Charissa J. Zaga

Motor neurone disease (MND) is a neurodegenerative disorder that causes progressive muscle weakness and severe disability. Median age of onset is 65 years, and life expectancy is typically two to t...

Introduction: Several tracheostomy clinical pathways and decannulation protocols have been proposed to optimize tracheostomy care; however, no universally accepted method exists. This study aimed to examine the characteristics of decannulated and non-decannulated subgroups to inform the development of tracheostomy clinical pathways which reflect the routine model of care. Methods: A retrospective observational cohort study design was employed to examine the clinical characteristics of patients who were decannulated and non-decannulated between January 2015 and December 2019. These data informed the development of two tracheostomy clinical pathways by an experienced multi-disciplinary team. Results: There were 440 tracheostomy admissions during the study period. Patients admitted with respiratory (n = 100; 23%) or neurological conditions (n = 70; 16%) were most represented in the study sample. Three-quarters of the cohort (n = 323; 73%) were decannulated before discharge or death. Survival to hospital discharge was 90% overall (95% of those decannulated patients; 76% of non-decannulated patients). Most were either discharged home (39%) or to an inpatient rehabilitation setting (37%). A clinical pathway for the management of patients who are simple to wean from mechanical ventilation (SW) was developed. A second clinical pathway for the management of patients who require prolonged weaning from mechanical ventilation (PW) was developed with two tiers: 1) Unable to wean from invasive mechanical ventilation (<4 hours continuously or no ventilator-free time) and 2) Able to wean from invasive mechanical ventilation. Discussion: Two tracheostomy clinical pathways were developed to reflect the multidisciplinary model of care of a centre with mature tracheostomy and weaning unit teams, in order to standardize approaches to rapid vs prolonged weaning from mechanical ventilation and tracheostomy decannulation. Robust programs of research are needed to strengthen the evidence in tracheostomy care globally. Future validation of these pathways is warranted.

There is developing evidence with regard to the feasibility, utility, and safety of verbal communication interventions with patients with tracheostomy who are invasively ventilated. In the past 2 decades, research efforts have focused on establishing evidence for communication interventions, including introducing an intentional leak into the ventilatory circuit such as with a fenestrated tube, leak speech or ventilator-adjusted leak speech, the use of a one-way valve in-line with the ventilator, and above cuff vocalization. This narrative review describes the benefits of a multi-disciplinary approach, summarizes verbal communication interventions, and provides guidance on the indications, contraindications and considerations for patient selection. Our clinical procedures based on collective clinical experience are shared. A multidisciplinary team approach enables holistic management across acuity, ventilation, airway, communication, and swallowing parameters. This collaborative approach is recommended to maximize the chance of successful opportunities for patients to communicate safely and effectively.