Question about decannulation sleep study

[zeebee14]

I work as a peds home health nurse. My patient is 2.5 years and has Down syndrome. He has had a trach since he was an infant and his parents are eager to have it removed. He is currently off the vent entirely, and uses an Airvo for humidification while sleeping. He wears a cap all day with no issues. He still does require suctioning about 3-4 times a day. He had a sleep study on Monday to determine if he could be decannulated, but he failed due to sleep apnea. The test was ordered by the pulmonologist, who doesn’t really answer any questions and doesn’t provide a whole lot of info. He did not order the patient a smaller sized trach for the study, which apparently is pretty standard in these studies. So now the parents think that he failed because he didn’t have the smaller trach and want to ask his ENT at his appointment Monday to order a new sleep study using the smaller trach. Do you think this would actually help him? My feeling is that if he has apnea and still needs suctioning, no matter the trach size, he will fail. What is the rationale behind using a smaller trach for the sleep study? Thanks!

[Kitiger, RN]

If he has sleep apnea, why doesn't he use a vent or CPAP at night?

[zeebee14]

He was only diagnosed with apnea during this study. He had a home sleep study a few months back to determine whether he needed the vent at night, and that one he passed and was able to come off the vent. I don’t think that at this point, he would be a good candidate for a CPAP. At his age and with his cognitive delays, he would just rip it off his face. I think that is why the pulmonologist is recommending he stay trached for the time being. 

[Kitiger, RN]

My vote goes to the pulmonologist for the trach, although it might be good if the parents could fine one who is willing to take the time to communicate better.

I don't know anything about using a smaller trach for the sleep study. I would be interested if others could chime in on that.

[RNinCLE, ADN, BSN]

I don’t know that a smaller trach would be a requirement for a psg to determine decannulation. I’ve often seen an inpatient capped sleep study. The ENT should also be able to determine the potential for decannulation based on those psg results. Much will depend on degree of sleep apnea, obstructive vs central sleep apnea, and if there are surgical options to address it. 

[Jade Flem]

There are three reasons I could think of. CPAP probably did not detect apnea. It is known to be less sensitive than auto CPAP. CPAP accessories could be loose, and apnea could be apparent. CPAP could not be able to regulate his airway and spillover could be obvious. If the tube is loose, suctioning will be much less effective, and, as you mentioned, there will be lots of suctioning. There are two ways to ensure that the tube stays in place; wrap the tube and tape the tube to the face or use a smaller tube. A smaller tube will make the airway narrower, which may help.