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VAN Hooff RJ, Lindelof M, Ghaziani E, Hørmann Thomsen T, Kruuse C, Gunge Riberholt C, Rath C. RETROSPECTIVE ANALYSIS OF PATIENTS WITH IMMEDIATE DECANNULATION IN SEVERE ACQUIRED BRAIN INJURY (RAPID-SABI). JOURNAL OF REHABILITATION MEDICINE. CLINICAL COMMUNICATIONS 2025; 8:42068. [PMID: 39935836 PMCID: PMC11812269 DOI: 10.2340/jrm-cc.v8.42068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2024] [Accepted: 01/13/2025] [Indexed: 02/13/2025]
Abstract
Objective To examine an early decannulation protocol in adult severe acquired brain injury (SABI) patients. Design Retrospective, observational cohort study. Subjects/patients Tracheotomized SABI patients ≥ 18 years admitted to a neurorehabilitation unit. Methods Primary outcome measure was difference in survival rate within first year of discharge. Secondary outcome measures were respiratory infections treated with antibiotics, rate of re-cannulation, time from admission to decannulation, length of stay, difference in rate of re-admission due to pneumonia within first year of discharge and difference in rate of tracheal tube dependency within first year of discharge. Results No statistical significance in survival rate within the first 12 months from discharge was found. Median time from admission to decannulation was 32 days (interquartile range [IQR] 14-61) vs 9 days (IQR 0-13) in the control and intervention group, respectively (p < 0.0003). Median length of stay was 66 days (IQR 54-92) in the control group vs 60 (IQR 48-75) days in the intervention group (p = 0.168). Conclusion A new early decannulation protocol omitting evaluation of tolerance to tracheostomy tube capping and fiberoptic endoscopic evaluation of swallowing was non-inferior to previous procedures in survival rate within first year of discharge. The early decannulation protocol allowed for significantly earlier decannulation.
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Affiliation(s)
- Robbert-Jan VAN Hooff
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Mette Lindelof
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Emma Ghaziani
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Trine Hørmann Thomsen
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Christina Kruuse
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Neurology, Neurovascular Research Unit, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Christian Gunge Riberholt
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Charlotte Rath
- Department of Brain and Spinal Cord Injury, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Rinawati W, Machin A, Aryati A. The Role of Complete Blood Count-Derived Inflammatory Biomarkers as Predictors of Infection After Acute Ischemic Stroke: A Single-Center Retrospective Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:2076. [PMID: 39768955 PMCID: PMC11679367 DOI: 10.3390/medicina60122076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2024] [Revised: 12/10/2024] [Accepted: 12/13/2024] [Indexed: 01/11/2025]
Abstract
Background and Objectives: Although a wide range of hematological parameters are used as blood-based inflammatory biomarkers, the role of complete blood count-derived inflammatory biomarkers in infection after acute ischemic stroke (AIS) is modest. Therefore, this study aimed to explore complete blood count-derived inflammatory biomarkers as predictors of infection after AIS. Materials and Methods: A single-center retrospective cross-sectional study was carried out at the National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Jakarta, Indonesia, between 1 October 2023, and 31 March 2024, using medical records of hospitalized first-ever ischemic stroke patients who underwent a complete blood count within 24 h of admission. Based on complete blood count-derived inflammatory biomarkers, this study included absolute numbers and related ratios or indices. Results: In total, 163 patients met the study criteria. The diagnosis of infection after AIS was established using reliable clinical symptoms and/or guidelines of the disease. According to the status of infection after AIS, the subjects were categorized into two groups, including 24 patients in the infection group and 139 patients in the non-infection group. Biomarkers that had significant accuracy (higher sensitivity and specificity, respectively) in predicting infection were the leukocyte count (LC; 70.8%, 74.1%, p < 0.001), absolute neutrophil count (ANC; 66.7%, 79.9%, p < 0.001), absolute monocyte count (AMC; 75.0%, 63.3%, p = 0.001), neutrophil to lymphocyte ratio (NLR; 62.5%, 71.9%, p = 0.003), derivative NLR (dNLR; 50.0%, 78.4%, p = 0.003), monocyte-granulocyte to lymphocyte ratio (MGLR; 62.5%, 73.0%, p = 0.003), systemic inflammatory response index (SIRI; 62.5%, 79.0%, p = 0.001), and systemic immune inflammation index (SII; 87.5%, 44.0%, p = 0.012) with chances of 74.4%, 75.4%, 71.0%, 69.0%, 68.7%, 69.3%, 73.4%, and 66.2%, respectively. Conclusions: Considering the overall ROC curve used to evaluate the complete blood count-derived inflammatory biomarkers, ANC has a better ability to predict infection in AIS patients, as denoted by the highest AUC, suggesting a 75.4% chance of correctly discriminating patients with infection after stroke.
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Affiliation(s)
- Weny Rinawati
- Doctoral Program of Medical Science, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia;
- Laboratory and Blood Bank, Department of Clinical Pathology, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Jakarta 13630, Indonesia
| | - Abdulloh Machin
- Department of Neurology, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
- Airlangga University Hospital, Surabaya 60115, Indonesia
- Dr. Soetomo General Academic Hospital, Surabaya 60132, Indonesia
| | - Aryati Aryati
- Dr. Soetomo General Academic Hospital, Surabaya 60132, Indonesia
- Department of Clinical Pathology, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
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Gallice T, Cugy E, Cugy D, Laimay J, Branchard O, Germain C, Dehail P, Cuny E, Engelhardt J. Effect of a Speaking Valve on Nasal Airflow During Tracheostomy Weaning: A Case Series. Neurocrit Care 2024; 41:1100-1105. [PMID: 38506973 PMCID: PMC11599294 DOI: 10.1007/s12028-024-01966-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Affiliation(s)
- Thomas Gallice
- Aging, Chronic Diseases, Technology, Disability, and Environment Team, Bordeaux Research Center for Population Health, Bordeaux Segalen University, UMR_S 1219, 33000, Bordeaux, France.
- Swallowing Evaluation Unit, Physical and Rehabilitation Medicine Unit, Tastet-Girard Hospital, Bordeaux University Hospital, 33000, Bordeaux, France.
- Neurosurgery Unit B, Pellegrin Hospital, Bordeaux University Hospital, 33000, Bordeaux, France.
