI 0.116-0.656), mechanical ventilation (OR 0.658, 95 % CI 0.461-0.940), intensive care unit (ICU) duration>4 weeks (OR 0.517, 95 % CI 0.332-0.805), duration of endotracheal tube (OR 0.855, 95 % CI 0.803-0.907), older age (OR 0.981, 95 % CI 0.966-0.996) were risk factors for decannulation failure. Conversely, peroral feeding (OR 1.684, 95 % CI 1.178-2.406), passive standing training≥60 min (OR 1.687, 95 % CI 1.072-2.656), private caregiver (OR 1.944, 95 % CI 1.350-2.799) and ICU duration<2 weeks (OR 1.758, 95 % CI 1.173-2.634) were protective factors conducive to successful decannulation. The 5-fold cross-validation revealed a mean area under the curve of 0.744. The ROC curve C-indexes for the training and validation sets were 0.784 and 0.768, respectively, and the model exhibited good stability and accuracy. The DCA revealed a net benefit when the risk threshold was between 0 and 0.4.
CONCLUSIONS: The nomogram can help adjust the treatment and reduce decannulation failure.
BACKGROUND: Clinical registration is not mandatory for retrospective studies.

Patients with acute respiratory distress syndrome due to COVID-19 require intensive care unit (ICU) admission with consecutive endotracheal intubation and invasive mechanical ventilation. In patients with long-term mechanical ventilation, percutaneous dilatational tracheostomy (PDT) may be considered. This retrospective analysis includes clinical data on patients treated at the ICUs of the COVID Hospital of the Clinical Center of Vojvodina in the period from September 3, 2021 to May 1, 2022, and underwent PDT. Patients were predominantly male (n=48; 65.8%). Weaning from mechanical ventilation was achieved in 31 (42.5%) and decannulation in 25 (34.2%) patients. The mean time from polymerase chain reaction SARS CoV-2 positivity until PDT was 15.59±6.85 days. The mean time of endotracheal intubation before the PDT procedure was 7.37±4.89 days. The mean weaning time from mechanical ventilation was 10.45±7.92 days. Twenty-five (34.2%) patients were decannulated at the mean time of 19.60±11.81 days. The complications were tracheostomy related bleeding (2 patients), pneumothorax (4 patients), subcutaneous emphysema (1 patient) and cricoid cartilage injury (1 patient). PDT is a simple, safe, and effective procedure performed in COVID-19 patients in the ICU.

BACKGROUND: Prolonged tracheal tube placement following severe traumatic brain injury (TBI) can cause serious complications. Safe removal requires sufficient ability for independent breathing and airway protection. Thus, identifying important factors for time to removal of the tracheal tube (decannulation) is essential for safe and efficient weaning. This study aimed to identify significant factors for time to decannulation in a Danish population of subjects with tracheostomy after TBI.
METHODS: This was a retrospective register-based cohort study. Subjects with moderate and severe TBI and a tracheal tube were selected from the Danish Head Trauma Database between 2011-2021. Time to decannulation was calculated as time from injury to decannulation. Associations between selected explanatory variables representing demographic and clinical characteristics and time to decannulation were analyzed using linear regression models.
RESULTS: A total 324 subjects were included with a median of 44 d to decannulation. Primary analysis found that an improvement in swallowing ability during the initial 4 weeks of rehabilitation was associated with an 8.2 d reduction in time to decannulation (95% CI -12.3 to -4.2, P < .001). Change in overall sensorimotor ability reduced time to decannulation by 0.94 (95% CI -0.78 to -0.10, P = .03) d. Change in cognitive abilities from rehab admission to 4-week follow-up did not significantly affect the number of days to decannulation (P = .66). Secondary analysis showed pneumonia was associated with the largest estimated increase of 24.4 (95% CI 15.9-32.9, P < .001) d and that increased cognitive functioning at rehabilitation admission was associated with a significant reduction in time to decannulation.
CONCLUSIONS: This study found that a change in swallowing ability is a potentially significant factor for reducing time to decannulation. Identifying factors that could explain differences in time to decannulation is essential for patient outcomes, especially if these factors are modifiable and could be targeted in rehabilitation and treatment.

Tracheostomized children have higher mortality compared to adults due to smaller airway anatomy and greater medical complexity and are at high risk for life-threatening complications. Following new tracheostomy placement, caregivers are required to successfully complete extensive training before discharge home. Training for tracheostomy emergencies such as tube obstruction and accidental decannulation is challenging without real-life, hands-on experience, but simulation training has shown promising effects on improving caregiver knowledge and comfort in preparing for emergency situations. Readmissions and emergency department visits are common following discharge, with many due to respiratory illness. Inhaled antibiotics are frequently prescribed to treat bacterial respiratory infection. However, guidelines for standardized management of tracheostomy-related respiratory illness are not available. Although standardized decannulation protocols are utilized, evidence-based guidelines are lacking, and the role of routine polysomnogram prior to decannulation is unresolved. Several knowledge gaps in management of pediatric tracheostomy present the opportunity for future research to improve patient outcomes.

