Bronchoscopy-guided non-capping decannulation pathway versus conventional capping trial in patients with prolonged tracheostomy: a retrospective comparative cohort study

Background Tracheostomy decannulation is commonly guided by capping trials that assess functional tolerance but do not directly evaluate airway anatomy. Whether a bronchoscopy-guided, non-capping decannulation pathway offers comparable safety with efficiency remains uncertain. Methods We conducted a retrospective comparative cohort study of adults with prolonged tracheostomy (≥ 4 weeks) between 2023 and 2025 at a tertiary center. Patients underwent either a bronchoscopy-guided non-capping pathway ( n = 23) or a conventional capping trial ( n = 58). The primary outcome was decannulation failure, defined as having a tracheostomy tube in place at hospital discharge. Secondary outcomes included time to decannulation, reinsertion within 72 h, infectious complications, and length of stay. Multivariable and sensitivity analyses were performed to address baseline imbalances and rare events. Results Eighty-one patients were analyzed. The non-capping group was older and had lower hemoglobin levels. Decannulation failure occurred in 4.3% of patients managed with the non-capping pathway and 20.7% with conventional capping ( p = 0.141). Reinsertion within 72 h occurred in 1 and 4 patients, respectively. All reinsertion cases ultimately had a tracheostomy tube in place at discharge. A shorter time to successful decannulation (adjusted HR 1.94, 95% CI 1.09–3.48; p = 0.03) and a lower number of infectious episodes ( p = 0.002) were observed in the non-capping pathway. Conclusion In this single-center observational study, the non-capping pathway was associated with a shorter time to decannulation without an apparent increase in short-term safety events. These findings suggest a direct anatomical non-capping pathway may be a feasible alternative, although this requires further validation.