Pediatric Tracheostomy Decannulation Do or Do not there

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Pediatric Tracheostomy Decannulation: Do or Do not there is no try… Dr. Robert Chun

Pediatric Tracheostomy Decannulation: Do or Do not there is no try… Dr. Robert Chun Pediatric Otolaryngology Pulmonology Medical College of Wisconsin Dr. Paul Boesch Pediatric Mayo Clinic

Disclosures No financial or commercial disclosures 2

Disclosures No financial or commercial disclosures 2

Educational Objectives • Understanding weaning of ventilation • Understand barriers to safe decannulation in

Educational Objectives • Understanding weaning of ventilation • Understand barriers to safe decannulation in the pediatric patients • Describe variable approaches to safe decannulation in children 3

Decannulation in the Vent Dependent Patient

Decannulation in the Vent Dependent Patient

Pediatric tracheostomy • Mortality 0. 5 – 3. 6% • High cost and Caregiver

Pediatric tracheostomy • Mortality 0. 5 – 3. 6% • High cost and Caregiver stress • Indications – – – Lung disease/ Mechanical ventilation: Fastest growth Subglottic stenosis Tracheomalacia Vocal fold paralysis Craniofacial abnormalities Neuromuscular disease Knollman PD and Baroody. Curr Opin Otolaryngol Head Neck Surg 2015 Prickett KK and Sobol SE. JAMA Otolaryngol Head Neck Surg 2015 Wiritz N et al. Otolaryngol Head Neck Surg 2016

Home mechanical ventilation trends • All longitudinal studies show increasing rate over study period

Home mechanical ventilation trends • All longitudinal studies show increasing rate over study period • Utah: 5. 0/100 K in 1996 vs. 6. 3/100 K in 2004 • Indiana: 1. 25/100 K in 1984 vs. 4. 77/100 K in 2010 • Massachusetts: 3 X increase over 15 years • Most due to increased survival of extreme prematurity and neuromuscular disease

How do these patients do? • Mortality: 9 - 20% – Most due to

How do these patients do? • Mortality: 9 - 20% – Most due to disease progression • Liberation: 29 - 50% – Highly dependent on cause for ventilation • Decannulation: 25 - 50% – Most that are wean-able from ventilator can be decannulated. Edwards JD, Kun SS, Keens TG. J Pediatr 2010 Com G et al. Clinical Pediatr 2013 Henningfeld JK et al. Pediatr Pulmonol 2016

Premature infants do great • Mortality: 10 -18. 6% • Liberation: 81. 5 -

Premature infants do great • Mortality: 10 -18. 6% • Liberation: 81. 5 - 83. 1% – Median time 20 - 24 months – Rate decreased by low birth weight (<1000 g) – Rate decreased by CNS injury • Decannulation: 25 - 72. 2% – Median time 37. 2 - 38 months – Persistent obstructive lung disease – 35 - 41% require laryngotracheoplasty Overman AE, et al. Pediatrics 2013 Cristea AI, et al. Pediatr Pulmonol 2015

Personal experience: infants ventilated for BPD • Cincinnati (19 patients, median 25 weeks): –

Personal experience: infants ventilated for BPD • Cincinnati (19 patients, median 25 weeks): – Mortality 10% – Liberated: 79%, median 26 months – Decannulated: 79%, median 40 months • 50% delayed by poor parent follow-up • 47% required laryngotracheoplasty • Mayo Clinic (7 patients, median 25 weeks): – Mortality 0% – Liberated: 100%, median 22 months – Decannulated: 86%, median 24 months • 14% required laryngotracheoplasty More phone/patient portal contact and progression of weaning

Keys to success: • Avoid tracheostomy/ventilator accidents • Control respiratory morbidity • Control non-respiratory

Keys to success: • Avoid tracheostomy/ventilator accidents • Control respiratory morbidity • Control non-respiratory morbidity – Tracheostomy related – Nutrition – Congenital heart disease • Reduce acute care hospitalizations • Have a plan – Keep family engaged This requires a coordinated team and well-prepared home caregivers

American Thoracic Society Practice Guideline • Recommend: – – – – Comprehensive medical home

