Tracheostomy decannulation methods and procedures in adults: a systematic scoping review protocol
Kutsukutsa et al. Systematic Reviews
Tracheostomy decannulation methods and procedures in adults: a systematic scoping review protocol
John Kutsukutsa 0
Tivani Phosa Mashamba-Thompson 2
Yougan Saman 1
0 Department of Otorhinolaryngology Head & Neck Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal , 5th Floor, Room 550 Main Building, Durban 4001 , South Africa
1 Department of Otorhinolaryngology Head & Neck Surgery, University of KwaZulu-Natal , Durban 4001 , South Africa
2 Discipline of Public Health, University of KwaZulu-Natal , Durban 4001 , South Africa
Background: The indications for and the number of tracheostomy procedures has increased with advances in critical care. Studies are indicating likely continued increase in number of tracheostomies. Despite the important benefits of a tracheostomy, its presence is associated with adverse health complications and lowered patient quality of life. Hence, it must be decannulated as soon as it is no longer indicated in a safe and effective manner. There is, however, no agreed universal standard of care for tracheostomy decannulation (TD) in adults. The aims of our study are to systematically map the literature on the decannulation process, reveal knowledge gaps and inform further research. Methods: The search strategy of this systematic scoping review will involve the following electronic databases: PubMed/MEDLINE, Google Scholar, Union Catalogue of Theses and Dissertations (UCTD) via SABINET Online and WorldCat Dissertations and Theses via OCLC. Articles will also be searched through the “Cited by” search as well as citations included in the reference lists of included articles. Studies from the databases will be title screened and duplicates removed followed by a parallel two-independent reviewer screening of abstracts followed by full articles of selected studies both guided by eligibility criteria. We will extract data from the included studies and the emerging themes will be analysed. The relationship of the emerging themes to the research question will be critically examined. The quality of the included studies will be determined by Mixed Method Appraisal Tool (MMAT). We will use NVIVO version 10 to extract the relevant outcomes and thematic analysis of the studies. Discussion: We anticipate to find studies that highlight evidence and preference as well as acceptability of TD methods and procedures. We hope to expose knowledge gaps and inform future research. Findings will be disseminated electronically, in print and through peer presentation, conferences and congresses. Systematic review registration: Our systematic review has been registered in PROSPERO: CRD42017072050.
Tracheostomy decannulation; Weaning; Methods and procedures
The indications for tracheostomies have expanded and
the rate at which the procedure carried out has also
increased with the advancement of critical care [
is estimated that up to 10% of intensive care unit (ICU)
patients will require a tracheostomy . This is in
addition to the tracheostomies done by various surgical
specialities outside of critical care. Although timing of
tracheostomy in ICU is still debated [
], it is leaning
towards early tracheostomy spurred on by some studies
showing benefits of early tracheostomy . In spite of
this increase, there is no consensus on the standard
approach to its reversal (tracheostomy decannulation)
thereby relegating decisions to expert opinion and
institutional protocols [
]. In a recent survey, non ENT
health professionals involved in airway care had a low
level of self-rated comfort with tracheostomy tube
]. All these may imply patients being exposed
to non-scientific, risky decannulation practises or
finding themselves under the care of non-ENT health
care workers who may not feel comfortable
Article 26 of the United Nations Convention on the
Rights of Persons with Disabilities obliges member states
to ‘take effective and appropriate measures, including
through peer support, to enable persons with disabilities
to attain and maintain maximum independence, full
physical, mental, social and vocational ability, and full
inclusion and participation in all aspects of life’ [
Regaining verbal communication is one of the benefits
of TD which allows attainment of these goals.
Decannulation improves patient comfort, perceived physical
appearance in addition to improved speech and
]. It is therefore prudent to have tracheostomy
decannulation (TD) as soon as it is no longer indicated
in a safe and effective manner.
Tracheostomy decannulation has a risk of failure with
fatal consequences if not managed appropriately. Experts
in different settings have different opinions and
approaches to TD [
]. This raises the question of whether
we understand what is available well enough to design
and carry out further research that speaks to all. It is our
contention that this systematic scoping review will better
our understanding of the decannulation process, expose
knowledge gaps and stimulate research to fill in the gaps.
We therefore aim to explore evidence on methods and
procedures for tracheostomy decannulation in adults.
