Tracheostomy clinical pathways for mechanical ventilation weaning and tracheostomy decannulation

Introduction Several tracheostomy clinical pathways and decannulation protocols have been proposed to optimize tracheostomy care; however, no universally accepted method exists. This study aimed to examine the characteristics of decannulated and non-decannulated subgroups to inform the development of tracheostomy clinical pathways which reflect the routine model of care. Methods A retrospective observational cohort study design was employed to examine the clinical characteristics of patients who were decannulated and non-decannulated between January 2015 and December 2019. These data informed the development of two tracheostomy clinical pathways by an experienced multi-disciplinary team. Results There were 440 tracheostomy admissions during the study period. Patients admitted with respiratory (n = 100; 23%) or neurological conditions (n = 70; 16%) were most represented in the study sample. Three-quarters of the cohort (n = 323; 73%) were decannulated before discharge or death. Survival to hospital discharge was 90% overall (95% of those decannulated patients; 76% of non-decannulated patients). Most were either discharged home (39%) or to an inpatient rehabilitation setting (37%). A clinical pathway for the management of patients who are simple to wean from mechanical ventilation (SW) was developed. A second clinical pathway for the management of patients who require prolonged weaning from mechanical ventilation (PW) was developed with two tiers: 1) Unable to wean from invasive mechanical ventilation (<4 hours continuously or no ventilator-free time) and 2) Able to wean from invasive mechanical ventilation. Discussion Two tracheostomy clinical pathways were developed to reflect the multidisciplinary model of care of a centre with mature tracheostomy and weaning unit teams, in order to standardize approaches to rapid vs prolonged weaning from mechanical ventilation and tracheostomy decannulation. Robust programs of research are needed to strengthen the evidence in tracheostomy care globally. Future validation of these pathways is warranted.