Post-Operative Tracheostomy Decannulation Protocol Following Head and Neck Free Flap Reconstruction: A Prospective Cohort Study.

[OBJECTIVE] Methods used in assessing decannulation timing after head and neck reconstruction vary widely. In this study, we examined the effect of implementation of a standardized post-operative tracheostomy decannulation protocol on our primary endpoint, return to the emergency room within 30 days for upper airway related issues, as well as on decannulation rates. We also examined the association between several patient/intervention characteristics and successful decannulation prior to discharge.

[METHODS] Data were collected prospectively for all patients who underwent free flap reconstruction requiring tracheostomy between September 2020 and October 2021 at a single tertiary center. A standardized protocol was implemented to determine candidacy for decannulation prior to discharge. Our protocol was two tiered with initial criteria including: tolerance of finger occlusion, passing of abbreviated fiberoptic evaluation of swallowing (FEES), requiring suction no more frequently than every 4 h, adequate cough, no supplemental oxygen requirements, and alert mental status. Patients meeting these criteria progressed to a 24-h capping trial.

[RESULTS] Our cohort consisted of 114 patients who underwent the decannulation protocol, as well as a retrospective control cohort of 96 patients from prior to protocol implementation for a total of 230 patients. Although not significant (p = 0.34), a higher proportion of our protocol cohort, 45/114 (39.5%) of patients decannulated before discharge versus 31/96 (32.3%) of our control patients. For our primary endpoint, only a single patient in the protocol cohort had a return to the ED within 30 days for upper airway related issues compared with 6 patients in the control cohort (0.9% vs. 6.2%; p = 0.048), and we found no significant difference in readmission rates. We also found that across both cohorts, patients with an anterior defect involving the genial tubercle had lower rates of decannulation vs. other patients (24.3% vs. 42.1%; p = 0.017).

[CONCLUSIONS] Implementation of a standardized protocol for post-operative head and neck reconstruction patients can give providers greater confidence in discerning which patients are appropriate for decannulation prior to discharge and prevent returns to the emergency room.