- Neurological Intensive Care Unit, Pellegrin Hospital, Bordeaux University Hospital, 33000, Bordeaux, France.
| | - Emmanuelle Cugy
- Swallowing Evaluation Unit, Physical and Rehabilitation Medicine Unit, Tastet-Girard Hospital, Bordeaux University Hospital, 33000, Bordeaux, France
- Physical and Rehabilitation Medicine Unit, Arcachon Hospital, 33260, La Teste de Buch, France
- Physical and Rehabilitation Medicine Unit, Tastet-Girard Hospital, Bordeaux University Hospital, 33000, Bordeaux, France
| | - Didier Cugy
- Sleep Medicine Unit, Pellegrin Hospital, Bordeaux University Hospital, 33000, Bordeaux, France
| | - Julie Laimay
- Neurosurgery Unit B, Pellegrin Hospital, Bordeaux University Hospital, 33000, Bordeaux, France
- Neurological Intensive Care Unit, Pellegrin Hospital, Bordeaux University Hospital, 33000, Bordeaux, France
| | - Olivier Branchard
- Neurosurgery Unit B, Pellegrin Hospital, Bordeaux University Hospital, 33000, Bordeaux, France
| | - Christine Germain
- Medical Information Unit, Pellegrin Hospital, Bordeaux University Hospital, 33000, Bordeaux, France
| | - Patrick Dehail
- Aging, Chronic Diseases, Technology, Disability, and Environment Team, Bordeaux Research Center for Population Health, Bordeaux Segalen University, UMR_S 1219, 33000, Bordeaux, France
- Physical and Rehabilitation Medicine Unit, Tastet-Girard Hospital, Bordeaux University Hospital, 33000, Bordeaux, France
| | - Emmanuel Cuny
- Neurosurgery Unit B, Pellegrin Hospital, Bordeaux University Hospital, 33000, Bordeaux, France
- Neurodegenerative Diseases Institute, Bordeaux University, 33000, Bordeaux, France
- CNRS, Neurodegenerative Diseases Institute, 33000, Bordeaux, France
| | - Julien Engelhardt
- Neurosurgery Unit B, Pellegrin Hospital, Bordeaux University Hospital, 33000, Bordeaux, France
- Polytechnic Institute of Bordeaux, Centre National de la Recherche Scientifique, Institut de Mathématiques de Bordeaux, Bordeaux University, 33400, Bordeaux, France
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Rinawati W, Machin A, Aryati A. A Single-Center Retrospective Study of Bacterial Infections After Acute Ischemic Stroke: The Prevalence Before and During the COVID-19 Pandemic. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1755. [PMID: 39596940 PMCID: PMC11596060 DOI: 10.3390/medicina60111755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2024] [Revised: 10/14/2024] [Accepted: 10/21/2024] [Indexed: 11/29/2024]
Abstract
Background and Objectives: The management of ischemic stroke involves care that is integrated and comprehensive, including the prevention of infection complications. This study aimed to investigate the prevalence and profile of bacterial infections after acute ischemic stroke both before and during the coronavirus disease 2019 (COVID-19) pandemic. Materials and Methods: A retrospective cross-sectional study examined the medical records of hospitalized acute ischemic stroke patients who had microbiological cultures taken at the National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Jakarta, Indonesia, from 1 January 2018 to 31 December 2021. The percentage of positive bacterial growth in the microbiological cultures was used to determine the prevalence of bacterial infection after acute ischemic stroke. Results: A total of 519 patients met the study criteria, including 48 and 471 patients with infections before and during the COVID-19 pandemic. The prevalence of bacterial infection after acute ischemic stroke was 17.9%. There were significant differences in the prevalence of bacterial infection after acute ischemic stroke before and during the COVID-19 pandemic (87.5% vs. 10.8%). Staphylococcus sp. and Klebsiella sp. were the most frequently observed. The risk factors that influenced bacterial infection after acute ischemic stroke were intensive care stay (OR 0.22; 95%CI 0.13-0.39, p-value < 0.001), sepsis (OR 1.99; 95%CI 1.12-3.53, p-value = 0.019), COVID-19 infection (OR 4.81; 95%CI 2.64-8.76, p-value < 0.001), the use of steroids (OR 0.31; 95%CI 0.14-0.67, p-value = 0.003), and the use of TPN (OR 0.34; 95%CI 0.13-0.86, p-value = 0.022). Conclusions: Following the start of the COVID-19 pandemic, there was a decrease in the prevalence of bacterial infections after AIS. Patients with bacterial infections had different profiles before and during the COVID-19 pandemic.
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Affiliation(s)
- Weny Rinawati
- Doctoral Program of Medical Science, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia;
- Department of Clinical Pathology, Laboratory and Blood Bank, National Brain Center Hospital Prof. Dr. dr. Mahar Mardjono, Jakarta 13630, Indonesia
| | - Abdulloh Machin
- Department of Neurology, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
- Airlangga University Hospital, Surabaya 60132, Indonesia
- Dr. Soetomo General Academic Hospital, Surabaya 60132, Indonesia
| | - Aryati Aryati
- Dr. Soetomo General Academic Hospital, Surabaya 60132, Indonesia
- Department of Clinical Pathology, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia
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Draghi F, Pancani S, De Nisco A, Romoli AM, Maccanti D, Burali R, Grippo A, Macchi C, Cecchi F, Hakiki B. Implications of the Consciousness State on Decannulation in Patients With a Prolonged Disorder of Consciousness. Arch Phys Med Rehabil 2024; 105:1691-1699. [PMID: 38734048 DOI: 10.1016/j.apmr.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 05/02/2024] [Accepted: 05/02/2024] [Indexed: 05/13/2024]
Abstract
OBJECTIVE To prospectively investigate the evolution of the consciousness state and the cannula-weaning progression in patients with prolonged disorders of consciousness. DESIGN Nonconcurrent cohort study. SETTING A rehabilitation unit. PARTICIPANTS Adult patients (N=144) with prolonged disorders of consciousness after a severe acquired brain injury admitted between June 2020 and September 2022. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Consciousness state was assessed by repeated Coma Recovery Scale-Revised (CRS-R) questionnaire administration at admission and weekly afterward. The dates of the first improvement of consciousness state and the achievement of decannulation were recorded. Decannulation followed an internal protocol of multiprofessional rehabilitation. RESULTS One hundred forty-four patients were included: age, 69 years; 64 (44.4%) with hemorrhagic etiology; time post onset, 40 days, CRS-R score at admission, 9, median length of stay, 90 days. Seventy-three (50.7%) patients were decannulated. They showed a significantly higher CRS-R (P<.001) and states of consciousness (P<.001) at admission, at the first improvement of the consciousness state (P=.003), and at discharge (P<.001); a lower severity in the Cumulative Illness Rating Scale at admission (P=.01); and a lower rate of pulmonary infections with recurrence (P=.021), compared with nondecannulated patients. Almost all decannulated patients (97.3%) improved their consciousness before decannulation. Consciousness states at decannulation were as follows: unresponsive wakefulness syndrome, 0 (0%); minimally conscious state (MCS) minus, 4 (5.5%); MCS plus, 7 (9.6%); and emergence from MCS, 62 (84.9%). Kaplan-Meier analysis showed a significant divergence between the curves with a higher probability of decannulation in patients who improved consciousness (P<.001). CONCLUSIONS This study showed that the presence of signs of consciousness, even subtle, is a necessary condition for decannulation, suggesting that consciousness may influence some of the components implied in the decannulation process.
