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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read the article by Pereira et al&#46; on tracheostomy prevalence in skilled nursing facilities &#40;SNFs&#41; with great interest&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The authors provided us with useful information about the situation of tracheostomized patients admitted to SNFs&#44; showed the relative omissions and insufficiencies of these facilities in performing decannulation safely and effectively and concluded that a coordinated multidisciplinary team is required to favorably perform the weaning process of the considerable size of population of tracheostomized patients admitted to SNFs&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The authors&#8217; conclusions reflect our own experience&#46; As a medical director of a SNF in Greece&#44; I am aware of this major deficit in numerous nursing facilities to provide proper tracheostomy care for these patients&#44; not to mention decannulation&#46; This is probably due to several reasons such as inadequate staff to patient ratio&#44; poor training programs and inappropriate nursing facility management&#46; When the above reasons do not exist and a multidisciplinary team handles the tracheostomized patients with care&#44; there is great potential for progress to be made&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> We report a case of a successfully performed decannulation in a COPD patient admitted to a SNF after a prolonged treatment in an ICU due to acute respiratory failure from mycoplasma pneumoniae infection&#46; He was a kyphosis-scoliotic asthenic tracheostomized man with a suitable level of consciousness&#44; presented with dyspnea&#44; tachypnoea&#44; tachycardia and oxygen saturation of 94&#37; under a FiO2 of 40&#37;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The physiotherapy planning program included maintaining and improving physical activity&#44; reducing breathlessness and the work of breathing&#44; aid with expectoration and clearance of secretions&#44; walking assistance with a walker and improvement of functional abilities&#46; Evaluation of swallowing function by a speech therapist revealed the presence of effective voluntary cough and a strong coughing reflex but high volume of yellowish orotracheal discharge and wet phonation&#46; Clinical swallowing assessment using 10&#8239;ml of water and few drops of methylene blue performed twice on the same day&#44; revealed ability to swallow fluids &#40;no traces of dye appeared in the subsequent bronchoaspiration&#41;&#44; but inability to swallow semisolid foods &#40;cream&#41;&#44; though immediate aspiration&#44; after administration of semisolid food with methylene blue was provided&#44; revealed colorant material and oxygen desaturation&#46; Needless to say assessment of the ability to swallow solid food was not performed&#46; Therefore&#44; decannulation was postponed and oral intake was considered improbable&#46; In order to restore the swallowing mechanism and prevent other complications caused by nasogastric tube insertion&#44; a surgical gastrostomy was performed a few days later&#46; Three weeks later&#44; following a strict physiotherapy training program&#44; muscle strengthening and high calorie intake according to the dietitian&#8217;s guidance&#44; the patient gained weight and physical strength&#46; The patient could be fed orally and all the above mentioned swallowing tests were performed without signs of broncho-aspiration&#46; The fiberoptic endoscopic evaluation of swallowing performed by an otolaryngologist revealed no major abnormalities regarding swallowing function&#44; thus attempt at decannulation was decided according to the criteria by Ceriana et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The method of immediate tube removal-instead of tracheostomy downsizing &#8212; was chosen and sterile gauze covered the opening in the neck&#46; His condition progressed gradually&#44; the gastric tube was removed and the patient followed his rehabilitation program until discharge five months after admission to the SNF&#46; During his stay&#44; his psychological state was reinforced by family members as well as by a professional psychologist&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This case highlights the importance and necessity of a coordinated multidisciplinary team dedicated to the care of tracheostomy patients&#44; which can favorably influence the weaning process in acute-care hospitals&#44; rehabilitation centers and last but not least in SNFs&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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