American Thoracic Society Practice Guideline • Recommend: – – – – Comprehensive medical home Standardized discharge criteria At least 2 trained family caregivers Ongoing education of in-home care providers Pulse oximeter + ventilator alarms Specific equipment list Insufflator-exsufflator if weak cough • Strongly recommend: – Awake and trained caregiver with child at all times Streni LM et al. Am J Respir Crit Care Med. 2016

Recommended equipment • • Ventilator + back-up ventilator Batteries Self-inflating resuscitation bag and mask

Recommended equipment • • Ventilator + back-up ventilator Batteries Self-inflating resuscitation bag and mask Portable suction Heated humidification Supplemental oxygen Nebulizer Pulse oximeter Streni LM et al. Am J Respir Crit Care Med. 2016

Discharge preparation • Medical stability • Home nursing • Caregiver training – At least

Discharge preparation • Medical stability • Home nursing • Caregiver training – At least 2 fully trained – All aspects of care: trach, vent, feeding, troubleshooting – In-room training and printed materials – CPR – Take off unit – Carseat trial – 24 hour stay: caregiver performs all care Home nursing availability and family engagement greatest barrier to discharge

Respiratory Comorbidity • Poor lung compliance – CLD/BPD, ILD, pulmonary fibrosis • Poor chest

Respiratory Comorbidity • Poor lung compliance – CLD/BPD, ILD, pulmonary fibrosis • Poor chest wall compliance – Scoliosis, thoracic dystrophies • Airway resistance – Tracheobronchomalacia, CLD/BPD • Poor respiratory muscle strength – Neuromuscular disease, mitochondrial myopathy, malnutrition • Poor central control of breathing – Chiari, encephalopathy • Infectious/Inflammatory disease – Bronchiectasis, aspiration, immunodeficiency • Reactive airway disease – Asthma, CLD/BPD • Pulmonary hypertension

Respiratory Comorbidity • Poor lung compliance – CLD/BPD, ILD, pulmonary fibrosis • Poor chest

Respiratory Comorbidity • Poor lung compliance – CLD/BPD, ILD, pulmonary fibrosis • Poor chest wall compliance – Scoliosis, thoracic dystrophies • Airway resistance – Tracheobronchomalacia, CLD/BPD • Poor respiratory muscle strength – Neuromuscular disease, mitochondrial myopathy, malnutrition • Poor central control of breathing – Chiari, encephalopathy • Infectious/Inflammatory disease – Bronchiectasis, aspiration, immunodeficiency • Reactive airway disease – Asthma, CLD/BPD • Pulmonary hypertension

Passy Muir Valve • Aggressively get kids to PMV once windowing • ALWAYS measure

Passy Muir Valve • Aggressively get kids to PMV once windowing • ALWAYS measure pressures: – Drill 1 -2 holes if necessary • Benefits: – Restoration of physiologic PEEP – Cough clearance – Secretion management – Improve appetite and swallowing – Phonation – Stimulation of upper airway Drying of trach secretions main downside

Speaking Valve Pressure Test = Expiratory pressure <10 cm H 20 pressure during quiet

Speaking Valve Pressure Test = Expiratory pressure <10 cm H 20 pressure during quiet breathing AND comfortable with no expiratory muscle use 1/16 in hole Exhaled pressure with quiet breathing essentially PEEP

Think of exhaled pressures as PEEP… This child wore a PMV all day for

Think of exhaled pressures as PEEP… This child wore a PMV all day for a year with a pressure of 30!

1. Skin and device assessments 2. Mepilex 3. Extended trach tubes Boesch RP et

1. Skin and device assessments 2. Mepilex 3. Extended trach tubes Boesch RP et al. Pediatrics 2012

Ventilator weaning • Best way to avoid ventilator-induced lung injury is not to be

Ventilator weaning • Best way to avoid ventilator-induced lung injury is not to be on a vent • Identify “weanable” patients and make assessment of readiness to wean part of every visit • In general will come off during the day first • (I) prefer sprints off vent to periods on intermediate settings – Risk for errors – Off vent = more developmental activities

Weaning • Most “weanable” patients have chronic lung disease – Goal with windowing is

Weaning • Most “weanable” patients have chronic lung disease – Goal with windowing is to gradually increase respiratory muscle endurance – Muscles acclimate to new load after ~ 2 weeks – Window-rest-window during day – Maintain good sleep at night for recovery

Ventilator Weaning Pathway Access Daytime Wean-ability Day study in Sleep Lab to confirm weaning

