Noninvasive Positive Pressure Ventilation by Means of a Nasal Mask May Avoid Recannulation After Decannulation in Pediatric Patients: Key Practical Aspects and Implications

Fig. 53.1

Necker hospital decannulation flow chart

The patient should be in a stable condition for at least 1 month. This delay depends on the child’s age and also on the season (with a greater risk of respiratory infection precluding a decannulation during the winter season).
A flexible laryngoscopy should document a patent airway with at least one mobile vocal cord.
Any granulation tissue should be excised prior to decannulation.
There should be no signs of ongoing aspiration events such as pneumonia or pooling secretions with the need of multiple suctioning to clear secretions.
Children over the age of 2 years should be able to breathe spontaneously around the cuffless or deflated cuffed cannula during daytime. If the child tolerates a cap, options prior to decannulation include but are not limited to a capped overnight sleep study with at least a careful clinical observation with oximetry and carbon dioxide monitoring. Prior to this test, the tracheal cannula should be changed for a smaller model, to favor easier breathing during nocturnal sleep.
In children younger than 2 years of age, capping is not recommended and the decannulation protocol should be individualized.
Adequate airway patency during sleep should be assessed by the absence of obstructive symptoms such as stridor, agitation, arousals, night sweats, and the absence of nocturnal hypoxemia (less than 5 consecutive minutes with a pulse oximetry (SpO₂) <90 %) and/or hypercapnia (transcutaneous carbon dioxide (PtcCO₂) >50 mmHg) while sleeping in room air with a cuffless or deflated cuffed cannula.

If the patient fulfils these criteria, decannulation can be performed without CPAP. A short-term (following days and nights), intermediate (following weeks), and long-term (following months) evaluation should be systematically performed with clinical examination, endoscopic evaluations when indicated, and regular nocturnal gas exchange recordings.

If the patient presents with persistent airway obstruction during sleep, as reflected by obstructive symptoms as described above and abnormal nocturnal gas exchange in room air with at least 5 consecutive minutes with a SpO₂ <90 % and/or a PtcCO₂ >50 mmHg, CPAP can be proposed prior to decannulation to promote sufficient airway patency. CPAP can also be proposed after several previous failed decannulation attempts. The CPAP acclimatization may be quite difficult in this group of patients because of young age and the anxiety associated with breathing without a cannula. The decannulation procedure with CPAP may take several days, according to the patient. The first step consists of the acclimatization of the patient to the nasal mask only, without the CPAP device. This step may take between 2 and 15 days, depending on the age of the patient, and on his or her medical and psychological history. Then, when the patient accepts wearing the nasal mask with the headgear, CPAP without sedation is tried for short periods, lasting 2–5 min, which are repeated during the daytime. When daytime tolerance exceeds 15 continuous minutes, CPAP is tried during the night with a cuffless or deflated cuffed cannula. Because of the partial airway obstruction due to the presence of the cannula, the CPAP pressure should be set at least 2 cm H₂O above the level that would have been chosen without the cannula in place. Overnight SpO₂ and PtcCO₂ recordings should be systematically performed. When the child is acclimatized to CPAP, the tracheal cannula can be removed with the adjustment of the CPAP settings to obtain a normal breathing pattern without stridor and normal nocturnal gas exchange.

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