Predictive factors for successful decannulation of the Montgomery T-tube in patients with complex airway stenosis during the COVID-19 pandemic at a tertiary hospital in Lima, Peru

Introduction

Complex airway stenosis has evolved into a more complex entity following the coronavirus disease 2019 (COVID-19) pandemic. Beyond prolonged intubation, its pathogenesis involves excessive cuff pressure, severe systemic inflammation, a dysregulated immune response, or post- intubation tracheomalacia (1). While historical series reported a baseline incidence of 1% to 2.6% (2,3), recent prospective data shows this rose to 7.1% in COVID-19 survivors (4). Furthermore, comparative analyses using propensity score matching have demonstrated that post-COVID-19 patients have a significantly higher frequency of post-tracheostomy etiology and a more complicated clinical course, including higher rates of postoperative glottic edema and dysphonia (5). These findings support the observation that COVID-19 related stenoses are more severe and require specialized stabilization strategies, such as the Montgomery T-tube (MTT).

This abnormal narrowing leads to partial or complete airway obstruction, frequently involving the larynx, specifically McCaffrey stage III or IV lesions, with symptoms such as dyspnea, stridor, and dysphonia (6). Symptoms vary according to the degree of obstruction and include dyspnea, stridor, dysphonia, and chronic cough after hospital discharge in patients recovering from severe COVID-19. Diagnosis is based on a combination of endoscopy, computed tomography (CT), and pulmonary function testing (7-9).

Treatment depends on the severity, extent, and location of the stenosis. In mild cases, corticosteroids, endoscopic dilations, or laser therapy may be used. In more severe cases, reconstructive surgery (cricotracheoplasty or tracheal resection with end-to-end anastomosis) is the definitive treatment (2,10). For patients who are not candidates for surgery, or to stabilize the airway after tracheal resection and anastomosis, placement of a MTT is performed to prevent collapse or excessive scarring (11).

Unlike conventional tracheostomy decannulation, which is primarily driven by physiological factors like cough strength and neurological status (12), successful decannulation of the MTT (SDMTT) depends on the long-term stabilization of the cartilaginous framework and the absence of obstructive granulation tissue Standard considerations for removal include a duration of 6 to 24 months, stabilized respiratory function, and patent endoscopic findings (13). Nevertheless, decannulation failure remains high, often necessitating new tracheostomies or repeated interventions to manage restenosis (11,14).

While recent studies have explored predictive factors for decannulation in general populations, focusing on systemic comorbidities like diabetes (15,16), there is a critical lack of evidence regarding the specific procedural and anatomical predictors in the post-COVID-19 phenotype. Specifically, the impact of technical and anatomical factors, as well as the complexity of pandemic-related injuries on SDMTT outcomes remains unexplored.

Therefore, the aim of this study was to determine the clinical and anatomical predictive factors for in patients with complex airway stenosis managed at a tertiary referral center during the COVID-19 pandemic. We present this article in accordance with the STROBE reporting checklist (available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-67/rc) (17).

Methods

Database

Retrospective cohort observational study that included 73 patients with a MTT due to post-COVID-19 tracheal stenosis, treated at Hospital Guillermo Almenara Irigoyen (HNGAI), Lima, Peru, between June 2020 and November 2024. Consecutive sampling was performed, and a standardized data collection form was developed as the research instrument.

Study population

We included 73 consecutive adult patients with confirmed diagnosis of complex airway stenosis during the COVID-19 pandemic who underwent bronchoscopy and cervicothoracic CT, which defined the anatomical characteristics of the larynx and trachea. Stenosis had to involve more than 50% of the lumen or be associated with respiratory symptoms such as dyspnea and stridor. Patients were not candidates for tracheal resection-anastomosis and were treated with a MTT to maintain airway patency and preserve phonation. Partial resection of tracheal rings was performed in some cases to prepare the tracheal bed for MTT placement but did not represent an intent for definitive repair.

Exclusion criteria consisted of congenital, neoplastic, or traumatic stenosis, and patients with less than 6 months of follow-up or incomplete medical records.

