Original Research
Otolaryngology–
A Pediatric Decannulation Protocol:
Outcomes of a 10-Year Experience
Nicholas Wirtz, MD1,2, Robert J. Tibesar, MD1,2,
Timothy Lander, MD1,2, and James Sidman, MD1,2
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objectives. (1) Describe an institutional protocol that focuses
on the essential steps for decannulation of pediatric patients
with long-term tracheostomies. (2) Discuss the preliminary
observations of the safety of this protocol in regard to decan-
nulation failures and successes in a selected patient population.
Study Design. Case series with chart review.
Setting. A tertiary pediatric hospital.
Subjects. Subjects were pediatric patients with chronic tra-
cheostomies undergoing decannulation. Ages ranged from 1
to 17 years old. Indications for initial tracheostomy included
chronic lung disease, airway obstruction, and trauma.
Methods. Subjects underwent decannulation attempt follow-
ing a specific protocol. The protocol consisted of operative
laryngoscopy and bronchoscopy. If the airway was deemed
adequate for decannulation at that time, the tracheotomy
tube was removed, and the child was monitored overnight;
the patient was considered for discharge the following day if
no complications arose. No routine capping, downsizing, or
polysomnography was performed.
Results. Thirty-five patients fit the criteria and were decannu-
lated within 24 hours of endoscopy. Successful decannulation
served as the primary outcome. Of the 35 decannulated
patients, 54% (n = 19) were discharged the day following
decannulation and another 37% (n = 13) on postdecannula-
tion day 2. There were no acute failures or readmissions.
Average inpatient stay for those decannulated was 1.8 days.
Conclusion. This study describes the preliminary observations
of a decannulation protocol in a small subset of patients.
The protocol resulted in no acute failures and offers a con-
servative approach to resource utilization, making it unique
when compared with other published protocols.
Keywords
decannulation, tracheostomy, protocol
Received September 22, 2015; revised December 16, 2015; accepted
January 4, 2016.
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Head and Neck Surgery
1–4
Ó American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2016
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599816628522
http://otojournal.org
D
ecannulation is the ultimate shared goal of the
patient, family, and provider for those children with
chronic tracheostomy. Pediatric tracheostomy is
performed most commonly for indications of obstruction
(eg, oral/oropharyngeal obstruction, craniofacial abnormal-
ity, or subglottic stenosis), chronic lung disease, chronic
ventilator dependency, or a neuromuscular disorder. Long-
term tracheostomy carries with it medical morbidity and
negative psychosocial impact.1,2 The majority of these
pediatric patients requiring tracheostomy can expect effec-
tive resolution of their underlying airway pathology and will
tolerate decannulation.3 The question then becomes, What is
the best way to proceed with decannulation?
To answer this, providers need to evaluate the safety of
their methods. Acute decannulation failures can be cata-
strophic, and this risk should be minimized. In addition to
safety, resource utilization should also be considered when
evaluating a particular decannulation method. The literature
discusses a myriad of protocols that use varying combinations
of inpatient resources, specialized tests, and procedures. In the
current cost-conscious health care environment, an ideal proto-
col should present an efficient utilization of resources while
not sacrificing patient safety.
The lack of consensus among providers for an optimal
decannulation protocol can, in part, be attributed to the pau-
city of studies focusing on decannulation and outcomes.
There have been limited prospective studies specifically on
decannulation or studies comparing various decannulation
methods. In 2013, a clinical consensus statement on tra-
cheostomy management was published by Mitchell et al4
that commented on pediatric decannulation. The paper
recommends tracheostomy-dependent children to be free
1
Children’s ENT and Facial Plastic Surgery, Children’s Hospitals and Clinics
of Minnesota, Minneapolis, Minnesota, USA
2
Department of Otolaryngology, University of Minnesota, Minneapolis,
Minnesota, USA
This article was presented at the 2015 AAO-HNSF Annual Meeting & OTO
EXPO; September 27-30, 2015; Dallas, Texas.
