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Tracheostomy Placement and Decannulation

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Subjects with SCI often undergo tracheostomy if it is anticipated that they are going to require ventilatory support for longer than 3 weeks. There is limited evidence for the timing for tracheostomy in spinal cord injured subjects who require prolonged mechanical ventilation. A 2005 systematic review of adult subjects (not SCI specific) reported a decrease in mechanical ventilation and ICU length of stay in subjects who had early tracheostomy. There is one retrospective study in SCI looking at early versus late tracheostomy placement.

Evidence for the decannulation of subjects with SCI is lacking. Subjects may not meet the traditional criteria for decannulation and should be assessed on an individualized basis (Bach and Alba 1990; Ross & White 2003).

Table 9: Tracheostomy Placement and Management

Table 10: Tracheostomy Decannulation

Discussion

Romero et al. (2009) performed a retrospective review of 152 subjects with early (ETG) or late (LTG) tracheostomy placement. Overall, subjects with earlier tracheostomy placement were significantly younger, had fewer complications and had significantly shorter times on mechanical ventilation and shorter lengths of stay in ICU. A second retrospective review showed that patients with earlier tracheostomy had fewer ICU stays, reduced tracheostomy duration, reduced length of time on mechanical ventilation and less tracheal stenosis (Ganuza et al. 2011).Overall percutaneous tracheostomy appears to be safe in cervical spinal cord injuries (Romero-Ganuza et al. 2011) including when compared to surgical tracheostomy (Ganuza et al. 2011).

Compared to subjects with LTG, subjects with ETG had no difference in pneumonia rates or mortality although there was a trend toward lower mortality in the ETG group. One of the drawbacks of these studies are their retrospective nature and the inability to account for decision factors regarding early versus late tracheostomy. In other words, there may have been a selection bias for early tracheostomy that influenced a more favourable outcome. Despite these limitations, the findings in these studies are corroborated by a meta-analysis performed on the efficacy of ETG in adults (Griffiths et al. 2005). There is a need to develop guidelines for timing of tracheostomy placement in SCI subjects.

Cameron et al. (2009) compared the outcomes of 34 tracheostomized subjects with SCI prior to the implementation of an interdicisplinary tracheostomy team to the outcomes of 34 subjects following implementation of the team. The implementation of a tracheostomy team (known as TRAMS) resulted in shorter acute care lengths of stay, shorter periods of cannulation, increase in speaking valve usage and reduced costs.

Ross and White (2003) describe a case series of 4 subjects with SCI who were successfully decannulated despite the presence of traditional contraindications for decannulation such as evidence of aspiration.  These 4 subjects were carefully selected by a multidisciplinary team who opted for decannulation after assessing the overall risks of decannulation versus the risks of prolonged tracheostomy.  Further studies examining the criteria for decannulation of subjects with SCI are required.

Conclusions

There is level 2 evidence (from 1 cohort study) (Cameron et al. 2009) that the Tracheostomy Review and Management Service (TRAMS) reduces length of stay (LOS), duration of cannulation (DOC) and saves costs, while increasing speaking valve usage.

There is level 4 evidence (from 2 case series) (Romero et al. 2009, Ganuza et al. 2011) that early tracheostomy, performed within a week of intubation, is beneficial.

There is level 4 evidence (from 1 case series study) (Ross & White 2003) that decannulation can be successful in subjects with evidence of aspiration.

  • Case by case consideration should be given to tracheostomy decannulation in subjects with SCI. The indications and criteria for tracheostomy decannulation have not been established in SCI.