Data collection

The primary independent variables included: age, sex, body mass index (BMI), intensive care unit (ICU) length of stay, duration of intubation, tracheostomy stoma level (standardized: 2nd–3rd tracheal rings vs. non-standardized: cricothyroidotomy or low stomas), stenosis length (mm), presence of subglottic involvement, and distal granuloma below the tracheostoma. MTT indwelling duration was recorded and treated as a surrogate marker of clinical severity rather than a modifiable predictor. The dependent variable was SDMTT.

Anatomical severity was formally staged using the McCaffrey classification (6,18): stage II (localized stenosis >1 cm), stage III (multi-level involvement), and stage IV (glottic involvement).

Successful decannulation definition

The following criteria were used for decannulation:

• Absence of dyspnea or stridor for at least 24–48 hours after T-tube removal during hospitalization;
• Absence of granulation tissue or signs of acute inflammation (ductal cyst, malacia) on flexible bronchoscopy; and
• Tracheal lumen diameter of at least 1 cm, confirmed by CT.

Decannulation attempts were scheduled every 12–18 months, in accordance with following institutional unified protocol established at our center since 2014 and international standards (15,18). Successful decannulation was defined as the permanent removal of the MTT without the need for reimplantation or new tracheostomy during a minimum follow-up of 12 months. The primary outcome was confirmed by follow-up bronchoscopy and clinical evaluation, verifying the absence of dyspnea, stridor, or dynamic airway collapse. When these criteria were not met, decannulation was considered unsuccessful. All patients were followed up in outpatient visits and underwent flexible bronchoscopy at 1, 3, 6, and 12 months after decannulation. It is worth noting that the study follow-up was censored in November 2024.

Statistical analysis

Categorical variables are expressed as frequencies and percentages. Numerical variables are summarized as mean with standard deviation or median with interquartile range (IQR), based on the Shapiro-Wilk normality test. For bivariate analysis, Chi-squared or Fisher’s exact tests were used for categorical data, and Student’s t-test or Mann-Whitney U test for numerical data.

A parsimonious multivariable logistic regression model was constructed to identify independent predictors for SDMTT. Model performance and calibration were evaluated using the Hosmer-Lemeshow goodness-of-fit test and the area under the receiver operating characteristic (AUROC) curve. To avoid overfitting, a backward elimination process was applied, retaining only variables with clinical significance or P<0.20 in bivariate analysis. Crucially, decannulation was analyzed as a time-to-event variable using Kaplan-Meier survival curves to provide a robust estimate of the success rate over time and minimize survivor bias. All analyses were performed using STATA BE 18, with a two-sided significance level of P<0.05.

Ethical consideration

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study protocol was approved by the Ethics Committee of Hospital Nacional Guillermo Almenara Irigoyen (No. 34-2025). Patient confidentiality and anonymity were strictly maintained, and informed consent was waived.

Results

A total of 73 medical records were reviewed. The mean age was 50 years, with the most frequent age group being 18–24 years (27.4%). Males represented 72.6% of the cohort, and 57.9% had no comorbidities before tracheal surgery or MTT placement; however, diabetes mellitus was present in 10.5% of cases. Additionally, 89% presented isolated tracheal stenosis and 11% had stenosis associated with tracheoesophageal fistula. Distal granuloma below the tracheostoma was found in 80.8%, and subglottic involvement in 21.9% on bronchoscopy before the first decannulation attempt.

Regarding the tracheostomy stoma level, 46.6% (n=34) were standardized surgical stomas (placed between the 2nd and 3rd tracheal rings), while 53.4% (n=39) were non-standardized. These non-standardized stomas primarily resulted from emergency procedures or interventions performed at lower-complexity centers during the peak of the COVID-19 pandemic to rapidly secure the airway. With respect to nutritional status, 31.5% of patients were overweight and 42% obese. The mean length of the stenosis was 38.4 mm, and the mean duration of MTT use was 30.4 months. Regarding decannulation attempts, 48% had one removal attempt, achieving successful decannulation in 45% of cases (Table 1). The number of removal attempts was documented as a marker of clinical severity and process complexity; consequently, this variable was treated descriptively and excluded from both bivariate and multivariable analytical models.

