Tracheostomy in critically ill patients is a necessary and prevalent procedure to support prolonged mechanical ventilation. As with the optimal timing for tracheostomy placement, which has been the subject of extensive research1,2 the prediction of successful decannulation and the most appropriate strategy to achieve it remain insufficiently defined.

In daily clinical practice, excessively early decannulation may lead to recannulation, with internationally accepted rates ranging between 2% and 5%.3 However, maintaining a tracheostomized patient for an unnecessarily prolonged period due to excessive conservatism is also a relevant concern. Cannula retention is associated with adverse events such as respiratory infections, increased secretions, tracheal injury, and swallowing disorders, as well as a substantial economic burden on healthcare systems.

In this context, an important advance in the generation of evidence aimed at identifying faster and safer decannulation strategies was provided by the REDECAP trial.4 This trial demonstrated that patients decannulated according to objective secretion management criteria—defined as a suctioning frequency of fewer than two aspirations every eight hours over a 24-h period—and who received high-flow oxygen therapy through the tracheostomy cannula were decannulated earlier than those managed with the traditional clinical practice of capping a fenestrated cannula for 24 h, without an increased risk of failure or recannulation. These findings suggest that excessively demanding strategies may unnecessarily delay decannulation, in a manner analogous to what has been observed in extubation, where overly demanding spontaneous breathing trials are known to increase the risk of respiratory failure.

In this issue of the journal Basoalto,5 …. et al. present an attempt to develop a comprehensive decannulation model through an international expert consensus involving specialists from Chile, Argentina, Mexico and Ecuador. The authors employed a structured Delphi methodology based on the ProDeM approach, which included three rounds of consensus and ultimately involved 55 professionals from different disciplines, including physicians, nurses, speech therapists, respiratory therapists, and physiotherapists.

The proposed model begins with a daily assessment of the patient’s readiness for decannulation and progresses from baseline evaluations to complete tracheostomy tube occlusion for a period ranging from 12 to 48 h. If this occlusion is tolerated, the cannula is subsequently removed.

When analyzing this model in light of the available evidence, a relevant limitation emerges: the absence of an explicit evaluation of secretion burden and suctioning frequency as criteria for decannulation readiness. The model focuses on well-established clinical variables such as respiratory muscle strength, tolerance of cuff deflation and speaking valve trials, assigning a central role to prolonged complete cannula occlusion. Although occlusion trials may retain a role in selected patient populations, it is difficult to consider them a generalizable method given the current evidence, which suggests that adequate secretion management and clinical control are key determinants of successful decannulation, potentially outweighing tolerance to prolonged capping trials. This consideration becomes particularly relevant when noninvasive respiratory support strategies, such as high-flow oxygen therapy delivered through the tracheostomy cannula, are available.

Even in settings with limited access to high-flow oxygen therapy, suctioning frequency represents a simple, reproducible, and widely available clinical variable that should be systematically incorporated into any comprehensive decannulation model. Other approaches, such as immediate bronchoscopy-guided decannulation or single-step decannulation protocols, although supported by limited evidence, have demonstrated safety and effectiveness, further questioning the need for prolonged occlusion trials as a universal requirement.6

The decannulation process in patients undergoing prolonged mechanical ventilation must be interpreted within the geographical and institutional context in which it takes place. In some countries, such as the United States, these patients are often transferred to post-acute care facilities for ventilator weaning and decannulation,7 where nurse-to-patient ratios and available resources differ substantially from those of intensive care units in other countries, such as Spain, where this process is more commonly managed within the ICU. In this regard, the authors clarify that their proposal is not intended to establish universal recommendations but rather to reflect consensus-based and feasible practices within a specific geographical context, prioritizing patient safety in resource-limited environments. This contextualization inevitably conditions the external validity of the model and should be considered when interpreting its findings.

Overall, successful decannulation depends on the appropriate integration of clinical and physiological factors within the care context. These include clinical stability; effective cough; adequate secretion management reflected by a low suctioning frequency; an appropriate level of consciousness; clinical screening for swallowing disorders and airway patency with endoscopic confirmation if positive, and adequate oxygenation. The development of structured protocols or guidelines integrating these criteria is needed to support more homogeneous and equitable decision-making and to facilitate safer and more efficient management of tracheostomized patients, ultimately promoting successful decannulation. From an institutional perspective, the timing of decannulation must also be considered in relation to its potential impact on ICU length of stay, particularly in settings with limited resources.