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Affiliation(s)
- Francesca Draghi
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Silvia Pancani
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence.
| | - Agnese De Nisco
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Anna Maria Romoli
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Daniela Maccanti
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Rachele Burali
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Antonello Grippo
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence
| | - Claudio Macchi
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Francesca Cecchi
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Bahia Hakiki
- Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Don Carlo Gnocchi Onlus, Florence; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Gallice T, Cugy E, Branchard O, Dehail P, Moucheboeuf G. Predictive Factors for Successful Decannulation in Patients with Tracheostomies and Brain Injuries: A Systematic Review. Dysphagia 2024; 39:552-572. [PMID: 38189928 PMCID: PMC11239766 DOI: 10.1007/s00455-023-10646-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 11/14/2023] [Indexed: 01/09/2024]
Abstract
Neurological patients frequently have disorders of consciousness, swallowing disorders, or neurological states that are incompatible with extubation. Therefore, they frequently require tracheostomies during their stay in an intensive care unit. After the acute phase, tracheostomy weaning and decannulation are generally expected to promote rehabilitation. However, few reliable predictive factors (PFs) for decannulation have been identified in this patient population. We sought to identify PFs that may be used during tracheostomy weaning and decannulation in patients with brain injuries. We conducted a systematic review of the literature regarding potential PFs for decannulation; searches were performed on 16 March 2021 and 1 June 2022. The following databases were searched: MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, PEDro, OPENGREY, OPENSIGLE, Science Direct, CLINICAL TRIALS and CENTRAL. We searched for all article types, except systematic reviews, meta-analyses, abstracts, and position articles. Retrieved articles were published in English or French, with no date restriction. In total, 1433 articles were identified; 26 of these were eligible for inclusion in the review. PFs for successful decannulation in patients with acquired brain injuries (ABIs) included high neurological status, traumatic brain injuries rather than stroke or anoxic brain lesions, younger age, effective swallowing, an effective cough, and the absence of pulmonary infections. Secondary PFs included early tracheostomy, supratentorial lesions, the absence of critical illness polyneuropathy/myopathy, and the absence of tracheal lesions. To our knowledge, this is the first systematic review to identify PFs for decannulation in patients with ABIs. These PFs may be used by clinicians during tracheostomy weaning.
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Affiliation(s)
- Thomas Gallice
- Neurosurgery Unit B, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France.
- Neurological ICU, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France.
- Physical and Rehabilitation Medicine Unit, Swallowing Evaluation Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France.
- Bordeaux Research Center for Population Health (BPH), Team: ACTIVE, University Bordeaux Segalen, UMR_S 1219, 33000, Bordeaux, France.
| | - Emmanuelle Cugy
- Physical and Rehabilitation Medicine Unit, Swallowing Evaluation Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
- Physical and Rehabilitation Medicine Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
- Physical and Rehabilitation Medicine Unit, Arcachon Hospital, 33260, La Teste de Buch, France
| | - Olivier Branchard
- Neurosurgery Unit B, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Patrick Dehail
- Bordeaux Research Center for Population Health (BPH), Team: ACTIVE, University Bordeaux Segalen, UMR_S 1219, 33000, Bordeaux, France
- Physical and Rehabilitation Medicine Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
| | - Geoffroy Moucheboeuf
- Neurological ICU, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
- Physical and Rehabilitation Medicine Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
- Traumatic and Surgical ICU, , Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
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Eskildsen SJ, Wessel I, Poulsen I, Hansen CA, Curtis DJ. Rehabilitative intervention for successful decannulation in adult patients with acquired brain injury and tracheostomy: a systematic review. Disabil Rehabil 2024; 46:2464-2476. [PMID: 37449332 DOI: 10.1080/09638288.2023.2233437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/22/2023] [Accepted: 07/01/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE Tracheostomy and dysphagia are independently associated with increased complications and poorer functional outcome after acquired brain injury (ABI). The aim of this study was to identify and evaluate rehabilitation to restore functional swallowing ability and respiratory capacity during tracheal tube weaning. MATERIALS AND METHODS The review was conducted according to PRISMA guidelines. Any study design with adult patients with ABI and tracheostomy was eligible. The primary outcome was decannulation. RESULTS A total of 2647 records were identified and eight papers included. Four studies investigated pharyngeal electrical stimulation (PES), two explored Facial Oral Tract Therapy (F.O.T.T.), one respiratory physiotherapy (RPT), and one study investigated external subglottic air flow (ESAF). Two RCTs found a significant difference between intervention and control on successful decannulation and readiness for decannulation in favour of PES. Time from rehabilitation admission and tracheostomy to decannulation was significantly reduced after implementing an F.O.T.T.-based protocol. CONCLUSION Four interventions were identified, PES, F.O.T.T., RPT, and ESAF, all aimed at increasing oropharyngeal sensory input through stimulation. Due to heterogeneity of interventions, designs and outcome measures, effect could not be estimated. This review highlights the limited research on rehabilitative interventions and thus the limited evidence to guide clinical rehabilitation.
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Affiliation(s)
- Signe Janum Eskildsen
- Department of Occupational Therapy and Physiotherapy, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Public Health, Aarhus University, Health, Aarhus, Denmark
| | - Irene Wessel
- Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Rigshospitalet, Copenhagen, Denmark
| | - Ingrid Poulsen
- Department of Public Health, Aarhus University, Health, Aarhus, Denmark
- Department of Clinical Research, Copenhagen University Hospital, Amager and Hvidovre Hospital, Hvidovre, Denmark
| | - Carrinna Aviaja Hansen
- Department of Orthopaedic Surgery, Zealand University Hospital, University of Copenhagen, Koege, Denmark
- Faculty of Health Sciences, Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Derek John Curtis
- Department of Pediatric Rehabilitation, Children's Therapy Center, The Child and Youth Administration, Copenhagen, Denmark
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Bjerrum K, Grove LMD, Mortensen SS, Fabricius J. Development and Effect Evaluation of an Action-Oriented Interdisciplinary Weaning Protocol for Cuffed Tracheostomy Tubes in Patients with Acquired Brain Injury. Healthcare (Basel) 2024; 12:480. [PMID: 38391855 PMCID: PMC10887695 DOI: 10.3390/healthcare12040480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 02/24/2024] Open
Abstract
The objective was to develop an interdisciplinary weaning protocol (IWP) for patients with tracheostomy tubes due to acquired brain injury, and to effect evaluate implementation of the IWP on decannulation rates and weaning duration. An expert panel completed a literature review in 2018 to identify essential criteria in the weaning process. Based on consensus and availability in clinical practice, criteria for guiding the weaning process were included in the protocol. Using the IWP, dysphagia is graded as either severe, moderate, or mild. The weaning process is guided through a protocol which specified the daily duration of cuff deflation until decannulation, along with recommendations for treatment and rehabilitation interventions. Data from 337 patient records (161 before and 176 after implementation) were included for effect evaluation. Decannulation rate during hospitalization was unchanged at 91% vs. 90% before and after implementation (decannulation rate at 60 days was 68% vs. 74%). After implementation, the weaning duration had decreased compared to before implementation, hazard ratio 1.309 (95%CI: 1.013; 1.693), without any increased risk of tube-reinsertion or pneumonia. Furthermore, a tendency toward decreased length of stay was seen with median 102 days (IQR: 73-138) and median 90 days (IQR: 58-119) (p = 0.061) before and after implementation, respectively. Scientific debate on weaning protocols for tracheostomy tubes are encouraged.
