Prospective validation of a non-invasive bedside protocol for tracheostomy decannulation in acquired brain injury with otolaryngologic concordance

Abstract

Decannulation of tracheostomy in individuals with acquired brain injury (ABI) is challenging and often requires endoscopic airway assessment. A reliable noninvasive bedside protocol could support decision-making in neurorehabilitation settings. We conducted a prospective observational cohort study at a tertiary neurorehabilitation center between July 2021 and March 2025. Thirty-six adults with chronic ABI and tracheostomies were assessed using a structured bedside protocol comprising tracheostomy capping tolerance, suction requirement ≤2 episodes per 24 hours, modified Evans blue dye aspiration screening, and laryngeal ultrasonography. All participants subsequently underwent blinded nasopharyngolaryngoscopic (NPL) examination as the reference standard. Twenty-six participants (72.2%) were protocol positive; 24 were suitable for decannulation on NPL and two were unsuitable. Among 10 protocol-negative participants, nine were unsuitable and one was suitable. Sensitivity was 96.0% (95% CI 79.6–99.9), specificity 81.8% (95% CI 48.2–97.7), and overall accuracy 91.7%. Agreement with NPL findings was strong (κ = 0.80). No aspiration pneumonia, respiratory deterioration, or recannulation occurred during four weeks of follow-up. The bedside protocol may serve as a screening tool to support decannulation assessment and guide the need for confirmatory endoscopic evaluation. Larger multicentre studies are warranted.