In the bivariate analysis, interestingly, while the overall McCaffrey Stage did not reach statistical significance (P=0.47), the specific presence of subglottic lesions proved to be a more precise anatomical predictor (Table 1).

In the bivariate analysis, the standardized tracheostoma level (placed between the 2nd and 3rd tracheal rings) was strongly associated with SDMTT (P=0.004), with success rates of 64.5% in the standardized group versus 30.9% in the non-standardized group. Likewise, stenosis length (P<0.001) (see Figure 1); subglottic involvement (P=0.001); duration of MTT use (P<0.001) (see Figure 2); and distal granuloma below the tracheostoma (P=0.047) were significantly associated with SDMTT. Conversely, sex, age, comorbidities, tracheal pathology, and preoperative BMI were not associated with SDTTM. Interestingly, while the overall McCaffrey Stage did not reach statistical significance (P=0.47), the specific presence of subglottic lesions proved to be a more precise anatomical predictor (Table 1).

Figure 1 Stenosis length and SDMTT (n=73). Box plot showing median length (horizontal line) and 95% CI: 30.0 mm (25.7–30.7) for the successful group (n=33) vs. 49.5 mm (35.3–50.0) for the failure group (n=40). P<0.001 (Mann-Whitney U test). CI, confidence interval; SDMTT, successful decannulation of the Montgomery T-tube.

Figure 2 T-tube duration and SDMTT (n=73). Box plot showing median duration (horizontal line) and 95% CI: 21.0 months (17.3–31.0) for the successful group (n=33) vs. 36.0 months (34.0–37.0) for the failure group (n=40). P<0.001 (Mann-Whitney U test). CI, confidence interval; SDMTT, successful decannulation of the Montgomery T-tube.

In the multivariable logistic regression analysis, a standardized tracheostoma level showed a notable trend toward clinical success, with a three-fold increase in the probability of SDMTT [adjusted odds ratio (aOR): 3.29; 95% confidence interval (CI): 0.96–11.28; P=0.055]. Although reaching the threshold of statistical significance, its clinical relevance as a procedural determinant warrants further investigation. Conversely, anatomical barriers significantly reduced the likelihood of success: subglottic involvement decreased the probability of decannulation by 80% (aOR: 0.20; 95% CI: 0.05–0.78; P=0.02), and each additional millimeter of stenosis length further reduced the odds of SDMTT (aOR: 0.92; 95% CI: 0.88–0.97; P=0.002). Other variables, including age, BMI, and distal granuloma, were not significant predictors in the adjusted model (P>0.05) (Table 2).

A parsimonious multivariable logistic regression model was constructed to identify independent predictors for SDMTT. The model exhibited excellent discriminative performance, with an AUROC curve of 0.8731 (Figure 3), indicating high accuracy in predicting successful decannulation based on the identified clinical and anatomical factors.

Figure 3 ROC curve for decannulation prediction. The multivariable model achieved an AUC of 0.8731 (95% CI: 0.78–0.96), demonstrating high discriminative performance for predicting successful Montgomery T-tube removal (n=73). AUC, area under the curve; CI, confidence interval; ROC, receiver operating characteristic.

Finally, to address the longitudinal nature of the data and minimize survivor bias, decannulation was analyzed as a time-to-event variable. The Kaplan-Meier survival analysis revealed that the probability of MTT persistence gradually declined over time, with cumulative success (decannulation) rates of 27% at 24 months, 41% at 36 months, and 76% at 48 months. The median time to successful decannulation was 21 months (95% CI: 17.3–31.0). By the end of the 48-month follow-up period, 75% of patients had achieved successful removal of the device (Figure 4).

Figure 4 Kaplan-Meier curve of time to successful decannulation (SDMTT). The plot estimates the cumulative probability of successful Montgomery T-tube removal over time (n=73). The median time to SDMTT was 21.0 months (95% CI: 17.3–31.0). Log-rank test confirmed the clinical progression of the cohort. CI, confidence interval; SDMTT, successful decannulation of the Montgomery T-tube; TTM, Montgomery T-tube.