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Affiliation(s)
- Katje Bjerrum
- Hammel Neurorehabilitation Centre and University Research Clinic, Department of Clinical Medicine, Aarhus University, 8450 Hammel, Denmark
| | - Linda-Maria Delgado Grove
- Hammel Neurorehabilitation Centre and University Research Clinic, Department of Clinical Medicine, Aarhus University, 8450 Hammel, Denmark
| | - Sine Secher Mortensen
- Hammel Neurorehabilitation Centre and University Research Clinic, Department of Clinical Medicine, Aarhus University, 8450 Hammel, Denmark
| | - Jesper Fabricius
- Hammel Neurorehabilitation Centre and University Research Clinic, Department of Clinical Medicine, Aarhus University, 8450 Hammel, Denmark
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Katsuno T, Ueha R, Fujisaki A, Unno T, Cotaoco C, Kaneoka A, Koyama M, Sato T, Goto T, Kondo K. Differences in residual volume above different tracheostomy tube cuffs depending on tube structure, tube tilt angle, and liquid viscosity. Eur Arch Otorhinolaryngol 2024; 281:311-317. [PMID: 37843617 PMCID: PMC10764502 DOI: 10.1007/s00405-023-08281-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/04/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Proper management of aspirated material above the tracheostomy tube cuff is crucial to prevent complications, such as aspiration pneumonia. This study aimed to thoroughly examine the effects of aspirated liquid viscosity, suction port positioning, and tube tilt angle on residual volume above the cuff (RVAC). METHODS Five types of tracheostomy tubes (approximately 9 mm outer diameter) were placed through a transparent cylinder with an inner diameter of 18 mm. The cuff was inflated to completely seal the interior of the cylinder. Four liquids with different viscosities were poured onto the cuff, and the liquid above the cuff was suctioned from the side port. The cylinder was angled at 90° and 20°, and each test was performed thrice to determine the average RVAC. RESULTS After side-port suctioning, some liquid residue was observed on the cuff of all tracheostomy tubes. The RVAC increased with higher liquid viscosity. The tubes with a longer distance from the suction port opening to the cuff top exhibited more RVAC. Moreover, the RVAC was almost the same regardless of the cylinder angle for tubes with a suction port on the lateral side. However, tubes with backside ports showed a decreased RVAC with cylinder tilt. CONCLUSIONS This study underscores the persistence of residual material on cuffed tracheostomy tubes even with regular subglottic secretion drainage. This emphasizes the need for specialized tracheostomy tube development aimed at reducing post-suction RVAC. Improved designs can potentially minimize complications associated with residue accumulation.
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Affiliation(s)
- Takahiro Katsuno
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan
| | - Rumi Ueha
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan.
- Swallowing Center, The University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Aiko Fujisaki
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan
| | - Takeshi Unno
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan
| | - Carmel Cotaoco
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan
- Ear Nose Throat Head and Neck Surgery Institute, The Medical City, Pasig, Philippines
| | - Asako Kaneoka
- Swallowing Center, The University of Tokyo Hospital, The University of Tokyo, 7-3-1 Hongo Bunkyo-ku, Tokyo, 113-8655, Japan
- Rehabilitation Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Misaki Koyama
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan
| | - Taku Sato
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan
| | - Takao Goto
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan
| | - Kenji Kondo
- Department of Otolaryngology and Head and Neck Surgery, The University of Tokyo, Tokyo, Japan
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Wen J, Chen J, Chang J, Wei J. Pulmonary complications and respiratory management in neurocritical care: a narrative review. Chin Med J (Engl) 2022; 135:779-789. [PMID: 35671179 PMCID: PMC9276382 DOI: 10.1097/cm9.0000000000001930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Indexed: 11/25/2022] Open
Abstract
ABSTRACT Neurocritical care (NCC) is not only generally guided by principles of general intensive care, but also directed by specific goals and methods. This review summarizes the common pulmonary diseases and pathophysiology affecting NCC patients and the progress made in strategies of respiratory support in NCC. This review highlights the possible interactions and pathways that have been revealed between neurological injuries and respiratory diseases, including the catecholamine pathway, systemic inflammatory reactions, adrenergic hypersensitivity, and dopaminergic signaling. Pulmonary complications of neurocritical patients include pneumonia, neurological pulmonary edema, and respiratory distress. Specific aspects of respiratory management include prioritizing the protection of the brain, and the goal of respiratory management is to avoid inappropriate blood gas composition levels and intracranial hypertension. Compared with the traditional mode of protective mechanical ventilation with low tidal volume (Vt), high positive end-expiratory pressure (PEEP), and recruitment maneuvers, low PEEP might yield a potential benefit in closing and protecting the lung tissue. Multimodal neuromonitoring can ensure the safety of respiratory maneuvers in clinical and scientific practice. Future studies are required to develop guidelines for respiratory management in NCC.
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Affiliation(s)
- Junxian Wen
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Dongcheng District, Beijing 100730, China
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11
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Chen R, Chien YC, Kao CM, Jen HJ, Loh EW. Effects of a modified Singh's algorithm care bundle on cannulation success rate in patients with neurological sequelae. Jpn J Nurs Sci 2022; 19:e12478. [PMID: 35199913 DOI: 10.1111/jjns.12478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/25/2021] [Accepted: 01/02/2022] [Indexed: 11/30/2022]
Abstract
AIM Prolonged tracheostomy tube placement leads to depression, communicative inconvenience, reduced life quality, and health complications. We retrospectively examined the effects of a modified Singh's algorithm (MOSA) care bundle in tracheostomy tube removal in patients with neurological sequelae. METHODS We retrieved medical records of 22 tracheostomized patients admitted to our early rehabilitation ward from 1 January 2018 to 31 December 2020 and compared their clinical outcomes before and after the MOSA introduction. We used a decannulation checklist and outcomes of decannulation training to judge the decannulation opportunity in the intervention group. In the control group, the patients received decannulation based on professional judgments. RESULTS Age, gender, body mass index, and admission diagnosis were not significantly different between the two groups. While 10 of 13 patients (76.9%) successfully decannulated in the intervention group, only 1 of 9 patients in the control group succeeded (11.1%; p = 0.008). The decannulation evaluation checklist revealed no statistically significant difference between the two groups except that the intervention group received more airway patency evaluations (p = 0.027). None of the decannulated patients required tracheostomy tube reinsertion before discharge, and no complications appeared. CONCLUSION Our study supports the feasibility of MOSA in aiding decannulation among patients with neurological illnesses. Further cluster randomized controlled trials and studies of decision aids and shared decision-making are warranted to help promote active decannulation.
