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 Table of Contents  
LETTER TO EDITOR
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 83-84

Managing a problematic decannulation of tracheostomy: use of high flow nasal cannula in ICU


Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India

Date of Submission01-Nov-2020
Date of Decision18-Feb-2021
Date of Acceptance18-Feb-2021
Date of Web Publication4-Aug-2021

Correspondence Address:
Dr. Jay Prakash
Department of Critical Care Medicine, Rajendra Institute of Medical Sciences, C/O- R.P. Sinha, HI-166, Harmu Housing Colony, Ranchi, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacp.jacp_63_20

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How to cite this article:
Bhattacharya PK, Prakash J, Khan MS, Kumar R. Managing a problematic decannulation of tracheostomy: use of high flow nasal cannula in ICU. J Assoc Chest Physicians 2021;9:83-4

How to cite this URL:
Bhattacharya PK, Prakash J, Khan MS, Kumar R. Managing a problematic decannulation of tracheostomy: use of high flow nasal cannula in ICU. J Assoc Chest Physicians [serial online] 2021 [cited 2021 Dec 1];9:83-4. Available from: https://www.jacpjournal.org/text.asp?2021/9/2/83/323094



Editor Sir,

Tracheostomy decannulation is a fundamental step toward making patients free from the artificial airway. However, despite its apparent significance, there is no generally acknowledged convention for this essential change. An intact sensorium, coordinated swallowing, and protective coughing are the base prerequisites for an effective decannulation and often the minimum requirements for a successful decannulation. Old age, obesity, low neurological status, sepsis, and tenacious secretions are the main reasons for decannulation failure.[1]

High-flow nasal cannula (HFNC) therapy is an oxygen supply device with an air oxygen blender permitting from 21% to 100% FiO2 and generates up to 60 L/min flow rates. The physiological impacts that delineate the advantage of HFNC are increased tidal volume, positive end-expiratory pressure (PEEP effect), decreased respiratory rate, pharyngeal dead space washout, and reduction of nasopharyngeal resistance, increased end-expiratory volume, alveolar recruitment, better control of FiO2, and better mucociliary clearance. Additional advantages are humidification, comfort, and better tolerance.[2] HFNC has been broadly studied in pediatric patients, where it is progressively used. However, evidence in adults is limited.[3] There are no established guidelines or dynamic pathways to control the use of HFNC therapy for adults.[4] In the current literature, we report the use of HFNC in the weaning and decannulation process of a tracheostomized patient whose weaning was challenging.

A 62-year-old male transferred to our intensive care unit (ICU) from a private hospital on invasive mechanical ventilation through a tracheostomy tube. Two months before the presentation to our ICU, he was diagnosed with acute necrotizing pancreatitis with walled-off necrosis for which he underwent endoscopic necrosectomy. He recovered from acute pancreatitis. Later in the course of ICU stay, he required prolonged mechanical ventilation due to persistent bilateral gross pleural effusion for which bilateral percutaneous drain tubes were inserted. However, postprocedure, he developed left-sided hemothorax, which required wide bore intercostal drain (ICD) placement. In our ICU, with the cardiothoracic team’s help, the left-sided hematoma was evacuated following thoracotomy. Postoperatively, serial chest radiographs showed gradual but remarkable improvement in left lung aeration. Both ICDs were removed. The patient’s T-piece tolerance was low, and the requirement of pressure support ventilation was frequent. It was prolonged and difficult weaning. The patient could be mobilized out of bed and was free of infection, dyselectrolytemia, and metabolic and nutritional deficiency. On echocardiography, he had normal cardiac functions.

At this point, we directly plugged the tracheostomy tube and started on HFNC (initial setting; FiO2 80%, and flow rate 40 L/min) [Figure 1]a. After ruling out vocal cord palsy with indirect laryngoscopy, we decannulated the tracheostomy tube closed the tracheostomy with adhesive tape. The patient maintained vitals in a normal range and felt comfortable on HFNC. In the next 3 days, HFNC was gradually weaned off (first flow rate from 40 to 25 L/min then FiO2 from 80% to 40%) to venturi mask with 40% FiO2 10 L flow rate over next 3 days. The patient tolerated HFNC removal, and then in a gradual step-down manner, the venturi mask, too, was removed. Our patient was entirely off oxygen support and discharged at home [Figure 1]b. It took 7 days for our team to complete the process of decannulation over HFNC to room air breathing successfully.
Figure 1 (a) Process of decannulation of a tracheostomized patient over HFNC. (b) Successful decannulation and discharged to home.

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To our knowledge, this is a technique to employ in cases of difficult weaning and decannulation of tracheostomy in a chronic critically ill patient. However, one should not be hasty and prior normalization of nutritional status, metabolic status (acid-base, glucose),

Dyselectrolytemia and cardiac function should be a rule before attempting this technique. In the future, a large prospective observational study may be conducted to establish the effectiveness of this technique in hastening the weaning and tracheostomy decannulation.



 
  References Top

1.
Schmidt U, Hess D, Bittner E. To decannulate or not to decannulate: a combination of readiness for the floor and floor readiness? Crit Care Med 2011;39:2360-1.  Back to cited text no. 1
    
2.
Nishimura M. High-flow nasal cannula oxygen therapy in adults: physiological benefits, indication, clinical benefits, and adverse effects. Respir Care 2016;61:529-41.  Back to cited text no. 2
    
3.
Milési C, Boubal M, Jacquot A et al. High-flow nasal cannula: recommendations for daily practice in pediatrics. Ann Intensive Care 2014;4:29.  Back to cited text no. 3
    
4.
Zhang J, Lin L, Pan K, Zhou J, Huang X. High-flow nasal cannula therapy for adult patients. J Int Med Res 2016;44:1200-11.  Back to cited text no. 4
    


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