Comprehensive Dynamic Airway Assessment: Audit of a Novel Technique to Improve Rates of Tracheostomy Decannulation

Abstract

Objectives:

Prolonged tracheostomy is associated with morbidity, mortality, and length of stay. Otolaryngologists are called upon to diagnose and manage patients who have failed to achieve decannulation through conventional protocols. Flexible nasendoscopy (FNE) is commonly used but examines only the supraglottic airway. The comprehensive dynamic airway assessment (CDAA) extrapolates the principles of awake fiber-optic intubation, allowing a complete upper airway assessment, including the subglottis with decannulation under direct vision, if appropriate.

Methods:

A two-cycle audit was performed on patients discharged from the intensive care unit with tracheostomy in situ. A retrospective 25 month audit of decannulation rates was performed to assess conventional management with ear, nose, and throat (ENT) review and standard FNE in cases that failed to achieve decannulation due to airflow problems. A prospective 8 month audit was then undertaken after the inception of CDAA.

Results:

Using conventional management, the number of patients discharged from intensive care unit (ICU) with tracheostomy in situ was 137, of which 17 failed to decannulate through protocol management alone. Five (31%) patients were eventually decannulated using a standard approach. After inception of CDAA, 76 were discharged from ICU. Eight underwent CDAA, of whom 6 (75%) were decannulated; a diagnosis for decannulation failure was made in the remaining 2 patients.

Conclusions:

CDAA is an essential diagnostic tool that can improve outcomes for complex patients with tracheostomies. It requires minimal resource, is versatile, and is a natural extension of the expert nasendoscopic skills of the otolaryngologist. CDAA should form an integral part of all decannulation protocols.