Tracheostomy weaning in community and the importance of the Multi-Disciplinary Team (MDT) to optimise outcomes.

Purpose

Patients discharged in to the community with a percutaneous tracheostomy often receive no follow up. The implications of this are huge.

A previous pilot scheme resulted in the decannulation of 5 patients who were living in community with tracheostomies. This led to improved quality of life and demonstrated significant cost savings. This highlighted the need for continual review and assessment of tracheostomy patients with regards to their future weaning potential.


This case report will discuss the success for one patient as part of a 10-month community MDT pilot scheme. The team comprised of a dedicated nurse, speech and language therapist (SLT) and physiotherapist. We highlight the importance of a collaborative MDT approach in order to optimise outcomes for patients with tracheostomies.

Approach

This case presents a 29-year-old male who suffered an acquired brain injury and was discharged to a nursing home with a cuffed tracheostomy in 2015. Ability to engage was limited due to severe physical and cognitive impairment. He was referred to the regional tracheostomy team to explore weaning potential in December 2018.

We began with initial cuff deflation of which was tolerated with an effective swallow reflex. The tracheostomy was changed to an uncuffed, fenestrated tube and a one way speaking valve was introduced to increase laryngeal airflow.

Once tolerating throughout the day we introduced capping trials for up to 90 minutes. We collaborated with the patient's private SLT to create joint therapy goals focusing on oral desensitisation helping to increase spontaneous swallows and encouragement with mouth opening whenever signs of nasal congestion. The patient had an adequate cough and minimal respiratory secretions. A laryngoscopy revealed no upper airway abnormalities, no pooling of secretions and normal functioning vocal cords suggestive of a patent upper airway.

After a 4-month weaning period the patient underwent de-cannulation on a specialist respiratory ward. Initial post-decannulation management involved cough assist therapy to optimise chest clearance. The patient developed a hospital acquired pneumonia after 72 hours however made a good recovery after treatment with antibiotics. The patient was discharged home after 8 days in hospital.

Outcomes

A collaborative approach to tracheostomy weaning in community resulted in a successful decannulation after 4 years of living with a tracheostomy. The long-term benefits to the patient include elimination of tracheostomy related infections; easier and safer access to activities in community; greater potential for voice and swallow rehabilitation and increased options for future care provision - this patient can now move closer to his family.

Estimated minimum ongoing annual cost savings are over £146,000 based on decreased care needs and reduction in tracheostomy consumables.
 

Long term tracheostomy patients may have potential to undergo weaning and de-cannulation when followed up by dedicated professionals resulting in improved long-term outcomes for the patient. The impact of this is not only relevant for patients, families, care teams but also commissioners of services due to reduced dependency and cost benefits.

Implications

MDT led Tracheostomy weaning in community can lead to improved outcomes and impact positively on quality of life while reducing cost to the NHS.

Funding acknowledgements

No specific funding was given to this project. 

Additional notes

This work was presented at Physiotherapy UK 2019.