Tracheostomy decannulation in hospitalized patients: physiotherapist's perspective and practiceAbstract
Introduction: Decannulation is crucial in rehabilitation but lacks standardized protocols. In Brazil, there is a conflict between the restrictions imposed by COFFITO Ruling 475/2016 and medical opinions permitting the procedure under medical supervision.
Objectives: To understand physiotherapists' practices and experiences regarding the decannulation process and their perceptions of current regulations.
Methods: An exploratory, qualitative study using online snowball sampling. Physiotherapists independently completed a two-part semistructured questionnaire via Google Forms (covering sociodemographic/professional characteristics and clinical experience with decannulation). Descriptive analysis was performed on demographic, educational, and professional practice data. Content analysis was used for the qualitative data.
Results: Fifty-one physiotherapists participated; the majority were female, aged 23 to 50. Most were from the state of São Paulo and had graduated between 1997 and 2021. The majority reported holding a postgraduate qualification in hospital physiotherapy. Half the sample had over eight years of professional experience, 25% had up to four years, and one-quarter had 12 years or more; 84% reported receiving training in the care of patients with tracheostomies; the majority participate in the decannulation process; about one-third reported that physiotherapists have the autonomy to perform it, and more than half reported feeling comfortable performing the procedure.
Conclusion: Comfort in managing tracheostomies contrasts with the diversity of opinions regarding the legislation. Professionals associate successful decannulation with interprofessional collaboration and motor functionality.
Keywords:
Tracheostomy; Physical therapists; Surveys and questionnaires
Resumo
Introdução: A decanulação é crucial na reabilitação, mas carece de protocolos. No Brasil, há dualidade entre a restrição do Acórdão COFFITO 475/2016 e pareceres médicos que admitem a execução sob supervisão médica.
Objetivos: Conhecer as práticas e experiências dos fisioterapeutas sobre o processo de decanulação e suas percepções sobre a regulamentação vigente.
Métodos: Trata-se de um estudo exploratório e qualitativo com recrutamento snowball via internet. Fisioterapeutas responderam, de forma autônoma e em ambiente virtual, um questionário semiestruturado de duas partes (caracterização sociodemográfica/profissional e vivência clínica na decanulação) no Google Forms. Realizou-se análise descritiva dos dados demográficos e de formação e atuação profissional. Para análise qualitativa, utilizou-se a técnica de análise de conteúdo.
Resultados: Participaram do estudo 51 fisioterapeutas, com predomínio do sexo feminino, idade entre 23 a 50 anos, a maioria do estado de São Paulo, graduados entre 1997 a 2021 e com pós-graduação em fisioterapia hospitalar. Metade da amostra possuía mais de oito anos de tempo de atuação, 25% tinha até quatro anos e um quarto tinha 12 anos ou mais; 84% relataram ter recebido capacitação para o atendimento de pacientes traqueostomizados; a maioria participa do processo de decanulação; cerca de um terço relatou que o fisioterapeuta tem autonomia para efetua-la e mais da metade relatou sentir-se confortável para realizar o procedimento.
Conclusão: O conforto no manejo da traqueostomia contrasta com a heterogeneidade de opiniões sobre a legislação. Os profissionais associam o sucesso da decanulação com a interprofissionalidade e funcionalidade motora.
Palavras-chave:
Traqueostomia; Fisioterapeutas; Inquéritos e questionários
Introduction
Tracheostomy is a common surgical procedure in critically ill patients, involving the insertion of an artificial airway that allows air to pass directly from the trachea to the lungs.1 Compared to prolonged endotracheal intubation, tracheostomy offers several benefits, such as airway stability, easier oral intake, and increased comfort; in some cases, it may also facilitate weaning from mechanical ventilation.2 However, patients undergoing tracheostomy generally present with greater illness severity, prolonged hospital stays, and extended use of mechanical ventilation and sedatives-factors that contribute to the development of intensive care unit (ICU)-acquired muscle weakness.2,3
Following weaning from mechanical ventilation, the tracheostomy tube can be removed. The process of removing the tracheostomy tube is known as decannulation and can be performed in ICUs, hospital wards, and even outpatient settings.4 Decannulation involves the assessment of specific clinical, ventilatory, and swallowing criteria, such as independence from mechanical ventilation, the absence of dysphagia, and the ability to manage secretions.4,5 Successful decannulation is crucial for patient recovery, as it is associated with reduced length of stay, a lower risk of adverse events, and a positive impact on cost reduction.2
Despite its importance, decannulation is still based on clinical judgment, and there is no universally accepted protocol to date.2 The literature points to a wide variation in decannulation success rates (20 to 100%), which reinforces the complexity and multifactorial nature of the process, as well as the need to develop protocols with more objective criteria.6,7
Rehabilitation with a multidisciplinary team has proven beneficial for better decannulation outcomes. In a study by Zivi et al.,8 sixty-six patients with severe brain injury were divided into an early rehabilitation group (n = 40) and a late rehabilitation group (n = 26). As a result, patients who received the early rehabilitation protocol were decannulated sooner and spent less time in the ICU. In another study, Mah et al.9 observed that the implementation of a multidisciplinary post-tracheostomy care bundle significantly improved decannulation success rates when comparing groups with and without the intervention.
