title: Standardized endoscopic swallowing evaluation for tracheostomy decannulation in critically ill neurologic patients.
abstract: OBJECTIVE
  Decisions regarding tracheostomy tube removal after mechanical ventilation often depend on the physician's individual experience because evidence-based practice guidelines are still scarce, especially for critically ill neurologic patients. In these patients, the prevalence of aspiration is high and regarded as an important contributor to decannulation failure. The presence of severe neurological deficits may, however, give clinicians the subjective impression that a tracheostomy tube is still necessary although decannulation may actually be safe. It is therefore crucial to test swallowing function reliably prior to decannulation in this patient population.
  
  
  METHODS
  Prospective observational study.
  
  
  METHODS
  University hospital, neurological ICU.
  
  
  METHODS
  One hundred tracheostomized patients with acute neurologic disease completely weaned from mechanical ventilation.
  
  
  METHODS
  An endoscopic protocol evaluating readiness for decannulation and a conventional clinical swallowing examination were carried out by separate, experienced practitioners blinded to each other's decisions. Patient management always followed the decision made with endoscopy.
  
  
  RESULTS
  Practitioners' decannulation decisions (yes/no) reached with both assessments were compared. Decannulated patients were monitored throughout their stay for complications related to tube removal. Endoscopy was performed successfully in all subjects without any complications. Following the protocol, the tracheostomy tube was successfully removed in 54 patients, whereas according to the clinical swallowing examination, only 29 patients would have been decannulated at that point. Only one patient needed recannulation due to respiratory problems, resulting in a failure rate of 1.9%.
  
  
  CONCLUSIONS
  In neurologic patients, speech-language pathologists' impressions about the patient's state when clinically assessing indirect variables of swallowing function often lead to the unnecessary prolongation of cannulation time. Endoscopic evaluation has the advantage of objectively visualizing the patient's ability to manage secretions directly and allows for faster but, nonetheless, safe decannulation. The endoscopic protocol proposed here is a safe, efficient, and objective bedside tool to guide decannulation decisions.
authors.affiliation: Department of Neurology, University of Muenster, Münster, Germany.
authors.forename: Tobias
authors.initials: T
authors.lastname: Warnecke
authors.forename: Sonja
authors.initials: S
authors.lastname: Suntrup
authors.forename: Inga K
authors.initials: IK
authors.lastname: Teismann
authors.forename: Christina
authors.initials: C
authors.lastname: Hamacher
authors.forename: Stephan
authors.initials: S
authors.lastname: Oelenberg
authors.forename: Rainer
authors.initials: R
authors.lastname: Dziewas
mesh_terms: D000328:Adult; D000368:Aged; D002985:Clinical Protocols; D003679:Deglutition; D020878:Device Removal / Q000379:methods*; D005260:Female; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D009422:Nervous System Diseases; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000379:methods*; D013066:Speech-Language Pathology; D014139:Tracheostomy / Q000379:methods*