Frequency of Suctioning Better Gauge for Decannulation Than Capping

By Gene Emery

September 10, 2020

(Reuters Health) - Using the frequency of tracheostomy suctioning -- less than twice every 8 hours -- combined with continuous high-flow oxygen therapy can get patients breathing without the tube 7 days faster than conventional decannulation based on 24-hour capping plus intermittent high-flow oxygen therapy, a study in The New England Journal of Medicine has concluded.

The test is the first large randomized trial to compare the two techniques for determining when decannulation can be safely done once conscious patients have been weaned from mechanical ventilation for at least 24 hours.

"This protocol not only accelerates decannulation, but also accelerates recovery of extra functions, and that increases comfort like swallowing and phonation," chief author Dr. Gonzalo Hernandez Martinez of the Virgin of Health University Hospital in Madrid told Reuters Health in an email.

He predicted that if the results are confirmed, "everybody everywhere will face the need to change their practice on tracheostomized patients."

The study was done on 330 patients in five intensive care units in Spain. The median time to decannulation was 6 days based on suctioning frequency versus 13 days with capping.

In addition, incidence of pneumonia was 59% lower, the rate of tracheobronchitis was 35% lower and the duration of hospitalization was 23% shorter.

The rate of decannulation failure was comparable between the two groups.

"The most plausible explanation for this result is that capping trials are highly demanding, thus delaying the time to decannulation as reflected by the high proportions of patients with capping trials that failed and of patients with weaning failure," the Hernandez team writes in the Journal.

"In addition, failure on capping trials preceded infection episodes and weaning failure, a finding that suggests that failure on capping trials could lead to a sequence of clinical deterioration," they said.

Whether the results can be applied to patients in the United States is uncertain.

In an editorial in the Journal, Dr. Daniela Lamas of Brigham and Women's Hospital in Boston noted that all the patients in the study were in the ICU. In the U.S., "patients are often transferred to post-acute care facilities for weaning from a mechanical ventilator and for decannulation . . . (where) the ratio of nurses and respiratory therapies to patients probably differs."

"To obtain broader applicability, these results might be reproduced in a long-term care setting," Dr. Lama said.

She also noted that "it will be a challenge to overcome clinical resistance and inertia in adopting a more aggressive protocol when the standard care does not result in clear harm."

Dr. Hernandez, an ICU physician, agreed that the findings may not be broadly accepted at first.

"I think this study will generate love or hate feelings," he said. "My unit has embraced the protocol, after years of research and education, but many centers around haven't."

He said the results show that, "What makes a doctor feel safe with his or her patient is not always the best for the patient."

In the intention-to-treat analysis, patients whose decannulation was timed to their suctioning frequency had their tubes removed from an interquartile range of 5 to 7 days. The range was 12 to 14 days in the capping group.

Decannulation failure occurred in 2.4% of patients in the suctioning-frequency group and in 5.6% of patients in the capping group, a non-significant difference.

Pneumonia rates were 4.1% in the experimental group and 9.9% with capping. Tracheobronchitis rates were 18.9% and 29.2% respectively. The differences were not statistically significant, although the researchers said they were "noteworthy."

The median hospital stay was 48 days when the suctioning standard was used and 62 days when capping served as the standard.

Another factor in the study might have been that "the patients in the intervention group spent more time receiving high-flow oxygen therapy than those in the control group, who received high-flow oxygen therapy when the tube was not capped. As the authors note, it is possible that the heated humidification of high-flow oxygen decreased the frequency of suctioning events. It is not clear how much of a role that played in the trial outcomes," Dr. Lamas said.

The study is known as REDECAP.

SOURCES: and The New England Journal of Medicine, online September 9, 2020.