Discussion

This study identified key independent predictors for SDMTT in a cohort of 73 patients. The overall success rate was 45%, consistent with international series managing complex airway stenosis (11,15,19). Notably, our results demonstrate that success is not merely a matter of time but is fundamentally driven by clinical and technical factors, as well as the anatomical complexity of the lesion.

One of the key findings was that a standardized tracheal stoma showed a strong clinical trend toward a three-fold increase in the probability of success (aOR: 3.29; 95% CI: 0.96–11.28; P=0.055). Although this did not reach strict statistical significance, possibly due to our cohort size, the magnitude of the size effect suggests that standardized surgical placement remains a pivotal procedural factor for successful decannulation. This contrasts with previous literature, which often generalizes tracheostomy as a risk factor without distinguishing the surgical technique (12,16,20). We argue that the high failure rate observed in non-standardized stomas, many of which were performed in lower-complexity centers during the peak of the pandemic, was due to suboptimal anatomical placement (either cricoid-adjacent or excessively low), which compromised tracheal architecture and promoted malacia. Standardizing the stoma site preserves the integrity of the first tracheal ring, a critical factor for airway stability after MTT removal (21).

Notably, subglottic involvement was confirmed as a potent negative predictor of success in our multivariable model (aOR: 0.20; 95% CI: 0.05–0.78; P=0.02). This finding is statistically supported by the fact that 95.9% of our cohort presented with McCaffrey stage III or IV lesions, reflecting an extraordinary degree of anatomical complexity. While previous series (15,18,22) have occasionally reported attenuated effects of subglottic involvement in benign stenoses, the intense inflammatory and fibrotic response characteristic of the post-COVID-19 phenotype explains this discrepancy in our results. This extensive fibrosis often creates a mechanical and functional ‘bottleneck’ effect at the subglottic level that resists long-term stabilization by the silicone stent and hinders stable airway patency after removal (22-24). Therefore, in high-complexity cases (stage III/IV), subglottic involvement, alongside stenosis length, remains the primary anatomical barrier to achieving successful MTT decannulation.

Stenosis length emerged as a critical anatomical determinant in our multivariable analysis. Greater lesion extent was independently associated with a lower likelihood of successful removal (aOR: 0.92; 95% CI: 0.88–0.96; P=0.002), a finding consistent with multiple prior reports (15,16,25). In the post-COVID-19 context, where stenoses are often longer and more fibrotic due to prolonged intubation and intense inflammatory responses (4,5,21,25), this variable acquires particular importance as a marker of clinical complexity. Specifically, in our cohort, each millimeter increase in stenosis length reduced the probability of successful decannulation by approximately 8%, independent of other factors. This reinforces the notion that the longitudinal extent of tracheal involvement significantly influences airway stability, as longer stenoses often require more complex interventions and exhibit poorer prognoses for MTT removal (26).

Regarding distal granulomas below the tracheostoma, our study identified the presence of a distal granuloma below the tracheostoma as a significant independent predictor of decannulation failure (aOR: 0.18; 95% CI: 0.03–0.99; P=0.04). These lesions, often reactive to the chronic presence of the cannula or previous high-pressure cuff injury, function as mechanical obstructions that compromise the effective airway diameter during decannulation trials (27-29). While some authors suggest that distal granulomas can be managed endoscopically (30), our findings underscore their role as a primary barrier to success, necessitating thorough bronchoscopic evaluation and treatment prior to considering T-tube removal in complex post-COVID-19 cases.

Interestingly, our multivariable analysis identified male sex as an independent factor associated with a lower probability of successful decannulation (P=0.03). Although literature on sex-based differences in tracheal stenosis remains controversial, prior studies suggest that anatomical variations or the higher incidence of severe COVID-19 complications in men, leading to more aggressive fibrotic remodeling, could explain this trend (4,16,27,31). In our cohort, however, this likely reflects a greater degree of initial clinical severity rather than a purely biological predisposition. Its inclusion in the final model serves to refine the predictive accuracy of the anatomical variables, reinforcing a key clinical message: while biological factors play a role, the anatomical framework, stenosis length, and the tracheal stoma remain the most determinant factors for SDMTT in high-complexity cases (McCaffrey stage III or IV).