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Affiliation(s)
- Ruey Chen
- Department of Nursing, Taipei Medical University, Shuang Ho Hospital, New Taipei, Taiwan.,Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan.,School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Yen-Chang Chien
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chia-Man Kao
- Department of Nursing, Taipei Medical University, Shuang Ho Hospital, New Taipei, Taiwan
| | - Hsiu-Ju Jen
- Department of Nursing, Taipei Medical University, Shuang Ho Hospital, New Taipei, Taiwan.,School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - El-Wui Loh
- Center for Evidence-Based Health Care, Department of Medical Research, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.,Department of Dentistry, Taipei Medical University Shuang Ho Hospital, New Taipei City, Taiwan
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12
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Memmedova F, Ger Akarsu F, Mehdiyev Z, Aykaç Ö, Pınarbaşlı MÖ, Gürbüz MK, Özdemir AÖ. Evaluation of Percutaneous and Surgical Tracheostomy Results in Neurocritical Care Unit. TURKISH JOURNAL OF NEUROLOGY 2022. [DOI: 10.4274/tnd.2022.77200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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13
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Muhle P, Suntrup-Krueger S, Burkardt K, Lapa S, Ogawa M, Claus I, Labeit B, Ahring S, Oelenberg S, Warnecke T, Dziewas R. Standardized Endoscopic Swallowing Evaluation for Tracheostomy Decannulation in Critically Ill Neurologic Patients - a prospective evaluation. Neurol Res Pract 2021; 3:26. [PMID: 33966636 PMCID: PMC8108459 DOI: 10.1186/s42466-021-00124-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 04/22/2021] [Indexed: 12/16/2022] Open
Abstract
Background Removal of a tracheostomy tube in critically ill neurologic patients is a critical issue during intensive care treatment, particularly due to severe dysphagia and insufficient airway protection. The “Standardized Endoscopic Evaluation for Tracheostomy Decannulation in Critically Ill Neurologic Patients” (SESETD) is an objective measure of readiness for decannulation. This protocol includes the stepwise evaluation of secretion management, spontaneous swallowing, and laryngeal sensitivity during fiberoptic endoscopic evaluation of swallowing (FEES). Here, we first evaluated safety and secondly effectiveness of the protocol and sought to identify predictors of decannulation success and decannulation failure. Methods A prospective observational study was conducted in the neurological intensive care unit at Münster University Hospital, Germany between January 2013 and December 2017. Three hundred and seventy-seven tracheostomized patients with an acute neurologic disease completely weaned from mechanical ventilation were included, all of whom were examined by FEES within 72 h from end of mechanical ventilation. Using regression analysis, predictors of successful decannulation, as well as decannulation failure were investigated. Results Two hundred and twenty-seven patients (60.2%) could be decannulated during their stay according to the protocol, 59 of whom within 24 h from the initial FEES after completed weaning. 3.5% of patients had to be recannulated due to severe dysphagia or related complications. Prolonged mechanical ventilation showed to be a significant predictor of decannulation failure. Lower age was identified to be a significant predictor of early decannulation after end of weaning. Transforming the binary SESETD into a 4-point scale helped predicting decannulation success in patients not immediately ready for decannulation after the end of respiratory weaning (optimal cutoff ≥1; sensitivity: 64%, specifity: 66%). Conclusions The SESETD showed to be a safe and efficient tool to evaluate readiness for decannulation in our patient collective of critically ill neurologic patients. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00124-1.
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Affiliation(s)
- Paul Muhle
- University Hospital Muenster, Department of Neurology with Institute for Translational Neurology, Albert-Schweitzer-Campus 1 A, 48149, Muenster, Germany. .,Institute for Biomagnetism and Biosignalanalysis, University Hospital Muenster, Malmedyweg 15, 48149, Muenster, Germany.
| | - Sonja Suntrup-Krueger
- University Hospital Muenster, Department of Neurology with Institute for Translational Neurology, Albert-Schweitzer-Campus 1 A, 48149, Muenster, Germany.,Institute for Biomagnetism and Biosignalanalysis, University Hospital Muenster, Malmedyweg 15, 48149, Muenster, Germany
| | - Karoline Burkardt
- Raphaelsklinik Muenster, Department of General Surgery, Loerstraße 23, 48143, Muenster, Germany
| | - Sriramya Lapa
- University Hospital Frankfurt, Department of Neurology, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
| | - Mao Ogawa
- Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
| | - Inga Claus
- University Hospital Muenster, Department of Neurology with Institute for Translational Neurology, Albert-Schweitzer-Campus 1 A, 48149, Muenster, Germany
| | - Bendix Labeit
- University Hospital Muenster, Department of Neurology with Institute for Translational Neurology, Albert-Schweitzer-Campus 1 A, 48149, Muenster, Germany.,Institute for Biomagnetism and Biosignalanalysis, University Hospital Muenster, Malmedyweg 15, 48149, Muenster, Germany
| | - Sigrid Ahring
- University Hospital Muenster, Department of Neurology with Institute for Translational Neurology, Albert-Schweitzer-Campus 1 A, 48149, Muenster, Germany
| | - Stephan Oelenberg
- University Hospital Muenster, Department of Neurology with Institute for Translational Neurology, Albert-Schweitzer-Campus 1 A, 48149, Muenster, Germany
| | - Tobias Warnecke
- University Hospital Muenster, Department of Neurology with Institute for Translational Neurology, Albert-Schweitzer-Campus 1 A, 48149, Muenster, Germany
| | - Rainer Dziewas
- Klinikum Osnabrück, Department of Neurology, Am Finkenhügel 1, 49076, Osnabrück, Germany
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14
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Huang HY, Lee CS, Chiu TH, Chen HH, Chan LY, Chang CJ, Chang SC, Hu HC, Kao KC, Chen NH, Lin SM, Li LF. Clinical outcomes and prognostic factors for prolonged mechanical ventilation in patients with acute stroke and brain trauma. J Formos Med Assoc 2021; 121:162-169. [PMID: 33750622 DOI: 10.1016/j.jfma.2021.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/28/2021] [Accepted: 02/16/2021] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND/PURPOSE Neurological dysfunction is a common condition necessitating prolonged mechanical ventilation (PMV). We investigated the clinical features and outcomes of patients with acute neurological diseases requiring PMV. METHODS This retrospective observational study was conducted at the Respiratory Care Center (RCC) of Chang Gung Memorial Hospital, Taiwan, between January 2011 and January 2014. The main outcome was weaning success, defined as successful withdrawal from mechanical ventilator support for more than 5 days. RESULTS The study included 103 patients with acute stroke and brain trauma receiving PMV. Weaning success was reported in 63 (61%) patients and weaning failure was reported in 40 (39%) patients. Patients in the weaning failure group were older and had a lower RCC Glasgow Coma Scale (GCS) score (6.0 vs 7.9, p = 0.005), lower albumin level (2.8 vs 3.1, p = 0.015), longer RCC stay (28.7 vs 21.3 days, p = 0.017), and higher in-hospital mortality rate (47% vs 9%, p < 0.01). Multivariate analysis revealed that reduced RCC GCS score is an independent prognostic factor for weaning failure (odds ratio [OR] = 1.22, 95% confidence interval [CI] = 1.05-1.46, p = 0.016) and that per unit increase of RCC GCS score is associated with a lower risk of in-hospital mortality (OR = 0.83, 95% CI = 0.70-0.96, p = 0.019). CONCLUSION Reduced RCC GCS score is an independent prognostic factor for weaning failure, and is associated with increased in-hospital mortality rates in patients with acute stroke and brain trauma requiring PMV.