Among the professionals involved, the physiotherapist plays an important role, being responsible for measuring vital ventilatory and musculoskeletal parameters, such as peak cough flow, general muscle strength, especially respiratory and appendicular strength, secretion management, functionality, as well as discussing daily care with the team and the patient.10
Regarding regulations in Brazil, Ruling No. 475,11 published in 2016, addresses the role of the physiotherapist in performing the procedure of decannulation and/or tracheal tube exchange. The document includes an opinion issued by the Brazilian Association of Cardiorespiratory and Intensive Care Physiotherapy (ASSOBRAFIR), stating that the reinsertion, exchange, or removal of a tracheostomy tube is a procedure involving risks-potentially requiring orotracheal intubation, pharmacological therapy, or surgical intervention. Such measures are not included in the scope of physiotherapeutic procedures. Consequently, ASSOBRAFIR holds the position that performing decannulation and tracheostomy tube exchange does not fall within the physiotherapist's scope of practice. This opinion was unanimously approved by the council members of the Federal Council of Physiotherapy and Occupational Therapy during its 265th Ordinary Plenary Session.
On the other hand, there are no specific regulations from the Federal Council of Medicine regarding decannulation. An opinion issued by the Regional Council of Medicine of Paraná (CRM-PR)12 was released in response to an inquiry submitted to the Council, as follows:
Is the changing of tracheostomy tubes or decannulation considered a medical act? Rationale: Some Regional Nursing Councils (Corens) have issued opinions supporting the performance of tracheostomy tube changes and decannulation by nursing professionals — such as Coren-SE Opinion No. 3/2018. Many chronic patients require monthly tube changes; the answer to this question would determine practice in hospitals, long-term care institutions, and home care settings.
The conclusion of the opinion highlights that the CRM-PR recommends that the exchange or removal of a recently placed tracheostomy cannula may be performed by a nursing or physiotherapy professional, provided there is always in-person supervision by a physician due to potential respiratory complications that could be life-threatening. The exchange or removal of a tracheostomy cannula — where the stoma tract is already established — may be performed by a nurse or physiotherapist, provided the plan has been discussed with the attending physician.12 A discrepancy is noted between Ruling No. 475 of the Federal Council of Physiotherapy, published in 2016,11 and the 2018 CRM-PR opinion.12 Similarly, practices may vary depending on the protocols adopted by the institutions.
Although professional autonomy and legal competencies are supported by current resolutions, bedside clinical practice is often shaped by diverse institutional cultures. Thus, understanding the perceptions and routines of these professionals is warranted by the need to identify any heterogeneity in clinical approaches, comprehend the challenges involved in the practical application of regulations, and, fundamentally, provide a basis for establishing protocols that leverage physiotherapeutic expertise during the patient's transition to a natural airway.
This study aims to understand the current perceptions and practices of physiotherapists working in hospital settings with tracheostomized patients. More specifically, to understand the role of the physiotherapist in the decannulation process. It should be noted that this study does not question the legitimacy of current regulations. The main purpose is to understand the practices and experiences of physiotherapists regarding the decannulation process and their perceptions of the current regulations.
Methods
This project was approved by the Ethics Committee of the Federal University of São Paulo (protocol number 5.761.862; CAAE: 61272222.5.0000.5505). It is an exploratory, descriptive, and qualitative study. This type of study consisted of a semi-structured questionnaire, administered to research participants who answered the questions on their own, characterizing information through self-reported data.