Our objectives are the following:
➢ To highlight evidence base for the different methods
and procedures for TD
➢ To determine the preference of method and
procedures for TD in adults
➢ To determine the acceptability (to patients and
health care workers) of method and procedures for TD
Systematically mapping the available evidence for TD
methods and procedures will cascade into better
outcomes for tracheostomy patients through enhanced
understanding and more scientific approaches to TD.
Systematic scoping review
We will conduct a systematic scoping review of
peer-reviewed and grey literature on the methods and
procedures of TD in adults. The review will include a quality
assessment. This review will be guided by Arksey and
] scoping review framework which
stipulates the following steps:
1. Identifying the research question 2. Identifying relevant studies 3. Study selection
4. Charting the data 5. Collating, summarising and reporting the results
Identifying the research question
The research question is, what is the evidence available
for the different methods and procedures for TD in
The sub research questions are as follows:
1. What is the preference of method and procedures
for tracheostomy decannulation in adults?
2. What is the acceptability of TD methods and
Eligibility of research question
The study has used the Population Intervention
Comparator Outcomes (PICO) framework to determine the
eligibility of research question as illustrated in Table 1 below.
Identifying relevant studies
Primary studies with a clear empirical base utilising
qualitative, quantitative and mixed methods published in
peer-reviewed journals as well as in grey literature
addressing the research question will be included. An
electronic search of the following databases will be
conducted: PubMed/MEDLINE, Google Scholar, Union
Catalogue of Theses and Dissertations (UCTD) via
SABINET Online and World Cat Dissertations and
Theses via OCLC. Websites such as the World Health
Organisation (WHO) and governmental websites will be
searched for policies and guidelines for TD. Studies will
be identified by searching literature published in any
language from January 1985 to date. A hand search
through the main published texts used in
otorhinolaryngology teaching and practise will also be conducted.
Articles will also be searched through the ‘Cited by’
search as well as citations included in the reference lists of
included articles. The search terms will include
tracheostomy, decannulation, weaning, procedures, methods,
complications and adults. After searching, duplicates will
be removed and the studies will be screened against the
inclusion and exclusion criteria.
Primary—evidence for procedures and methods
Secondary—preference and acceptability: successful
decannulation, reduced complications of long-term
tracheostomy and increased comfort by health care
workers in undertaking the procedure
The eligibility criteria were developed to ensure specific
information relating to the research question is included
in the studies.
For studies to be included they should meet the
➢ Be in all languages
➢ Be available in full text
➢ Must focus or include adult TD methods and
procedures regardless of patient groups
➢ Must show evidence of preference and acceptability
of TD methods and procedures
➢ Must have been published between 1985 to present
Studies will be excluded if they met the following
➢ Studies including or focusing on paediatric TD
methods and procedures
➢ Studies published before 1985
➢ Studies with no evidence of preference and
acceptability of TD methods and procedures
➢ Studies not focusing or including TD methods and
procedures regardless of patient groups
➢ Studies not available in full text
Search strategy was piloted to check the
appropriateness of selected electronic databases and key words
(Table 2). An Endnote library will be created for this
review. The primary investigator will conduct a
comprehensive search and screening of the study titles from the
above-mentioned databases. All studies with eligible
titles will be exported to the endnote library, and all
duplicates will be removed before abstract screening.
Two reviewers will conduct abstract followed by full
((((((((((((((((((((((((((((((((((((((((tracheostomy[MeSH Terms]) OR tracheostomy)
AND decannulation) OR tracheostomy) AND percutaneous) OR tracheostomy
decannulation) OR tracheostomy care) OR tracheostomy) AND care) OR
tracheostomy decannulation protocol) OR tracheostomy) AND protocol)
OR tracheostomy decannulation methods) OR tracheostomy) AND decannulation
methods) OR tracheostomy complications) OR tracheostomy) AND complications)
OR tracheostomy weaning) OR tracheostomy) AND weaning) OR tracheostomy
long stay) OR tracheostomy) AND long stay) OR tracheostomy rehabilitation) OR
tracheostomy) AND rehabilitation)) OR percutaneous tracheostomy) OR percutaneous)
AND tracheostomy)) OR removal tracheostomy) OR removal) AND tracheostomy))
OR decannulation method) OR decannulation) AND method)) AND ("1985/01/01
"[Date - Publication] : "3000"[Date - Publication])
article screening of selected studies independently with
guidance from the eligibility criteria.
To optimise the article search procedure, we will
utilise our local library services, the UKZN library services
to help with retrieving and finding articles to be
included in the full-article screening. Authors will also
be contacted for electronically unavailable papers.