Ventilator Weaning Pathway Access Daytime Wean-ability Day study in Sleep Lab to confirm weaning readiness (Optional) Observe w/ NICO 2 (15 min): Off Rate Off PS Off Vent Vte Preserved? ETCO 2 <50 Sa. O 2 > 92% RR < 10 over baseline Minimal change in WOB Follow up in 3 mos Each clinic visit should include: 1. Weight and height: GOAL: BMI% 30 -60% If outside goal alert RD and have present at next clinic visit. or Begin Windows 1 week 30 -60 min, TID, then 1 week 2 hours TID, then 1 week 3 hours TID, then 1 week 4 hours TID Follow-up 6 -8 weeks In clinic at end of window Vte Preserved? ETCO 2 <50 Sa. O 2 > 92% RR < 10 over baseline Minimal change in WOB Rationale: Timely weaning: Decrease vent lung injury, caregiver burden, and cost and facilitates development Balancing: weight loss, fatigue, decreased function, and infection. This should be a consideration at EVERY clinic visit and readiness tested each time. Who is “wean-able”? Any child whose chronic respiratory failure is due to factors that will improve with growth: 1: Alveolarization YES: former preemies, Trisomy 21, congenital heart 2: Tracheobronchomalacia disease, tracheobronchomalacia 3: Pulmonary hypoplasia NO: NM disease, CCHS, many spinal cord injury 4: Some with hypotonia PMV trial <8 -10 cm. H 20 quiet breathing Weaning PSG Weight Preserved No change in secretions No increased oxygen Vent PRN for observation duration based on clinical factors 2. Modifiable barrier assessment: Respiratory infections Aspiration Secretion management Airway dehydration Asthma/RAD Pulmonary Hypertension All weaning patients should be seen AT LEAST every 3 months PMV day / vent night Change to TTS trach if necessary PMV trial <8 -10 cm. H 20 quiet breathing Flex Bronch and MLB to identify/treat obstruction Return to last tolerated windows PMV windows / vent night Change to TTS trach if necessary Evaluation for capping and/or decannulation

Minnesota Children’s protocol Overman AE, et al. Pediatrics 2013

Minnesota Children’s protocol Overman AE, et al. Pediatrics 2013

Night weaning protocol: Colorado • 20/21 successfully weaned. • 52% weaned at home •

Night weaning protocol: Colorado • 20/21 successfully weaned. • 52% weaned at home • Median age at attempt: 28 months Liptzin DR, et al. Pediatr Pulmonol. 2016

Weaning Challenges • Medical barriers: – – 3 – – – 1 – Recurrent

Weaning Challenges • Medical barriers: – – 3 – – – 1 – Recurrent infections Aspiration/secretion management Asthma/RAD Pulmonary hypertension Tracheobronchomalacia Over/under nutrition • Social barriers – Stressed families – Poor follow-up 2 • System barriers – Variable approach to management 4 – Poor resources for complex chronic care

Weaning Challenges • Medical barriers: – – – Recurrent infections Aspiration/secretion management Asthma/RAD Pulmonary

Weaning Challenges • Medical barriers: – – – Recurrent infections Aspiration/secretion management Asthma/RAD Pulmonary hypertension Tracheobronchomalacia Over/under nutrition • Social barriers – Stressed families – Poor follow-up • System barriers – Variable approach to management – Poor resources for complex chronic care

Decannulation Process

Decannulation Process

Why decannulation fails • We know surprisingly little about this • Prickett and Sobol:

Why decannulation fails • We know surprisingly little about this • Prickett and Sobol: – No statistically significant predictor of failure – Trend for younger age, vocal cord immobility, and tracheomalacia • Riley: – Favorable: trach for chronic respiratory failure – Unfavorable: Swallow dysfunction, genetic disease, craniofacial, obstructive airway lesion • Especially SGS, stomal gran, adenoid, tracheomalacia, laryngomalacia Prickett KK and Sobol SE. JAMA Otolaryngol Head Neck Surg 2015 Bandyopadhyay A, at al. Ann Am Thorac Soc 2016

Why airway reconstruction fails • Insufficient pre-operative evaluation – Un-identified lesions – Missed non-airway