Children who require home mechanical ventilation (HMV) with an artificial airway or invasive mechanical ventilation (HMV) have a possibility of successful weaning due to the potential of compensatory lung growth. Internationally accepted guidelines on how to wean from HMV in children is not available, we summarize the weaning strategies from the literature reviews combined with our 27-year experience in the Pediatric Home Respiratory Care program at the tertiary care center in Thailand. The readiness to wean is considered in patients with hemodynamic stability, having effective cough measured by maximal inspiratory pressure, requiring a fraction of inspired oxygen (FiO2) < 40%, positive end expiratory pressure <5 cmH2O, and acceptable arterial blood gases. The strategies of weaning is start weaning during the daytime while the child is awake and close monitoring is feasible. Disconnect time is gradually increased through naps and sleeping hours. Weaning from the conventional mechanical ventilator to Bilevel PAP or CPAP are optional. Factors affected the successful weaning are mainly the underlying diseases, complications, growth and development, caregivers, and resources. Weaning should be stopped during acute illness or increased work of breathing. The readiness for decannulation could be determined by using the speaking devices, tracheostomy capping, and measurement of end-expiratory pressure. Polysomnography and airway evaluation by bronchoscopy are recommended before decannulation. Weaning when the child is ready is crucial because living with HMV can be challenging and stressful. Failure to remove a tracheostomy when indicated can result in delayed speech, social problems as well as risk for infection.

The number of tracheotomized patients with dysphagia and their need for treatment are continuously increasing in clinical and community settings. The revised version of the directive on home care and community-based intensive care of the Federal Joint Committee (G-BA) requires that tracheotomized patients are regularly evaluated with the aim of identifying and promoting the therapeutic potential after hospital discharge. Dysphagia treatment plays a crucial role as without improvement of severe dysphagia there is practically no possibility for decannulation. Tracheotomized patients with dysphagia are treated by speech and language therapists (SLT); however, the contents of tracheostomy management (TM) are not obligatory in the speech and language therapeutic training curricula, so that there is a need for further education and treatment standards must be secured. Therefore, the German Interdisciplinary Society for Dysphagia (DGD) in cooperation with the participating German medical and therapeutic societies developed a postgraduate curriculum for TM. This should serve as the basis for contents in TM and qualification of therapists within the framework of the delegation of medical services. The goals of the TM curriculum are the definition of theoretical and practical contents of TM, the qualification to perform TM according to current standards of care and quality assurance. The curriculum defines two qualification levels (user and trainer), entry requirements, curricular contents, examination and qualification criteria as well as transitional regulations for SLTs already experienced in TM.
UNASSIGNED: Die Anzahl tracheotomierter dysphagischer PatientInnen im klinischen und außerklinisch-ambulanten Setting und der damit einhergehende Behandlungsbedarf steigen kontinuierlich. Die Neufassung der Richtlinie des Gemeinsamen Bundesausschusses über die Verordnung außerklinischer Intensivpflege (AKI) sieht zudem vor, dass PatientInnen in der AKI regelmäßig evaluiert werden, um Therapiepotenzial nach stationärer Entlassung zu erkennen und zu fördern. Eine besondere Rolle nimmt dabei die Dysphagietherapie ein, da ohne Besserung schwerer Dysphagien kaum die Möglichkeit einer Dekanülierung besteht. Tracheotomierte dysphagische PatientInnen werden von LogopädInnen und akademischen SprachtherapeutInnen behandelt. Inhalte zum Trachealkanülenmanagement (TKM) finden sich jedoch nicht obligatorisch in den sprachtherapeutisch-logopädischen Ausbildungs-Curricula, sodass Weiterbildungsbedarf im therapeutischen Umgang mit Trachealkanülen besteht und Behandlungsstandards gesichert werden müssen. Daher wurde von der Deutschen interdisziplinären Gesellschaft für Dysphagie (DGD) in Kooperation mit den beteiligten therapeutischen und medizinischen Fachgesellschaften ein Curriculum zum TKM entwickelt. Dieses soll Basis für das inhaltliche Vorgehen im TKM sein und als Qualifikationsnachweis der TherapeutInnen im Rahmen der Delegation ärztlicher Leistungen dienen. Ziele des TKM-Curriculums sind die Definition theoretischer und praktischer Weiterbildungsinhalte, die Befähigung zur Durchführung des TKM nach aktuellen Standards sowie die Qualitätssicherung. Das Curriculum definiert zwei Qualifikationsstufen (AnwenderIn und AusbilderIn), Eingangsvoraussetzungen, curriculare Inhalte, Prüfungs- und Qualifikationskriterien sowie Übergangsregelungen für bereits im TKM erfahrene TherapeutInnen.