The screening results will be reported by use of the
adapted PRISMA chart as in Fig. 1.
Charting of data
Data charting table (Table 3 below) will be used to extract
background information and process the information
from each utilised study. A data charting form
highlighting the important aspects for the study will be developed
and piloted. The variables and themes included will
answer the research question. The data charting form will
be continually updated.
Collating, summarising and reporting the results
A narrative account of the data extracted from the included
studies will be analysed using the thematic content analysis.
Data will be extracted around the following themes: TD
procedures and methods, utility and acceptability, reduced
complications of long-term tracheostomy, complexity of
intervention and comfort by health care workers in
undertaking the procedure. Emerging themes will also be
extracted. The NVIVO software version 10 will be used to
code and analyse data from included studies.
The resulting themes will be analysed and their
relationship to the research question critically examined.
Reviewers will also analyse the implication of the
findings in relation to the aim of the study as well as to
future research and evidential framework for policy and
practise in low- and medium-income settings. An
attempt will be made to draw from evidence safe and
Date of search
Search engine used
effective guidelines that are practical in low- to
mediumincome countries for specific patient groups.
The Mixed Method Appraisal Tool (MMAT)-version
] will be used to determine quality of the
studies. For appraising a qualitative study, we will use
section 1 of the MMAT, for a quantitative study, we will
use section 2 for randomised controlled, section 3 for
non-randomised, and section 4 for descriptive studies.
For a mixed methods study, we will use section 1 for
appraising the qualitative component, the appropriate
section for the quantitative component (2 or 3 or 4) and
section 5 for the mixed methods component. The tool
will be used to examine the appropriateness of aim of
study, adequacy and methodology, study design, data
collection, study selection, data analysis, presentation of
findings, author’s discussions and conclusions. The
results from scrutiny of above mentioned aspects will
determine quality of resultant article.
Tracheostomy decannulation marks a significant point
in-patient rehabilitation post a frequently severe illness.
It marks the return to normal or near normal phonation
with improved communication, improved physical
appearance and elimination of potential health
complication of having a tracheostomy. A recent systematic
review by Santus et al. [
] focussed on assessing
predictor factors of successful decannulation and to propose
a predictive score to help clinicians in choosing
decannulation timing. Another more recent systematic review
by Singh et al. [
] focussed on objective criteria for
decannulation. Both studies concluded there is need for
higher evidence research around the subject; we however
aim to map literature around the whole process,
contextualise it according to its themes to allow a better
understanding thereby exposing knowledge deficits from
which the higher evidence research can be built on.
Tracheostomy in children is different from
tracheostomy in adults in terms of indications and decannulation
time although the complications are similar [
systematic scoping review focuses on decannulation in
adults regardless of the indication for tracheostomy. It
includes all studies from January 1985 to date because
studies published prior are unlikely to reflect or include
aspects pertaining to percutaneous dilatational
tracheostomy which was first published in that year. It is
anticipated that the results of this systematic scoping review
will contribute to safe and effective rehabilitation of
patients with tracheostomies.
ICU: Intensive care unit; MMAT: Mixed Method Appraisal Tool;
PICO: Population Intervention Comparator Outcomes; PRISMA: Preferred
Reporting Items for Systematic Reviews and Meta-Analyses;
TD: Tracheostomy decannulation
The authors would like thank the College of Health Sciences, University of
KwaZulu-Natal for financially supporting the development of this research
study and Dr. Kuhn–Stanger ENT Consultant for critiquing the work.
The University of KwaZulu-Natal College of Health Sciences funded this
research study. They also provided the resources used in the development
of this protocol.
Availability of data and materials
All data generated or analysed during this study will be included in the
published systematic scoping review article and will also be available upon
JK conceptualised the study and prepared the draft proposal under the
guidance and supervision of TPM-T and YS. All three authors contributed to
the development of the background and planned output of the research as
well as the design of the study. TPM-T contributed to the development of
the methods relating to the review and synthesis of data including the
sifting and data extraction process. JK prepared the manuscript, and TPM-T
and YS reviewed it. All three authors contributed to the reviewed draft
version of the manuscript and approved the final version.
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
1. Beatrous WP . Tracheostomy (tracheotomy) . Its expanded indications and its present status based on an analysis of 1,000 consecutive operations and a review of the recent literature . Laryngoscope . 1968 ; 78 ( 1 ): 3 - 55 .