Corresponding Author:
Nicholas Wirtz, MD, Children’s ENT and Facial Plastic Surgery, Children’s
Hospitals and Clinics of Minnesota, Department of Otolaryngology,
University of Minnesota, Phillips Wangensteen Building, 516 Delaware
Street SE, Suite 8A, Minneapolis, MN 55455, USA.
Email: wirtz039@umn.edu.
2 Otolaryngology–Head and Neck Surgery
from ventilator support for 2 to 4 months as well as free
from any aspiration events to be considered for decannula-
tion. The authors also recommend visualization of the
airway to confirm patency and removal of any obstructing
suprastomal granulation prior to a decannulation attempt. In
addition, a daytime tracheostomy tube–capping trial is rec-
ommended for those children of at least 2 years of age lead-
ing up to decannulation. Further options are also mentioned,
such as a capped sleep study, capped exercise test, and inpa-
tient nighttime capping trial. These recommendations are
constructed from expert opinions and serve as a sound
guideline based on the existing evidence, but there remains
room for further discussion and research on the subject. The
following study explores a unique protocol consisting of a
resource-conserving approach to decannulation.
Methods
The study was approved by the Children’s Hospital
Institutional Review Board. Patient charts were gathered from
the electronic medical record from 2004 through 2013 consist-
ing of patients treated by 3 pediatric otolaryngologists at a ter-
tiary care facility. Charts were selected that included procedure
codes for tracheostomy tube removal or bronchoscopy for
patients with a diagnosis code representing current tracheost-
omy status. The charts included in the study comprised those
patients who were admitted solely for the purpose of decannu-
lation. Only those patients for which decannulation was
attempted per protocol were included. Exclusion criteria
included decannulation following airway reconstruction and
inpatient status leading up to decannulation.
The criteria for patients being chosen for decannulation
included stable pulmonary status, resolution of offending
obstruction, and no further necessity for ventilator support
for at least 2 months, which is in accordance with the
recently published clinical consensus statement. The specific
protocol being studied consisted of the following.
Operative laryngoscopy and bronchoscopy are performed
for the purpose of diagnostic airway evaluation and thera-
peutic procedures to the airway in preparation for decannu-
lation. The patient is sedated but left spontaneously
breathing. The tracheostomy tube is removed in the operat-
ing room, and the airway is evaluated via transnasal flexible
bronchoscopy. The flexible scope is utilized to avoid any
incidental stenting of the airway that could occur with rigid
techniques, which may mask minor airway collapse with
spontaneous breathing. The stoma is gently finger occluded,
and the patency along with the dynamics of the entire
airway is observed while the patient breathes. Specifically,
the airway is examined for areas of obstruction, stenotic
segments, dynamic collapse, and at least 1 mobile vocal
cord. Maintaining spontaneous respirations is crucial to
visualizing the dynamics of the airway; it allows the sur-
geon to better predict how the airway will respond to decan-
nulation. Direct laryngoscopy with rigid telescopic
visualization is sometimes performed to better inspect the
peristomal airway or when flexible bronchoscopy cannot
provide adequate visualization. Peristomal granulomas are
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Table 1. Patient Characteristics.
Characteristic Patients, n (%)
Age at decannulation, y
\1 2 (6)
1-3 18 (51)
3-5 5 (14)
5-7 5 (14)
7-9 0
9-11 2 (6)
11-13 0
13-15 1 (3)
15-17 2 (6)
Indications for tracheostomy
Upper airway obstruction 14 (40)
Chronic lung disease 20 (57)
Trauma 1 (3)
removed via laser, cautery, or cold knife technique. If the
airway is then deemed adequate for decannulation, the tra-
cheotomy tube is removed in the operating room or in the
immediate postoperative setting (within 24 hours). The
stoma site is temporarily covered with a small gauze dres-
sing or left uncovered. The child is monitored overnight in
an inpatient monitored setting. Staff available for these
patients includes 24-hour in-house physicians trained in
pediatric critical care and a pediatric otolaryngologist (out-
of-house night call). The support staff consists of nursing
with critical care backgrounds and respiratory therapists.
The patient is then considered for discharge the following
day if no complications arise. No routine capping or down-
sizing is performed in the perioperative period before
decannulation.