Statistical analysis
A descriptive analysis of demographic data and information regarding professional training and practice was conducted; continuous variables were expressed as mean and standard deviation, while categorical variables were presented as numbers and proportions. The qualitative approach enables an analysis of relationships, processes, and phenomena, wherein meaning itself constitutes the primary concept and object of investigation.13 Thus, content analysis was employed for the qualitative analysis to examine hypotheses and research questions.
Recruitment
Physiotherapists were invited to participate in the study via invitations sent through email and social media. A "snowball" method was used to facilitate participant recruitment.
This is a non-probability convenience sampling technique in which selected individuals invite new participants from their networks of friends and acquaintances. The only requirement was that the physiotherapists worked in a hospital setting and had frequent contact with patients with tracheostomies. However, it is important to acknowledge that this technique presents a methodological limitation and a potential for selection bias. Since participants are interconnected or share social and professional networks, the final sample may not be representative of the broader population, tending instead to cluster individuals with similar characteristics or perspectives.14,15
Procedures
After reading the invitation, participants indicated their agreement with the informed consent form, which was made available electronically. Subsequently, they completed the questionnaire via a link to a Google Forms platform. The estimated time for completing the questionnaire was a maximum of ten minutes. To refine this estimate, a pilot study was conducted to standardize the completion time. During the data collection period, researchers re-sent the invitation monthly to reach the target sample of potential participants who had not yet taken part.
Data collection concluded upon reaching theoretical saturation. The collection period spanned from November 2022 to March 2023. Saturation-based sampling is defined by the decision to stop recruiting new participants, based on the researcher's ongoing analysis of the collected material. A combination of factors leads to a saturation point, where new data would merely repeat existing information and contribute little to the research's objectives or theoretical development.16
Data collection instrument
The questionnaire was divided into two parts, both comprising a mix of objective and open-ended (or descriptive) questions. The first part consisted of 19 questions regarding the physiotherapist's involvement in the decannulation process for hospitalized patients, while the second part — containing seven questions — covered the physiotherapist's academic and professional background. To address the study's objective, open-ended questions 13, 17, and 19 were analyzed; they were titled, respectively: "Describe your perception regarding the performance of the decannulation procedure," "Do you think patients with higher levels of mobility and functionality are more likely to succeed in decannulation? Describe your perception of this," and "Describe your perception regarding the court ruling presented above; do you agree or disagree, and what is the reason for your opinion?" Participant responses were analyzed by two researchers experienced in qualitative analysis to identify thematic categories and units of analysis, thereby gaining insight into the participants' perceptions.17
Results
Fifty-one physical therapists participated in the study. There was a predominance of women, aged between 23 and 50 years. Most participants were from the state of São Paulo, followed by Minas Gerais, Rondônia, Paraná, Sergipe, and Pará (Table 1).
Participants graduated between 1997 and 2021. The majority of the sample reported having postgraduate training in hospital-based physical therapy (residency, specialization, or advanced training programs). The median professional experience indicated that half of the sample had more than eight years of practice, one-quarter had up to four years, and one-quarter had 12 years or more. Among the participants, 84% reported having received some form of training for the care of patients with tracheostomies (Table 1).
Characterization of professional practice
All participants reported having clinical experience with tracheostomized patients, and the majority participate in the decannulation process. About one-third reported that the physical therapist has the autonomy to perform decannulation, and more than half feel comfortable performing it. Almost all reported that tracheostomized patients receive physical therapy care, and onequarter reported that their institution lacks a multidisciplinary team for performing decannulation (Table 2).
Table 3 presents the main professional practices and experiences related to the decannulation procedure. The following points stand out: out of 49 responses obtained, 37 indicated the participation of a speech-language pathologist in the decannulation process. The states that reported the participation of speech-language pathologists were: São Paulo (n = 29), Rondônia (n = 4), Minas Gerais (n = 2), Sergipe (n = 1), and Pará (n = 1). The use of a decannulation protocol was reported by 14 professionals. The majority of professionals reported having experienced complications following tracheostomy decannulation.
Qualitative analysis – physiotherapists' perceptions regarding decannulation
Questions 13, 17, and 19 of the form provided in-depth information on physiotherapists' perceptions of the decannulation process, highlighting the following topics respectively: perception of the physiotherapist's role in the decannulation process; the relationship between mobility and functionality levels and decannulation outcomes; and Ruling 475. A qualitative analysis of the responses to each question was conducted, yielding four thematic categories: "classification of the procedure," "role of the multidisciplinary team," "patient conditions and decannulation success," and "perception regarding Ruling 475."