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Affiliation(s)
- Hung-Yu Huang
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Saint Paul's Hospital, Taoyuan, Taiwan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Chung-Shu Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Tzu-Hsuan Chiu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Hsiang Hsuan Chen
- School of Medicine, College of Medicine, Chang Gung University, Kaohsiung, Taiwan; Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Li-Yi Chan
- School of Medicine, College of Medicine, Chang Gung University, Kaohsiung, Taiwan
| | - Chee-Jen Chang
- Faculty of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Research Services Center for Health Information, Chang Gung University, Taoyuan, Taiwan
| | - Shu-Chen Chang
- Research Services Center for Health Information, Chang Gung University, Taoyuan, Taiwan
| | - Han-Chung Hu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan; Department of Respiratory Therapy, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kuo-Chin Kao
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan; Department of Respiratory Therapy, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ning-Hung Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Shu-Min Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Chang Gung University, Taoyuan, Taiwan
| | - Li-Fu Li
- Chang Gung University, Taoyuan, Taiwan; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan.
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15
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Michelutti A, D'Angelo M, Szulin M, Stroppolo G, Bargellesi S, Giorgini T, Quattrin R, Biasutti E. The tracheotomy tube weaning in patients with severe acquired brain injury: comparison of two operative procedures in a postacute rehabilitation hospital. Eur J Phys Rehabil Med 2021; 57:347-355. [PMID: 33448751 DOI: 10.23736/s1973-9087.21.06342-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite the high frequency of tracheotomy in severe acquired brain injury (sABI) patients, available literature about the weaning procedure is mainly represented by expert opinions with no standardized and evidence-based criteria. AIM The Institute of Physical and Rehabilitation Medicine "Gervasutta" adopted a new decannulation procedure, recommended by the Italian Society of Physical Medicine and Rehabilitation (SIMFER). This study evaluates whether the new procedure helps to improve the decannulation process of sABI patients. DESIGN A prospective observational with historical control was performed by dividing sABI patients into two groups depending on whether they were treated with or without the new procedure. SETTING The Department of Neurorehabilitation of the Institute of Physical and Rehabilitation Medicine "Gervasutta" in Udine, Italy. POPULATION sABI patients with tracheal cannula admitted to the Institute of Physical and Rehabilitation Medicine "Gervasutta" from January 2015 to March 2019. METHODS Clinical data were collected as both process and outcome indicators before and after the adoption of the new procedure. Data have been processed with Simple Interactive Statistical Analysis (SISA; Irving, TX, USA) software. RESULTS A sample of 141 patients was analysed. Among the 141 patients, 57 (40.4%) were treated with the new procedure. No differences were found between the two groups in terms of complications, functional independence measure (FIM), or level of cognitive functioning (LCF) at the admission. When the new procedure was applied, the decannulation rate was significantly higher (OR=1.8; 95% CI=1.2-9.8; P=0.01) and the time (days) between admission and oral feeding resumption was significantly lower (P<0.001; 95% CI=-10, -34 days). CONCLUSIONS The introduction of the new protocol allowed the safe achievement of both oral feeding resumption and decannulation, which are two of the main early rehabilitation goals. CLINICAL REHABILITATION IMPACT The standardization of the decannulation process has determined the achievement of a significantly faster oral feeding resumption and an increase in the decannulation rate during the rehabilitation of sABI patients.
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Affiliation(s)
- Alessandro Michelutti
- Institute of Physical and Rehabilitation Medicine "Gervasutta", Friuli Centrale University Health Service (ASU-FC), Udine, Italy
| | - Matteo D'Angelo
- Department of Medicine, University of Udine, Udine, Italy - matteo.dangeluniud.it
| | - Michela Szulin
- Institute of Physical and Rehabilitation Medicine "Gervasutta", Friuli Centrale University Health Service (ASU-FC), Udine, Italy
| | - Giulia Stroppolo
- Institute of Physical and Rehabilitation Medicine "Gervasutta", Friuli Centrale University Health Service (ASU-FC), Udine, Italy
| | - Stefano Bargellesi
- Unit of Severe Brain Injury, Department of Physical and Rehabilitation Medicine, Marca Trevigiana AULSS, Treviso Hospital, Treviso, Italy
| | - Tullio Giorgini
- Institute of Physical and Rehabilitation Medicine "Gervasutta", Friuli Centrale University Health Service (ASU-FC), Udine, Italy
| | - Rosanna Quattrin
- Unit of Accreditation, Clinical Risk Management and Performance Assessment, Friuli Centrale University Health Service (ASU-FC), Udine, Italy
| | - Emanuele Biasutti
- Institute of Physical and Rehabilitation Medicine "Gervasutta", Friuli Centrale University Health Service (ASU-FC), Udine, Italy
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16
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Warnecke T, Muhle P, Claus I, Schröder JB, Labeit B, Lapa S, Suntrup-Krueger S, Dziewas R. Inter-rater and test-retest reliability of the "standardized endoscopic swallowing evaluation for tracheostomy decannulation in critically ill neurologic patients". Neurol Res Pract 2020; 2:9. [PMID: 33324915 PMCID: PMC7650070 DOI: 10.1186/s42466-020-00055-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 03/03/2020] [Indexed: 01/22/2023] Open
Abstract
Background Removal of a tracheostomy tube in critically ill neurologic patients is a difficult issue, particularly due to the high incidence of oropharyngeal dysphagia. For an objective evaluation of decannulation readiness the "Standardized Endoscopic Swallowing Evaluation for Tracheostomy Decannulation in Critically Ill Neurologic Patients" (SESETD) - a stepwise evaluation of 'secretion management', 'spontaneous swallows' and 'laryngeal sensibility/cough' - has been introduced. With the recent study detailed data on inter-rater and test-retest reliability are presented. Methods To obtain inter-rater reliability levels both in a group of raters with at least 5 years of experience ('experts') and in a group of raters with no or only minor experience using the SESETD ('non-experts'), for each single item of the protocol and the sum score α-, respectively κ-levels were determined. The 'experts' assessed the same videos after a four-week interval to determine test-retest reliability. Ten videos from tracheostomized neurological patients completely weaned from mechanical ventilation were assessed independently by six 'experts'. 27 'non-experts' applied the SESETD on 5 videos from the same patient population after introduction to the protocol in a one-hour workshop. Results For the items 'secretion management' and 'spontaneous swallows' α-levels were identified at > 0.800 both in the group of 'experts' and 'non-experts'. With regard to the item 'laryngeal sensibility/cough' in both groups, the α-level was ≥0.667. With κ-levels of 1.0 for 'secretion management', 0.93 for 'spontaneous swallows' and 0.76 for 'laryngeal sensibility/cough' test-retest reliability showed at least substantial agreement for each item. Intraclass correlation coefficient for the sum score was excellent in both groups (α ≥ 0.90). Conclusions The SESETD demonstrates good to excellent agreement for each single item included as well as the sum score in experienced and unexperienced raters supporting its usefulness for implementation in daily clinical routine and as an outcome measure for clinical trials.