Results
Thirty-five patients fit the criteria and were decannulated
per the protocol within 24 hours of endoscopy. Ages at
decannulation ranged from 5 months to 17 years. Primary
indications for tracheostomy were airway obstruction,
chronic lung disease, and trauma. The median duration of
tracheostomy was 18 months (range, 41 days to 11 years).
Of the 35 patients, 9 (26%) had airway procedures per-
formed during their airway endoscopy; 8 required suprasto-
mal granulation excision; and 1 required adenoidectomy.
Other patient characteristics are described in Table 1.
There were no immediate failures, defined as the need
for recannulation or intubation within 1 week. Readmissions
were evaluated for the 90-day period following decannula-
tion. In total, there were 4 readmissions among 3 patients.
Two of these patients ultimately failed decannulation in the
long term. One patient had severe obstructive sleep apnea
following the tracheocutaneous fistula closure 49 days after
decannulation and ultimately required retracheostomy and
mandibular distraction for micrognathia. The second patient
Wirtz et al
required recannulation 30 days after decannulation and
underwent laryngotracheal reconstruction soon thereafter.
The third patient was readmitted 8 days after decannulation
with respiratory distress and underwent further excision of
suprastomal granulation tissue; emergent airway interven-
tion or recannulation was never required. This latter patient
was admitted again 3 days later for observation due to noisy
breathing and was discharged the following day after clini-
cal improvement with no significant concerns or further pro-
cedures performed.
The majority of these patients were stable for discharge
on the day following decannulation (54%, n = 19). Another
37% (n = 13) were discharged on postdecannulation day 2.
Of the remaining subjects, 1 was taken back to the operating
room for further excision of a suprastomal granuloma (dis-
charged on postdecannulation day 3); another was kept for
further monitoring due to suprastomal collapse (discharged
postdecannulation day 5 without further intervention); and 1
was kept inpatient for non-airway-related issues with no
complications relating to the airway or decannulation (dis-
charged on postdecannulation day 5). The average total hos-
pital stay was 1.8 days for all subjects.
Discussion
Evaluating decannulation failure rate is a simple way to
assess the success of our methods. Decannulation failure
rates vary in the literature from 6.5% to 21.4%,5 with multi-
ple recent studies quoting between 5% and 10%.5-9 Our
study showed no acute decannulation failures resulting in
intubation or recannulation within the first week; 1 patient
(3%) did require an additional operative procedure to further
remove suprastomal granulation tissue 1 day after removal
of the tracheostomy tube. There were 2 patients in the study
who exhibited long-term tracheostomy failure presenting as
severe obstructive sleep apnea after tracheocutaneous fistula
closure and gradual increasing respiratory distress from sub-
glottic stenosis. These 2 cases presented nonemergently. It
can be concluded that this protocol demonstrated a compa-
rable safety profile in the selected study population.
Numerous decannulation protocols in the literature vary
widely in methods. Operative endoscopy prior to decannula-
tion is a common component of the majority of these proto-
cols,2,4,6,8-16 and its importance is not disputed. This is
necessary for not only diagnostic evaluation but also thera-
peutic treatment of the airway. Suprastomal granulation
tissue often needs to be addressed prior to tracheostomy
tube removal,6,14 as evident by the 23% (n = 8) of patients
requiring endoscopic intervention in our study. The impor-
tance of spontaneous ventilation during endoscopy should
be emphasized, as this allows one to better assess any
dynamic collapse or obstruction.6,14
The use of capping and downsizing is also a common
part of many protocols,4-6,12,16,17 although the implementa-
tion of these tools is not universal.10,18,19 The argument in
favor of these practices is that the reduction and occlusion
of tube diameter not only predict decannulation success but
also acclimate the child to the changing airway physiology
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3
that accompanies tracheostomy tube removal (increased dead
space, use of the mouth/nose).17 The argument against these
methods being used routinely is that decreasing lumen size
puts children at risk for mucous plugging, a potentially fatal
complication. In addition, capping decreases the cross-
sectional area of the airway to such a degree that those who
do not tolerate capping may still tolerate decannulation. The
current study protocol does not employ routine capping or
downsizing for these reasons. This serves as a significant dif-
ference between our methods and those recommended by the
previously published clinical consensus statement, which
states that a child 2 years old should have his or her tra-
cheostomy tube capped all day and the cap removed at night
for several weeks.4 Routine daytime capping is not performed
in our decannulation process, because it does not offer an
accurate physiologic representation of the decannulated child
due to the obstruction of the capped tube. We believe that the
operative endoscopic examination of the spontaneously
breathing patient is a superior evaluation for decannulation.