Why airway reconstruction fails • Insufficient pre-operative evaluation – Un-identified lesions – Missed non-airway diagnoses • Inappropriate patient selection • Technical causes – Wrong technique, wrong staging • Poor patient optimization – – Infection Aspiration Steroids Eosinophilic esophagitis/ Gastroesophageal reflux de Alarcon A, Rutter MJ. Otolaryngol Clin N Am 2008

Pulmonologist’s role? • Pulmonary perspective – Interaction between respiratory, airway, and chest wall disease

Pulmonologist’s role? • Pulmonary perspective – Interaction between respiratory, airway, and chest wall disease • Complimentary anatomic evaluation of airway • Characterization of respiratory comorbidities for airway reconstruction • Post-operative management

Key- Combined endoscopy Airway evaluation within month of decannulation Combined perspective of the ORL,

Key- Combined endoscopy Airway evaluation within month of decannulation Combined perspective of the ORL, pulmonologist, GI at the time of airway evaluation is the greatest strength of our airway program Doesn’t work as well when separated in place/time. Mitchell RB, et al. (AAOHNS) Clinical consensus statement Tracheostomy Care. Otolaryngol Head Neck Surg 2013 Sherman JM, et al. (ATS) Care of the child with a chronic tracheostomy. Am J Respir Crit Care Med 2000

Combination procedure - Benefits • Better shared understanding of issues • Tempers the “confidence

Combination procedure - Benefits • Better shared understanding of issues • Tempers the “confidence of the noncombatant” • Can’t blame everything on reflux when gastroenterologist standing right there • Assessment often modified as each procedure completed • Fosters collaborative creativity • Strong impression on family

3 D modeling is cool! Azygous vein RUL bronchus

3 D modeling is cool! Azygous vein RUL bronchus

What procedures can be performed to evaluate and treat upper and lower airway obstruction?

What procedures can be performed to evaluate and treat upper and lower airway obstruction?

Resolution of Underlying Airway Pathology • Upper airway obstruction – – – • •

Resolution of Underlying Airway Pathology • Upper airway obstruction – – – • • • Nasopharynx Palate Lateral Pharyngeal Wall Tongue base Supraglottis Unilateral vocal cord mobility Lack of significant aspiration Stenosis and granulation Tracheomalacia Ventilation

DISE: Evaluation of Upper Airway

DISE: Evaluation of Upper Airway

Subglottic Stenosis

Subglottic Stenosis

Single versus Two Stage • Removal of tracheotomy with airway reconstruction • Requires prolonged

Single versus Two Stage • Removal of tracheotomy with airway reconstruction • Requires prolonged intubation and sedation/paralysis • Leaves the Tracheotomy in place while the airway heals • Consider: – High grade stenosis – Tracheal Obstruction – Pulmonary Disease/Tracheomalacia – Social History • Potential Airway Obstruction • Limited trach changes • Feeding and Nutrition • Upper airway obstruction of unclear significance • Inexperienced ICU staff

Tracheomalacia

Tracheomalacia

Anterior Tracheal Suspension • 21 pts (5 months) • No Mortality • No long

Anterior Tracheal Suspension • 21 pts (5 months) • No Mortality • No long term trach in any patient • One decannulation

Compete Tracheal Rings and Slide Tracheoplasty

Compete Tracheal Rings and Slide Tracheoplasty

Pediatric Tracheostomy and Decannulation Decision Making ü Who is likely to succeed? ü Who

Pediatric Tracheostomy and Decannulation Decision Making ü Who is likely to succeed? ü Who is at risk to failure? ü Do we cap? ü Do we order a PSG? ü What is the role of endoscopy? ü What guidelines are available to us? ü What is we fail, what do we do? 44

Who do we trach and how successful is decannulation?

Who do we trach and how successful is decannulation?