The perceptions of the participants who answered the questions are described below, along with details regarding their respective units of analysis. To ensure confidentiality and anonymity, the subjects are identified by the letter "P" and distinguished by numbers ranging from 1 to 51, based on the order in which they responded.
In the "procedure classification" category, physiotherapists classify the decannulation procedure as a simple procedure and an easy-to-manage process. This can be seen in the statements below that illustrate the category:
It's a simple process, but I haven't done it in so many years that I feel insecure about doing it today. (P44)
I have worked in institutions where only the physiotherapist performed the decannulation process, and I found it very complicated; it's a process that can be lengthy and requires experience. When there is a multidisciplinary team, especially the presence of a speech therapist, it makes the process a little simpler. Regarding removing the tracheostomy, it's quite simple, but first the procedure needs to be properly indicated. (P38)
However, despite considering it a simple procedure, they feel safer when the doctor is present during the procedure:
In an environment with easy access to the doctor, after performing occlusion tests to verify airway patency, with the appropriate cannula size for performing a tracheostomy, I see no difficulty in performing the decannulation. (P45)
In the second category, the professionals described that although it is a simple procedure, the involvement of a multidisciplinary team and a medical professional is necessary to intervene in case of possible complications, such as "risk of causing fistulas or false passage errors":
The decannulation procedure should involve multidisciplinary and interdisciplinary participation, where professionals must pay attention to the knowledge of each area to ensure patient safety. (P18)
Tracheostomy weaning and the subsequent decannulation depend on numerous factors and can be a complex process; hence the importance of a multidisciplinary team approach. (P51)
In the third category produced by the analysis, participants indicated that higher levels of mobility and functionality are more likely to lead to successful decannulation due to the level of consciousness, muscle strength, and autonomy and independence.
I realize that patients who maintain a good level of physical activity are the easiest to decannulate; generally, bedridden patients are affected by other issues that delay the decannulation process (pressure injuries that end up becoming infected, decreased cardiorespiratory fitness due to muscle weakness). (P5)
Patients with greater mobility consequently have better muscle strength values, as well as greater oscillation in lung volumes and capacities. (P45)
Patients who are more independent and tolerate more exercise end up having a smoother tracheostomy removal. (P19)
However, for three of the study participants, other factors such as the reason for placement, the duration of intubation, the tracheostomy technique, as well as mobility and functionality, may influence the success of decannulation:
It depends on the reason the patient required the prosthesis, as there are cases involving fully functional patients with preserved mobility who do not present with clinical conditions such as tracheal stenosis resulting from trauma or infection, as well as cases of neurodegenerative disease where there is no possibility of regaining functionality or achieving decannulation. (P13)
(…) but decannulation also depends on how long the patient remained intubated. (P36)
(…) but it is necessary to consider whether the patient will be able to swallow, cough, and breathe adequately; that is, to consider the musculature that facilitates all these movements. It is of no use for the patient to have a good level of upper and lower limb functionality if they cannot coordinate breathing with speech. (P38)
Finally, the fourth category of analysis presented the participants' opinions regarding COFFITO Ruling 475/2016. Perceptions varied, as some participants stated they agreed with it (n = 24), others disagreed (n = 9), and others partially agreed (n = 3), as illustrated by the following statements:
I agree, due to a lack of theoretical and practical training. It's not something taught or practiced in undergraduate studies, and because of the risks of complications that exist in the decannulation process. (P30)
I agree! Decannulation is a medical procedure; if any complication arises during the procedure, the person performing it must have the capacity and skills to reverse the problem. (P7)
I disagree; we manipulate the airway just as the other professionals involved do. We should participate in all the processes. (P9)
I partially agree. I believe that since we have the technical skills to perform extubation, we can also safely perform decannulation. Tracheostomy tube changes should be performed by the physician, with the physiotherapist providing assistance; this is because such changes are often necessitated by obstruction or prolonged use, and complications may arise that the physiotherapist lacks the technical expertise to resolve. (P36)
I partly agree, but in an ICU setting — where we have easy access to a physician — we could remove or replace the tracheostomy tube when necessary. (P35)
Discussion
This study aimed to explore the experiences and clinical routines of physical therapists regarding the decannulation process. Furthermore, to describe these professionals' perceptions of the current legislation, Ruling 475/2016,11 which addresses the role of the physiotherapist in performing the decannulation and/or tracheal cannula exchange procedure.