The utility of tidal flow measurements and polysomno-
graphy (PSG) has also been explored. Mallory et al studied
peak inspiratory flow obtained through the tracheostomy
cannula during tidal breathing and compared this with peak
flow through the mouth.20 While this showed some promise
in the predictability of successful decannulation, there was a
high false-negative rate, and a prolonged admission was
required. Although a potentially useful tool, it has not
become a routine step in published protocols.
The role of capped PSG in decannulation has gained
wider acceptance,9,13,15 although its routine use is debatable.
The current literature is composed of retrospective reviews
and case series, and there are discrepancies on what is
termed a ‘‘favorable’’ PSG when determining candidates for
tracheostomy tube removal.13,15 Many of those with mild
and even moderate obstructive sleep apnea can be decannu-
lated successfully. Gurbani et al compared the predictive
value of operative endoscopy with that of PSG and found
that PSG alone was inferior.13 In their study population,
26% of those with ‘‘unfavorable’’ PSGs were still decannu-
lated successfully. They concluded that combining PSG
with endoscopy offers superior predictive value than that of
endoscopy alone, although the increase in sensitivity was
only 5%. PSG is a resource-intensive examination that does
not have a place in our routine decannulation protocol. It is
a valuable tool, however, that can provide additional infor-
mation in those more complex cases.
The duration of inpatient stay was another inconsistency
across protocols. Hospital stays for various decannulation
studies ranged from 3 to 10 days.4,5,12,16 Acute failures are
typically noted within the first 12 hours, which means that
monitoring beyond the first day in an otherwise stable
patient may not be necessary.5 The financial burden of a
prolonged hospital stay is significant. The average inpatient
stay of our 35 decannulated patients was \2 nights, which
is the lowest that we have come across in the literature. The
shorter hospital stay is partially attributable to the protocol’s
lack of inpatient downsizing, capping, or PSG.
4 Otolaryngology–Head and Neck Surgery
There are several limitations to this study. First, it is a
retrospective review that focuses solely on those who under-
went our protocol for decannulation. This included only a
select population at a single institution, and the results
cannot be generalized widely. There was no control group;
therefore, direct comparisons cannot be made to other meth-
ods. Second, a larger study population could allow for extra-
polation of patient characteristics that would predict failure/
success of decannulation. Third, the study included only
those in which decannulation was attempted. In doing this,
like all decannulation studies, we do not have the ability to
know how many of those not deemed appropriate for decan-
nulation would have tolerated removal of their tracheostomy
tubes. The study protocol is not meant to supplant existing
guidelines and methods but rather to serve as preliminary
observations of a varied approach to decannulation.
The purpose of this study was to explore outcomes of a
resource-conserving protocol for pediatric decannulation.
The protocol exhibited failure rates among the lowest
reported in the literature despite not employing capping,
downsizing, or PSG. As a result of the efficient use of
resources, peridecannulation days spent in the hospital were
lower than what any other decannulation study has reported.
This protocol breaks from the trends in the literature and
offers a new perspective in the continuing discussion on the
optimal management of these complex patients.
Author Contributions
Nicholas Wirtz, designed study, completed chart review, compiled
data, wrote manuscript, approved final version; Robert J. Tibesar,
contributed to conception of study, provided patients, assisted with
review and editing, approved final version; Timothy Lander,
assisted with design of study, provided patients, assisted with
review and editing, approved final version; James Sidman, con-
tributed to conception of study, assisted with data interpretation,
provided patients, assisted with review and editing, approved final
version.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
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