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Affiliation(s)
- Tobias Warnecke
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1 A, 48149 Muenster, Germany
| | - Paul Muhle
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1 A, 48149 Muenster, Germany.,Institute for Biomagnetism and Biosignalanalysis, University Hospital Muenster, Malmedyweg 15, 48149 Muenster, Germany
| | - Inga Claus
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1 A, 48149 Muenster, Germany
| | - Jens B Schröder
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1 A, 48149 Muenster, Germany
| | - Bendix Labeit
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1 A, 48149 Muenster, Germany.,Institute for Biomagnetism and Biosignalanalysis, University Hospital Muenster, Malmedyweg 15, 48149 Muenster, Germany
| | - Sriramya Lapa
- Department of Neurology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt/Main, Germany
| | - Sonja Suntrup-Krueger
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1 A, 48149 Muenster, Germany.,Institute for Biomagnetism and Biosignalanalysis, University Hospital Muenster, Malmedyweg 15, 48149 Muenster, Germany
| | - Rainer Dziewas
- Department of Neurology with Institute of Translational Neurology, University Hospital Muenster, Albert-Schweitzer-Campus 1 A, 48149 Muenster, Germany
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17
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Racca F, Vianello A, Mongini T, Ruggeri P, Versaci A, Vita GL, Vita G. Practical approach to respiratory emergencies in neurological diseases. Neurol Sci 2020; 41:497-508. [PMID: 31792719 PMCID: PMC7224095 DOI: 10.1007/s10072-019-04163-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/15/2019] [Indexed: 02/06/2023]
Abstract
Many neurological diseases may cause acute respiratory failure (ARF) due to involvement of bulbar respiratory center, spinal cord, motoneurons, peripheral nerves, neuromuscular junction, or skeletal muscles. In this context, respiratory emergencies are often a challenge at home, in a neurology ward, or even in an intensive care unit, influencing morbidity and mortality. More commonly, patients develop primarily ventilatory impairment causing hypercapnia. Moreover, inadequate bulbar and expiratory muscle function may cause retained secretions, frequently complicated by pneumonia, atelectasis, and, ultimately, hypoxemic ARF. On the basis of the clinical onset, two main categories of ARF can be identified: (i) acute exacerbation of chronic respiratory failure, which is common in slowly progressive neurological diseases, such as movement disorders and most neuromuscular diseases, and (ii) sudden-onset respiratory failure which may develop in rapidly progressive neurological disorders including stroke, convulsive status epilepticus, traumatic brain injury, spinal cord injury, phrenic neuropathy, myasthenia gravis, and Guillain-Barré syndrome. A tailored assistance may include manual and mechanical cough assistance, noninvasive ventilation, endotracheal intubation, invasive mechanical ventilation, or tracheotomy. This review provides practical recommendations for prevention, recognition, management, and treatment of respiratory emergencies in neurological diseases, mostly in teenagers and adults, according to type and severity of baseline disease.
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Affiliation(s)
- Fabrizio Racca
- Department of Anaesthesia and Intensive Care, Sant'Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Andrea Vianello
- Respiratory Pathophysiology Division, University of Padua, Padua, Italy
| | - Tiziana Mongini
- Neuromuscular Center, Department of Neurosciences, University of Turin, Turin, Italy
| | - Paolo Ruggeri
- Unit of Pneumology, Department BIOMORF, University of Messina, Messina, Italy
| | - Antonio Versaci
- Intensive Care Unit, AOU Policlinico "G. Martino", Messina, Italy
| | - Gian Luca Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina, Italy
| | - Giuseppe Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina, Italy.
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
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18
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Ischemic Stroke in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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19
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Suntrup-Krueger S, Schmidt S, Warnecke T, Steidl C, Muhle P, Schroeder JB, Labeit B, Minnerup J, Dziewas R. Extubation Readiness in Critically Ill Stroke Patients. Stroke 2019; 50:1981-1988. [PMID: 31280655 DOI: 10.1161/strokeaha.118.024643] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background and Purpose- Predicting safe extubation represents a clinical challenge in acute stroke patients. Classical respiratory weaning criteria have not proven reliable. Concerning the paramount relevance of postextubation dysphagia in this population, criteria related to airway safety seem to perform better, but diagnostic standards are lacking. We compare clinical and instrumental swallowing examination tools to assess extubation readiness and propose a simple Determine Extubation Failure in Severe Stroke score for decision making. Methods- Data of 133 orally intubated acute stroke patients were prospectively collected in this observational study. Classical extubation criteria, a modified semiquantitative airway score, and an oral motor function score were assessed before extubation. A 3-ounce water swallow test and validated 6-point fiberoptic endoscopic dysphagia severity scoring were performed thereafter. Association of demographic and clinical parameters with extubation failure (EF) was investigated. Independent predictors of EF were translated into a point scoring system. Ideal cutoff values were determined by receiver operator characteristics analyses. Results- Patients with EF (24.1% after 24±43 hours) performed worse in all swallowing assessments (P<0.001). Fiberoptic endoscopic dysphagia severity scoring was the only independent predictor of EF (adjusted odds ratio, 4.2; P<0.007) with optimal cutoff ≥5 (sensitivity 84.6% and specificity 76.5%). Restricting regression analysis to parameters collected before extubation, a 4-item Determine Extubation Failure in Severe Stroke score (duration of ventilation, the examination of oral motor function, infratentorial lesion, and stroke severity) was derived. The score demonstrated excellent discrimination (area under the curve 0.89; 95% CI, 0.83-0.95) and calibration (Nagelkerkes R2=0.54) with an ideal cutoff ≥4 (sensitivity: 81.3% and specificity: 78.2%). Conclusions- Risk of EF is strongly correlated with postextubation dysphagia severity in stroke. Fiberoptic endoscopic examination of swallowing best predicts necessity of reintubation but requires a trial of extubation. The Determine Extubation Failure In Severe Stroke score is based on easy to collect clinical data and may guide extubation decision making in critically ill stroke patients.
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Affiliation(s)
- Sonja Suntrup-Krueger
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
| | - Sarah Schmidt
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
| | - Tobias Warnecke
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
| | | | - Paul Muhle
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
| | - Jens B Schroeder
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
| | - Bendix Labeit
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
| | - Jens Minnerup
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
| | - Rainer Dziewas
- From the Department of Neurology, University of Muenster, Germany (S.S.-K., S.S., T.W., P.M., J.B.S., B.L., J.M., R.D.)
