Authors' reply.

Sir,

We appreciate the authors for reading the article with great interest and contributing comments to it. Truly, to decannulate a patient on chronic ventilator support involves multifactorial effort.[1] The points raised are valid and were considered as part of management during the weaning process, some of which we have discussed in our article as well.[2] The patient was on high-protein enteral tube feed with all nutritional supplements, and exhibited no nutritional deficiencies. Use of several drugs during the intensive care stay is known, and authors have already written in the manuscript that the patients on prolonged ventilation develop critical-induced polyneuropathy, which could not be completely ruled out in the present case.[2] Mild mitral regurgitation as mentioned was an incidental finding, which was asymptomatic without cardiac decompensation, and the patient was not advised any medical management.[3] Chest X-ray was unremarkable without any cardiac enlargement or signs of vascular engorgement.[1] The patient was in the intensive care unit for a long time and was not able to be decannulated due to pain and retained secretions from the left side of the lung. However, it was only after intervention with anti-tubercular treatment (ATT) that the patient reported feeling of well being, the lymph node mass regressed, bronchial compression relieved and he was able to cough out secretions followed by successful decannulation with the same cardiac condition in situ. To make it even more objective, the evidence of repeat computed tomography after 1 month showed regression of mass compressing upon the left lower lobe bronchus, which pinpointed tubercular mediastinal lymphadenopathy TML as the only possible cause of failed decannulation of tracheostomy at that point of time. Writing all the details is not in the purview of writing of a case report, and the authors attempted to highlight in detail the main factor responsible for difficulty in decannulation of tracheostomy in the present case.

The patient's response to ATT was dramatic and was the additional only cause that resulted in the benefit and recovery of the patient.