The sample consisted mainly of female physiotherapists working in the state of São Paulo, with training in hospital physiotherapy. Only one-quarter of the sample had four years or less of experience, and the majority reported having training to manage patients with tracheostomies, as well as having completed postgraduate studies in hospital-based physical therapy. These characteristics are similar to those found in the study by Shiwa et al.,18 which surveyed 2,323 physical therapists in the state of São Paulo, 80% of whom were women. In this survey, 283 (17.9%) reported working in the cardiorespiratory area, 475 (20.4%) stated they worked in public and private hospitals, and 1,577 (66.7%) completed postgraduate specialization courses.
Clinical experience with tracheostomized patients and participation in the decannulation process were reported by almost all participants. Despite current regulations, one-third of the sample stated that they perform the decannulation procedure as part of their routine work. Furthermore, more than half of the sample reported feeling comfortable performing decannulation. A portion of the professionals (15.7%) reported not having received training in the management of patients with tracheostomies.
No Brazilian studies describing the practices and perceptions of physical therapists regarding the decannulation process were identified. A study from Saudi Arabia19 evaluated clinical practices, self-confidence, and perceived barriers regarding tracheostomy care among respiratory therapists. A total of 1,012 professionals participated in the survey. Although respiratory therapists demonstrated knowledge of tracheostomy care, variations in clinical practices and confidence levels were observed, primarily due to the absence of standardized protocols and formal training.19 The authors suggest that implementing educational initiatives and developing protocols could improve the quality of tracheostomy care and patient outcomes. The heterogeneity of practices and experiences reported in this study reinforces the need for educational initiatives, whether in the academic field, in the continuing education of professionals, or through the publication of consensus statements guided by representative institutions.19
The absence of a multidisciplinary team for decannulation was reported by one-quarter of the study sample. The lack of speech-language pathologist involvement in decannulation was reported by 14 participants. The use of institutional decannulation protocols was reported by slightly more than one-quarter of the participants (27.5%). Current literature suggests that the involvement of a multidisciplinary team appears to have positive effects on decannulation. A systematic review published by Ninan et al.20 concluded that tracheostomized patients receiving care from a dedicated interprofessional team showed improvements in various clinical outcomes, such as safety, the likelihood of speaking valve placement, time to decannulation, and length of hospital stay.
In 2023, Papi et al.21 published a study on the role of physiotherapists in the decannulation process for tracheostomized neurological patients in the neurological ICU. The authors demonstrated that the use of a protocol involving respiratory physiotherapists in collaboration with speech-language pathologists led to higher decannulation success rates. These studies reinforce the importance of a multidisciplinary team in achieving better outcomes. Data from our study revealed the absence of speech-language pathologists — professionals essential to the decannulation process — in some reports.
In the present study, 29 out of 39 participants from the state of São Paulo reported the involvement of a speech-language pathologist in the decannulation process. Despite the state being considered developed, it is assumed that there is still a shortage of these professionals in hospitals. According to Costa et al.,22 the basic speech-language pathology assessment includes level of consciousness, breathing (plastic or metal tube, cuff inflated or not, whether the patient maintains a breathing pattern when the cuff is deflated), appearance of tracheal secretions, phonation, cough, and swallowing. For the clinical assessment of swallowing in tracheostomized subjects, the Blue Dye Test may be used; this procedure involves coloring saliva or food with blue dye to detect aspiration in tracheostomized individuals. Most decannulation protocols include these assessment items. The participation of this professional is, therefore, essential for achieving better decannulation outcomes.
According to Singh et al.,6 after verifying the integrity of the sensorium, the identification of the patient's readiness for decannulation is based primarily on the assessment of cough and swallowing.
The participants' perceptions were analyzed, and their accounts offered interesting insights for reflecting on the physiotherapist's role in the decannulation process: physiotherapists classify it as a simple procedure that is easy to perform. However, despite its simplicity, the involvement of a multidisciplinary team and a physician is necessary to intervene in the event of potential complications, such as the "risk of causing fistulas or creating a false tract." The reports reinforce the importance of the multidisciplinary team and the experience of the study participants, which focuses not only on performing a procedure, but on the context; that is, on possible complications and the impact on patient prognosis. According to Epstein,23 late complications of tracheostomy include granulation tissue formation, tracheal stenosis, tracheomalacia, innominate artery-trachea fistula, tracheoesophageal fistula, ventilator-associated pneumonia, and aspiration. The clinical significance of these complications is considerable, given that their manifestations range from minimal symptoms to the inability to extubate (tracheal stenosis) and life-threatening hemorrhage (innominate artery-trachea fistula).