The final model integrated key clinical and procedural predictors for successful decannulation: male sex, stenosis length, subglottic involvement, and the presence of distal granulomas. Notably, the standardized tracheostoma level was retained in the final model due to its substantial clinical effect (aOR: 3.29) and its contribution to the model’s overall stability. This integrated model demonstrated excellent discriminative power, with an area under the receiver operating characteristic (AUROC) curve of 0.8731 (Figure 3). Furthermore, the Hosmer-Lemeshow test confirmed an adequate goodness-of-fit (P>0.05), indicating that the model’s predictions are highly consistent with the observed clinical outcomes in our cohort.

Conversely, variables such as age, BMI, and the presence of distal granulomas did not show significant associations in the adjusted model. This suggests that the primary anatomical framework (length and subglottic location) and the surgical entry point (standardized stoma) better capture the true clinical complexity of the affected segment (15,22,24,31).

Our median time to decannulation was 21 months, significantly shorter than the 30–36 months reported by Terra et al. (12,15,26,30,31). However, our multivariable model showed that for each additional month of MTT indwelling, the odds of success decreased by 10%. We interpret this not as the T-tube causing failure, but as time acting as a surrogate for clinical severity. Patients requiring longer stenting periods are those with more extensive fibrosis and higher McCaffrey stages. Thus, the 21-month median reflects the necessary “maturation” period for these complex airways, beyond which the likelihood of success diminishes as chronic remodeling takes hold. Consequently, T-tube duration serves as a key clinical marker of airway stenosis severity. The prolonged T-tube dependency observed in a significant portion of our cohort reflects the complexity of the inflammatory and structural changes in these patients.

This study has some limitations that warrant discussion. First, its retrospective design and the relatively small sample size from a single institution may limit the generalizability of our findings. Nevertheless, our cohort represents one of the first Latin American series specifically focused on complex airway stenosis managed during the COVID-19 pandemic.

Second, many patients underwent their initial tracheostomy at other healthcare centers during the peak of the pandemic, where emergency conditions often led to non-standardized stoma placement. Furthermore, this study did not explicitly account for the potential confounding effect of patients’ socioeconomic status on the timing of decannulation. While our institution serves an insured population, individual financial constraints or geographic barriers to specialized follow-up could have influenced the duration of MTT use and adherence to the protocol.

Finally, while male sex was identified as a significant predictor of failure, this non-modifiable biological variable likely serves as a surrogate for underlying constitutional differences, such as airway diameter or the intensity of the fibro-inflammatory response. Therefore, its primary value in our model is to refine predictive accuracy for modifiable anatomical and technical factors.

Conclusions

The independent predictors for SDMTT in patients with complex airway stenosis operated during the COVID-19 pandemic are shorter stenosis length, the absence of subglottic involvement and distal granulomas. Remarkably, a standardized surgical tracheostoma emerged as a clinically relevant procedural determinant, which, despite its marginal statistical significance (P=0.055), demonstrated a substantial effect size (aOR: 3.29) and was essential for the model’s high discriminative power (AUROC 0.873). These findings reinforce that success in high-complexity cases (McCaffrey III–IV) is not merely a function of time but is primarily driven by precise anatomical and technical factors.

From a clinical perspective, these results highlight that a standardized tracheostoma acts as a protective factor, while subglottic involvement, extensive longitudinal lesions, and the presence of reactive distal granulomas remain the primary barriers to success in complex airway management.

Acknowledgments

The authors would like to express their sincere gratitude to the Thoracic Surgery Service of the Hospital Nacional Guillermo Almenara Irigoyen. We extend our special thanks to the medical and nursing staff of the surgical center (Operating Room 11) for their unwavering dedication and professionalism in the management of patients with complex airway disease during the COVID-19 pandemic.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-67/rc

Data Sharing Statement: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-67/dss

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-67/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-67/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study protocol was approved by the Ethics Committee of Hospital Nacional Guillermo Almenara Irigoyen (No. 34-2025). Patient confidentiality and anonymity were strictly maintained, and informed consent was waived.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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