Tracheostomy Indications Review of 11 studies (2003 -2014) 1395 pediatric trach patients • 48%

Tracheostomy Indications Review of 11 studies (2003 -2014) 1395 pediatric trach patients • 48% (449) placed before 1 year old • 62% were decannulated – Mean duration 2. 3 years Indications § Upper airway obstruction 18% § Neurologic 14% § Lower airway disease 14% § Craniofacial 13% § Trauma 10% § Infection 9% § Cardiac 5% • Tracheostomy mortality 1. 1% (15) • All-cause mortality 18% (248) • Decannulation Failure Adoga AA 2010, Butnaru CS 2006, Corbett 6. 5%HJ 2007, de. Trey 2013, Funamura JL Rate in children 2014, Leung R 2005, Mahadevan M 2007, Ogilvie LN 2014, Ozman S 2009, Sidman vs 2003 Adults 1. 9%JD 2006, 21. 4% Tantinikorn W 46

 • Rate of successful decannulation was shorter from tracheotomy for maxillofacial and laryngotracheal

• Rate of successful decannulation was shorter from tracheotomy for maxillofacial and laryngotracheal trauma compared to UAO, CPD, and neurological disease

 • 142 patients 1990 -1999 • 34%(50/142) were trialed for decannulation – Successful

• 142 patients 1990 -1999 • 34%(50/142) were trialed for decannulation – Successful in 85% • Tracheotomy < 1 yr: 100% success • Tracheotomy > 1 yr: 83% success – 32% (16/50) TCF – 12%(6/50) Recannulations

 • 35 patients for decannulation – Age 5 months to 17 years –

• 35 patients for decannulation – Age 5 months to 17 years – Median trach duration was 18 months – Stable lungs, resolution of airway obstruction, no ventilation for 2 months, Normal flexible decannulated laryngoscopy, Normal DLB – 54%(19) discharge one day following decannulation – 37% (13) discharged on post decannulation Day 2 – No routine capping or downsizing of trach – No capped sleep studies – 8. 5%(3/35) failure to decannulate – 4 readmissions from 3 patients • 2/3 required recannulation (Mandibular distraction, LTR)

 • • 122 tracheotomies 1987 -2003 4. 5 months for UAO 16 months

• • 122 tracheotomies 1987 -2003 4. 5 months for UAO 16 months for prolonged ventilation Decannulation in 75% ( 92/122) Tracheotomy Related Deaths 1. 6% TC Fistula 13. 1% Recannulation in 6. 5% (6/92) – Bronchoscopy – Decannulation in ICU (3. 3 years) – 12 of decannulated children have ongoing stridor or OSA No sleep studies performed

 • 177 patients from 1985 -1994 • 30/177 Decannulated (5. 75 years) –

• 177 patients from 1985 -1994 • 30/177 Decannulated (5. 75 years) – Duration of tracheotomy 22 months – 26/30 Bronchoscopy – 6. 7% (2/30) failed but decannulated later • Decannulation Technique – – DISE (VC mobility/ATH) DLB: Trachea/Suprastomal Granuloma/Stomal Prolapse Downsize Trach and capping and Decannulation (2 night stay) No sleep studies performed • These 2 studies show that without PSG and with downsizing and capping and ICU stay you can have a DFR of 6%

What is the importance of downsizing, capping and a capped sleep study?

What is the importance of downsizing, capping and a capped sleep study?

Capping and Downsizing…. • Reduction and occlusion of tube may predict decannulation success but

Capping and Downsizing…. • Reduction and occlusion of tube may predict decannulation success but acclimate the child to changing airway physiology • Decreasing lumen size puts children at risk for mucus plugging • Capping may decrease the trachea lumen to such a degree that decannulation may still be successful in those not tolerating capping

Capping in Smaller Caliber Airways Trach tubes obstruct >50% of lumen Effective Tracheal Cross

Capping in Smaller Caliber Airways Trach tubes obstruct >50% of lumen Effective Tracheal Cross -Sectional Area (mm^2) with Tracheostomy in Place by Age 500. 00 0 -1 1 -2 Trachea Xsctn 2 -4 4 -6 Biv. Xsctn 6 -8 8 -10 Shi. Xsctn % Effective trachea Cross-Section with Tracheostomy in place by age 8 -10 6 -8 4 -6 2 -4 1 -2 0 -1 Santer DM D’Alessandro MP Pediatric Virtual Library © 1992 -2016 0%http: //www. virtualpediatrichospital. org/ 10% 20% 30% 40% 50% 60% 70% 80% Shi % Area Biv % Area Trachea 90% 54 100%

Capped Polysomnography • Recommended capped PSG protocol for patients with long term tracheotomy and

Capped Polysomnography • Recommended capped PSG protocol for patients with long term tracheotomy and concomitant airway disorders (OSA, Craniofacial, NM dz) • Supplemented clinical and endoscopic assessment