Participants indicated that patients with higher levels of mobility and functionality are more likely to succeed in decannulation due to their level of consciousness, muscle strength, autonomy, and independence. For some of the study participants, factors such as the reason for tracheostomy placement, duration of intubation, and the tracheostomy technique — in addition to mobility and functionality — may also influence the success of decannulation.
Lima et al.24 conducted a retrospective analysis of 143 patients who had undergone tracheostomy and found that muscle strength assessed on the day of decannulation was greater in the group that was successfully decannulated. In a narrative review of patients on prolonged mechanical ventilation, which includes a large proportion of hospitalized tracheostomized patients, the authors report that evidence for the benefits of early mobilization and physiotherapy has progressed over the past 15 years with randomized clinical trials, systematic reviews, and recommendations, including mobilization protocols and electrical muscle stimulation.25 Another study evaluated the effect of increasing physical therapy sessions for patients undergoing tracheostomy weaning; results showed that a 50% increase in staffing levels led to an increase in physical therapy rehabilitation sessions from two to four times per week.26 The duration of tracheostomy use was reduced by 11 days, and the length of hospital stay by 19 days. Functional status at discharge also improved: 33% of patients were able to mobilize at discharge with standard staffing levels, whereas 77% were able to do so with increased staffing.26
Perceptions regarding COFFITO Ruling 475/201611 varied among the participants. Those in agreement highlighted the issue of potential complications related to decannulation and the need for medical intervention and greater educational support on the subject during undergraduate studies. The disagreement cited the physiotherapist's expertise in managing artificial airways as an argument. Generally, this expertise is more common among physiotherapists working in intensive care or emergency and urgent care settings. Partial agreement takes into account a different procedure — specifically, cannula replacement — which is usually performed by physicians, particularly for patients dependent on mechanical ventilation, as noted in the previously cited CRM-PR opinion.12 Another consideration was the location, in this case the ICU, where access to a doctor can be almost immediate in case of complications. All the arguments reflect clinical experience and provide material for important reflections on the subject.
No similar studies were identified on physiotherapists' perception of the decannulation process and current legislation. The insights collected provide interesting information that demonstrates the knowledge and clinical experience of the participants, as well as interesting arguments about the different opinions on the COFFITO Ruling 475/2016.11 Furthermore, this study reinforces the need for investments in continuing education, promotion of formal training since graduation and the development of consensus directed by representative institutions. Such measures are crucial to standardize care practices, mitigate late complications and length of hospital stay, ensuring greater patient safety and technical-legal support for the physiotherapist.
However, due to the limitation resulting from the concentration of the sample in the state of São Paulo, the need for future investigations of a national scope is evident. Such studies will be crucial for characterizing the situation in regions with lower densities of subspecialties and hospital resources.
Conclusion
This study provided an unprecedented overview of the experiences, routines, and perceptions of physiotherapists — mostly working in the State of São Paulo and with solid hospital training — regarding the decannulation process and COFFITO Ruling 475/2016. The findings reveal a scenario of transition and duality: although most professionals have specific training and feel comfortable managing tracheostomized patients, opinions on current legislation are heterogeneous, reflecting the technical complexity and clinical responsibility of the procedure in the face of the risk of serious complications.
It became evident that successful decannulation transcends the mere execution of a specific technique, being intrinsically linked to two fundamental pillars addressed in this research: the interprofessional approach and patient functionality. The professionals' perception of the relationship between improved levels of mobility and peripheral muscle strength and the success of decannulation was observed, reinforcing the relevance of physiotherapy in tracheostomy weaning; however, the reported lack of standardized institutional protocols and essential professionals — such as speech-language pathologists — highlights the urgent need to establish dedicated multiprofessional teams within hospitals.
Acknowledgments
To all the professionals who generously collaborated on the research, expressing their opinions and perceptions and sharing their experiences and knowledge.
Data availability statement
Data are available upon reasonable request.
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