Tracheostomy decannulation in chronic severe brain injury patients: The role of fiberbronchoscopy

Data from literature show that 60% of patients tracheostomized in intensive care unit are discharged without removing the tracheostomy tube (Marchese Respir Med 2010, 104:749). Further, in neurological patients the overall incidence of airway stenosis after decannulation is 20% (Richard Arch Phys Med Rehabil 1996, 77:493). Thus, identifying successful procedures for removing tracheostomy tubes has gained increasing interest among clinicians. In this observational study we tested the hypothesis that fiberbronchoscopy (FBS) might play a pivotal role in driving tracheostomy weaning in patients admitted to high intensity rehabilitation units following severe brain injury. After standard clinical assessment, we performed FBS in 129 patients. In 41 patients (32%) who fulfilled the clinical decannulation criteria, tracheostomy tube was removed during the first FBS. In 49 patients (38%) who did not fulfill the clinical decannulation criteria at first FBS, tracheostomy tube could also be removed after changing or downsizing the tube or after medical or laser therapy, based upon FBS findings. In 3 patients who successfully overcame all clinical evaluation, FBS pointed out stenosis >50% requiring laser therapy. In 39 patients (30%) tracheostomy tube was not removed due to cough ineffectiveness (7), inability to tolerate the deflated tube (10), low level of consciousness (10) or concurrent acute events (12 patients). In conclusion our data show that in patients with severe brain injury FBS drives successful tracheostomy weaning even in a relevant proportion of the patients who do not fulfill decannulation criteria on a purely clinical basis.