 • 50 decannulations from 1/2012 to October 2013 • Mean Hospitalization 2. 7

• 50 decannulations from 1/2012 to October 2013 • Mean Hospitalization 2. 7 days (1 -8) • Failure rate of 16%(8/50) – 4 did not tolerate capping: symptomatic • Inpatient Capped PSG • 3/4 later decannulated – 4 recannulated prior to discharge: • Longest interval 11 hours • 3/4 had UIR within 2 weeks prior – 1 recannulated 6 months later – 5/46 recannulated 10. 8% – 45% of successful decannulation had TA • Recannulation – Younger 45. 7 Months vs 68. 2 Months – Diagnosis of VCP (5/8) • Capped PSG in 42% (21/50) – 6/21 had a change in management based on PSG – 4 failed initial decannulations: none had PSG.

 • Patients who failed decannulation were symptomatic during inpatient capping • Symptomatic patients

• Patients who failed decannulation were symptomatic during inpatient capping • Symptomatic patients with capping should be considered poor candidates or advance cautiously toward decannulation

No-downsizing, no capping? All you need is a PSG… • 189 decannulation attempts –

No-downsizing, no capping? All you need is a PSG… • 189 decannulation attempts – Following bronchoscopy, Trach removed, stoma occluded, PSG • 78% success – Daytime observation and overnight PSG • • AHI>10 Hypoventilation Co 2 >45 Respiratory Distress Prolonged Desaturation – 42 failures (22. 2%) • 36 immediate re-trach/ 6 re-trached within 6 months – – Chronic Respiratory Insufficiency Genetic abnormalities Feeding Dysfunction Multiple Co-Morbidities – PSG alone has the highest DFR

 • 59 patients undergoing 78 capped PSG for decannulation assessment • Successful decannulation

• 59 patients undergoing 78 capped PSG for decannulation assessment • Successful decannulation – AHI 4. 0 vs. 9. 6 – Max CO 2: 51. 3 vs 55. 3 – Favorable pre-decannulation MLB, favorable capped PSG (AHI <10), no evidence of hypoventilation, predicted decannulation success compared to MLB alone – 26% of those with unfavorable PSG were still decannulated

Figure 7. Model represents the Apnea Hypopnea Index and favorable microlaryngoscopy and bronchoscopy (MLB)

Figure 7. Model represents the Apnea Hypopnea Index and favorable microlaryngoscopy and bronchoscopy (MLB) as predictors of successful decannulation compared with favorable MLB only. Neepa Gurbani et al. Otolaryngology -- Head and Neck Surgery 2015; 153: 649 -655

 • • • Using both PSG and MLB increased Sensitivity 93% to 98%

• • • Using both PSG and MLB increased Sensitivity 93% to 98% and Specificity 46% to 69% However, 31% of ND had favourable PSG and MLB This captured only 25% of their decannulations Neepa Gurbani et al. Otolaryngology -- Head and Neck Surgery 2015; 153: 649 -655

 • • • 28 patients with tracheotomies with capped PSG prior to decannulation

• • • 28 patients with tracheotomies with capped PSG prior to decannulation 71% (20/26) decannulated Decannulated AHI 2. 75 Capped PSG Failure AHI 15. 99 Failed PSG multiple comorbidities, multilevel airway obstruction, need for additional surgery, need for chronic pulmonary toilet 5 decannulated had repeat PSG – 4/5 were similar to pre decannulation AHI – AHI 3. 5 to 32. 8 recannulated (downs, UVCP, Renal Failure) – 5% decannulation failure rate with PSG. • • If moderate OSA or if persistent obstruction after decannulation is suspected, repeat PSG If severe OSA, No decannulation and further airway evaluation ?

 • Two night ICU admission after PSG: first night capping and second night

• Two night ICU admission after PSG: first night capping and second night decannulation Copyright © by American Academy of Otolaryngology- Head and Neck Surgery

Are there guidelines to help us?

Are there guidelines to help us?