2. Cheung NH , Napolitano LM . Tracheostomy: epidemiology, indications, timing, technique, and outcomes . Respir Care . 2014 ; 59 ( 6 ): 895 - 915 . discussion 916- 9
3. Goldenberg D , et al. Tracheotomy: changing indications and a review of 1130 cases . J Otolaryngol. 2002 ; 31 ( 4 ): 211 .
4. Regan K , Hunt K. Tracheostomy management . Continuing Education in Anaesthesia Critical Care & Pain . 2008 ; 8 ( 1 ): 31 - 5 .
5. Apezteguia C , Ríos F , Pezzola D. Tracheostomy in patients with respiratory failure receiving mechanical ventilation: how, when, and for whom? In: Evidence-Based Management of Patients with Respiratory Failure, A . Esteban , D.J. Cook , and A. Anzueto . Berlin, Heidelberg: Springer Berlin Heidelberg; 2004 . p. 121 - 34 .
6. Ceriana P , et al. Weaning from tracheotomy in long-term mechanically ventilated patients: feasibility of a decisional flowchart and clinical outcome . Intensive Care Med . 2003 ; 29 ( 5 ): 845 - 8 .
7. Young D , et al. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial . JAMA . 2013 ; 309 ( 20 ): 2121 - 9 .
8. Rumbak MJ , et al. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients . Crit Care Med . 2004 ; 32 ( 8 ): 1689 - 94 .
9. Santus P , et al. A systematic review on tracheostomy decannulation: a proposal of a quantitative semiquantitative clinical score . BMC Pulmonary Medicine . 2014 ; 14 ( 1 ): 201 .
10. Singh RK , Saran S , Baronia AK . The practice of tracheostomy decannulation-a systematic review . Journal of Intensive Care . 2017 ; 5 ( 1 ): 38 .
11. Choate K , Barbetti J , Currey J . Tracheostomy decannulation failure rate following critical illness: a prospective descriptive study . Aust Crit Care . 2009 ; 22 ( 1 ): 8 - 15 .
12. Al Sharhan S , Sohail M , Ahmad K , Siddiqui MI . Self-reported comfort with tracheostomy tube care Cross-sectional survey of non-ear, nose and throat health care professionals . Saudi med Journal . 2014 ; 35 : 63 - 6 .
13. Rights , U.N.H. Convention on the Rights of Persons with Disabilities . 1996 [cited 29 July 2017 ]; Available from: http://www.ohchr.org/EN/HRBodies/ CRPD/Pages/ConventionRightsPersonsWithDisabilities.aspx# 26 .
14. Christopher KL . Tracheostomy decannulation . Respir Care . 2005 ; 50 ( 4 ): 538 - 41 .
15. Durbin CG . Tracheostomy: why, when, and how? Respir Care . 2010 ; 55 ( 8 ): 1056 - 68 .
16. O 'Connor HH , et al. Decannulation following tracheostomy for prolonged mechanical ventilation . J Intensive Care Med . 2009 ; 24 ( 3 ): 187 - 94 .
17. Shreeharsha Maruvala , R.C. , Ruchi Rajput . Tracheostomy Decannulation: When and How? Research in Otolaryngology, 2015 . Vol. 41 : p. pp. 1 - 6
18. Stelfox HT , et al. Determinants of tracheostomy decannulation: an international survey . Crit Care . 2008 ; 12 .
19. Arksey H , O'Malley L . Scoping studies: towards a methodological framework . Int J Soc Res Methodol . 2005 ; 8 ( 1 ): 19 - 32 .
20. Pluye , P. , Robert , E. , Cargo , M. , Bartlett , G. , O 'Cathain , A. , Griffiths , F. , Boardman , F. , Gagnon , M.P. , & Rousseau,. Proposal: a mixed methods appraisal tool for systematic mixed studies reviews . 2011 [cited 2017 29 July 2017 ]; Available from: http://mixedmethodsappraisaltoolpublic.pbworks. com/w/file/fetch/84371689/ MMAT%202011%20criteria% 20and % 20tutorial % 202011 - 06 -29updated2014. 08 .21.pdf.
21. Santus P , et al. A systematic review on tracheostomy decannulation: a proposal of a quantitative semiquantitative clinical score . BMC Pulm Med . 2014 ; 14 : 201 .
22. Suslu N , Ermutlu G , Akyol U . Pediatric tracheotomy: comparison of indications and complications between children and adults . Turk J Pediatr . 2012 ; 54 ( 5 ): 497 - 501 .