American Thoracic Society (ATS) Care of the Child with a Chronic Tracheostomy Official Statement

American Thoracic Society (ATS) Care of the Child with a Chronic Tracheostomy Official Statement of the ATS, July 1999 – re: Decannulation Fundamental Criteria for Decannulation 1. “Original need for tracheostomy is no longer present” 2. “Patient is able to maintain a safe and adequate airway independent of the tracheostomy tube. ” Essentially 2 Decannulation Techniques November 26, 2020 65

American Thoracic Society (ATS) Care of the Child with a Chronic Tracheostomy Official Statement

American Thoracic Society (ATS) Care of the Child with a Chronic Tracheostomy Official Statement of the ATS, July 1999 – re: Decannulation • Sequential downsizing to smallest size, then remove if tolerated well – Higher failure rate, risk of mucous plugging & airway obstruction, difficulties in small children • Endoscopic assessment of the anatomic and functional patency of the decannulated airway • Considerable experience req’d • Patients monitored 24 -48 hours 66

American Academy of Otolaryngology – Head & Neck Surgery (AAOHNS) Clinical Consensus Statement Tracheostomy

American Academy of Otolaryngology – Head & Neck Surgery (AAOHNS) Clinical Consensus Statement Tracheostomy Care 2013 Fundamental Criteria for Pediatric Decannulation 1. No ventilator support x 3 months, although O 2 support may be OK 2. Airway endoscopy show no anatomic obstruction and at least 1 mobile vocal fold or patent glottis 3. No significant aspiration precluding decannulation 4. Child 2 yo >: Full all-day capping for several weeks prior 67

American Academy of Otolaryngology – Head & Neck Surgery (AAOHNS) Clinical Consensus Statement Tracheostomy

American Academy of Otolaryngology – Head & Neck Surgery (AAOHNS) Clinical Consensus Statement Tracheostomy Care 2013 • If the Child tolerates capping: – Capped sleep study – Capped exercise test – Nighttime capping trial while hospitalized • In younger and smaller children the smaller trachea lumen may preclude capping and decannulation 68

 • • 46 children HMV independence and Decannulation HMC Independence 25. 5 mths

• • 46 children HMV independence and Decannulation HMC Independence 25. 5 mths Decannulation 40. 5 Mths 6. 9% (3/43) Recannulation – • 3 deaths after decannulation – • 50% normal 12% UAO One month PSG to Decannulation 66% had VFSS – • 21 TA /9 LTR Capped PSG 65% (28/43) – – – • Sepsis, ARDS, Sudden Cardiac Arrest 65% (30/43) required airway surgery – • 1 for TA/ 1 NM dz with Pna/ H 1 N 1 infection 60% approved for oral feedings Two children require non invasive ventilation after decannulation – NM dz and CCHS

 • 15 patients who required NPPV following decannulation • Stoma closed initially by

• 15 patients who required NPPV following decannulation • Stoma closed initially by sticking plaster • 9/15 needed TC fistula closure – 3/9 in delayed NPPV – 5/5 immediate NPPV • No recannulation • No deaths

Pulmonary toilet Voice Easy trach changes Flexible laryngoscop y Sleep endoscopy Sleep study Tracheobronchoscop

Pulmonary toilet Voice Easy trach changes Flexible laryngoscop y Sleep endoscopy Sleep study Tracheobronchoscop y Operative endoscopy Decannulation Concerns Trach indication resolved No mechanical ventilation Infrequent pulmonary infection Anatomic Indicators Clinical Indicators Pediatric Decannulation Readiness PSG interpretati on T&A prior? Medical Observation Duration Managemen t of fistula 71

What are other centers doing to decannulate?

What are other centers doing to decannulate?

Decannulation at the Johns Hopkins Children’s Center • Trach downsized, meeting clinical & PSG

Decannulation at the Johns Hopkins Children’s Center • Trach downsized, meeting clinical & PSG criteria • Full assessment of trachea within past 1 -2 months* • Tracheobronchoscopy with retroflexion • Operative endoscopy • NO changes in voicing, no clinical indication of obstruction • Airway health confirmed within 24 -48 hours • Trach removed, patient observed in ICU 73

Are You Ready for Decannulation? How to Interpret the Sleep Study? 1. Adequate sleep

Are You Ready for Decannulation? How to Interpret the Sleep Study? 1. Adequate sleep time with cap in place • Adequate REM time (>15% TST in REM & > 1 hr) 2. Mild apnea-hypopnea index (<5/hour) • If AHI > 5 recommend adenotonsillectomy, sleep endoscopy 3. Supplemental O 2 is ok unless needed for OSA 4. Hypercapnia: • CO 2 >50 for <25% sleep time, peak CO 2<53 74

Great Ormond Street Decannulation Protocol • Stepwise downsizing to 3. 0 mm tracheotomy –

Great Ormond Street Decannulation Protocol • Stepwise downsizing to 3. 0 mm tracheotomy – <12 kg downsize to 2. 5 ID • Endoscopic airway evaluation • Ward admission for five days – Family and patient understanding – Day One: 3. 0 trach and observation of cyanosis, anxiety, poor appetite, stertor/stridor, tracheal tugging, dyspnea – Day 2: Occlude Tracheotomy Tube – Day 3: Remove Tracheotomy Tube, Waterproof dressing, Can Not Leave Ward – Day 4: Observation Day: Continue occlusive dressing but now allowed to leave ward – Day 5: Discharge: Follow up in 6 weeks – No mention of PSG, Capping

Children’s Colorado Decannulation Protocol Liptzin DR, et al. Pediatr Pulmonol. 2016

Children’s Colorado Decannulation Protocol Liptzin DR, et al. Pediatr Pulmonol. 2016

Variation in Practices Common • Do we downsize? If so how small of a

Variation in Practices Common • Do we downsize? If so how small of a downsize? • Even if lower airway clear should DISE/TA be done prior to Capped PSG? • Is a sleep study warranted? If so, do you downsize? • Consideration of acute decannulated sleep study vs prolonged inpatient monitoring post decannulation • 24 hour capping in inpatient monitored settings, even if normal PSG? • Requirements for weight gain/thriving • Use of sleep endoscopy alone – Capping, and capped sleep study, may not be POLL: How many routinely perform capped PSG tolerated due to small airway caliber prior to decannulation? 77

 • Proposed Algorithm at Childrens Hospital of Wisconsin

• Proposed Algorithm at Childrens Hospital of Wisconsin

Mayo Decannulation Protocol • Clinical readiness assessment – Most already daytime PMV or capping

Mayo Decannulation Protocol • Clinical readiness assessment – Most already daytime PMV or capping • Always rigid and flexible airway evaluation prior • Intervene, downsize, fenestrate as necessary • 48 hr night capping trial followed by 24 -48 hr decan trial – May be separated in time • Particularly if chronic lung disease (1 -3 mos) • Daytime capping only unless night nursing – Don’t cap same day as granulation removal – Most formerly ventilated patients have capped sleep study • Also those with CNS disease • Risk of obstructive hypoventilation or persistent pulmonary hypertension

Tracheocutaneous Fistula • About ½ of children with long-term tracheostomy will have a persistent

Tracheocutaneous Fistula • About ½ of children with long-term tracheostomy will have a persistent tracheocutaneous fistula – Stoma maturation does not increase rate of TCF (Levi JR Laryngoscope 2016) – Airway endoscopy and surgical excision 3 -6 months after decannulation • Secondary healing of excised cutaneous tract • Little risk of pneumomediastinum or pneumothorax • Wound heals quickly: hours to days • Reasonable cosmesis • Primary closure, variety of techniques • All have risks of trapped air, airway catastrophe • Consider de-epithelialized subcutaneous closure • Children have died from airway obstruction, pneumothorax or pneumomediastinum after tracheocutaneous fistula closure 82

14 articles reviewed 413 primary closure 233 tract excision and secondary healing Success rate

14 articles reviewed 413 primary closure 233 tract excision and secondary healing Success rate 95. 7% vs 92. 7% Subcutaneous emphysema or urgent airway problems 3. 8% vs 3. 6% • 5 studies had MA • • • – No difference in success, overall complications, need for revision, incidence of subq emphysema or pneumothorax, urgent airway problems, wound infection, or wound dehiscence

What can we do better? • Communication – Between inpatient and outpatient – Between

What can we do better? • Communication – Between inpatient and outpatient – Between core team and other consultants – Multiple modes of communication with family • Consistency – Adhere to standardized, time-based approach to weaning and decannulation – Process to ensure follow-up • Resources for families – Respite care – Long term care for families not capable of home-based care

Thank you ! • Robert Chun • Rchun@mcw. edu • Paul Boesch • Boesch.

Thank you ! • Robert Chun • Rchun@mcw. edu • Paul Boesch • Boesch. Paul@mayo. edu