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Dasenbrock HH, Rudy RF, Gormley WB, Frerichs KU, Aziz-Sultan MA, Du R. The Timing of Tracheostomy and Outcomes After Aneurysmal Subarachnoid Hemorrhage: A Nationwide Inpatient Sample Analysis. Neurocrit Care 2018; 29:326-335. [PMID: 30298335 DOI: 10.1007/s12028-018-0619-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The goal of this study was to investigate the association of tracheostomy timing with outcomes after aneurysmal subarachnoid hemorrhage (SAH) in a national population. METHODS Poor-grade aneurysmal SAH patients were extracted from the Nationwide Inpatient Sample (2002-2011). Multivariable linear regression was used to analyze predictors of tracheostomy timing and multivariable logistic regression was used to evaluate the association of timing of intervention with mortality, complications, and discharge to institutional care. Covariates included patient demographics, comorbidities, severity of subarachnoid hemorrhage (measured using the NIS-SAH severity scale), hospital characteristics, and other complications and length of stay. RESULTS The median time to tracheostomy among 1380 poor-grade SAH admissions was 11 (interquartile range: 7-15) days after intubation. The mean number of days from intubation to tracheostomy in SAH patients at the hospital (p < 0.001) was the strongest predictor of tracheostomy timing for a patient, while comorbidities and SAH severity were not significant predictors. Mortality, neurologic complications, and discharge disposition did not differ significantly by tracheostomy time. However, later tracheostomy (when evaluated continuously) was associated with greater odds of pulmonary complications (p = 0.004), venous thromboembolism (p = 0.04), and pneumonia (p = 0.02), as well as a longer hospitalization (p < 0.001). Subgroup analysis only found these associations between tracheostomy timing and medical complications in patients with moderately poor grade (NIS-SAH severity scale 7-9), while there were no significant differences by timing of intervention in very poor-grade patients (NIS-SAH severity scale > 9). CONCLUSIONS In this analysis of a large, national data set, variation in hospital practices was the strongest predictor of tracheostomy timing for an individual. In patients with moderately poor grade, later tracheostomy was independently associated with pulmonary complications, venous thromboembolism, pneumonia, and a longer hospitalization, but not with mortality, neurological complications, or discharge disposition. However, tracheostomy timing was not significantly associated with outcomes in very poor-grade patients.
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Affiliation(s)
- Hormuzdiyar H Dasenbrock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Robert F Rudy
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - William B Gormley
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Kai U Frerichs
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - M Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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Abstract
Stroke is a leading cause of death and adult disability in the UK. A stroke can have significant negative effects on the lives of patients and their families and carers. While improved stroke management has contributed to a reduction in mortality and improved outcomes following rehabilitation, the incidence of stroke continues to rise in the UK, partly because of the ageing population. Stroke rehabilitation involves a multidisciplinary approach, with nurses performing a central role. This article describes the risk factors and types of stroke, the main areas of stroke rehabilitation and the role of the nurse. It emphasises that providing support to families and carers is a particularly important element of caring for people who have experienced a stroke.
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Schneider H, Hertel F, Kuhn M, Ragaller M, Gottschlich B, Trabitzsch A, Dengl M, Neudert M, Reichmann H, Wöpking S. Decannulation and Functional Outcome After Tracheostomy in Patients with Severe Stroke (DECAST): A Prospective Observational Study. Neurocrit Care 2018; 27:26-34. [PMID: 28324263 DOI: 10.1007/s12028-017-0390-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Tracheostomy is performed in ventilated stroke patients affected by persisting severe dysphagia, reduced level of consciousness, or prolonged mechanical ventilation. The study aim was to determine the frequency and predictors of successful decannulation and long-term functional outcome in tracheotomized stroke patients. METHODS A prospective single-center observational study recruited ventilated patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Follow-up visits were performed at hospital discharge, 3, and 12 months. Competing risk analyses were performed to identify predictors of decannulation. RESULTS We included 53 ventilated stroke patients who had tracheostomy. One year after tracheostomy, 19 patients were decannulated (median [IQR] time to decannulation 74 [58-117] days), 13 patients were permanently cannulated, and 21 patients died without prior removal of the cannula. Independent predictors for decannulation in our cohort were patient age (HR 0.95 [95% CI: 0.92-0.99] per one year increase, p = 0.003) and absence of sepsis (HR 4.44 [95% CI: 1.33-14.80], p = 0.008). Compared to surviving patients without cannula removal, decannulated patients had an improved functional outcome after one year (median modified Rankin Scale score 4 vs. 5 [p < 0.001]; median Barthel index 35 vs. 5 [p < 0.001]). CONCLUSIONS Decannulation was achieved in 59.4% of stroke patients surviving the first 12 months after tracheostomy and was associated with better functional outcome compared to patients without decannulation. Further prospective studies with larger sample sizes are needed to confirm our results.
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Affiliation(s)
- Hauke Schneider
- Department of Neurology and Dresden University Stroke Center, University Hospital, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - Franziska Hertel
- Department of Neurology and Dresden University Stroke Center, University Hospital, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Matthias Kuhn
- Institute for Medical Informatics and Biometry, Technische Universität Dresden, Dresden, Germany
| | - Maximilian Ragaller
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Birgit Gottschlich
- Department of Anesthesiology and Intensive Care Medicine, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Anne Trabitzsch
- Surgery Center, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Markus Dengl
- Department of Neurosurgery, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Marcus Neudert
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Heinz Reichmann
- Department of Neurology and Dresden University Stroke Center, University Hospital, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Sigrid Wöpking
- Department of Neurology and Dresden University Stroke Center, University Hospital, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
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Challenges in the Anesthetic and Intensive Care Management of Acute Ischemic Stroke. J Neurosurg Anesthesiol 2017; 28:214-32. [PMID: 26368664 DOI: 10.1097/ana.0000000000000225] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Acute ischemic stroke (AIS) is a devastating condition with high morbidity and mortality. In the past 2 decades, the treatment of AIS has been revolutionized by the introduction of several interventions supported by class I evidence-care on a stroke unit, intravenous tissue plasminogen activator within 4.5 hours of stroke onset, aspirin commenced within 48 hours of stroke onset, and decompressive craniectomy for supratentorial malignant hemispheric cerebral infarction. There is new class I evidence also demonstrating benefits of endovascular therapy on functional outcomes in those with anterior circulation stroke. In addition, the importance of the careful management of key systemic physiological variables, including oxygenation, blood pressure, temperature, and serum glucose, has been appreciated. In line with this, the role of anesthesiologists and intensivists in managing AIS has increased. This review highlights the main challenges in the endovascular and intensive care management of AIS that, in part, result from the paucity of research focused on these areas. It also provides guidelines for the management of AIS based upon current evidence, and identifies areas for further research.
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Kim YK, Lee SH, Lee JW. Effects of Capping of the Tracheostomy Tube in Stroke Patients With Dysphagia. Ann Rehabil Med 2017; 41:426-433. [PMID: 28758080 PMCID: PMC5532348 DOI: 10.5535/arm.2017.41.3.426] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 09/09/2016] [Indexed: 11/25/2022] Open
Abstract
Objective To investigate the impact of tracheostomy tube capping on swallowing physiology in stroke patients with dysphagia via videofluoroscopic swallowing study (VFSS). Methods This study was conducted as a prospective study that involved 30 stroke patients. Then, 4 mL semisolid swallowing was conducted with capping of the tracheostomy tube or without capping of the tracheostomy tube. The following five parameters were measured: laryngeal elevation, pharyngeal transit time, post-swallow pharyngeal remnant, upper esophageal sphincter width (UES), and penetration-aspiration scale (PAS) score. Results On assessment of the differences in swallowing parameters during swallowing between ‘with capping’ and ‘without capping’ statuses, statistically significant differences were found in the post-swallow pharyngeal remnant (without capping, 48.19%±28.70%; with capping, 25.09%±19.23%; p<0.001), normalized residue ratio scale for the valleculae (without capping, 0.17±0.12; with capping, 0.09±0.12; p=0.013), normalized residue ratio scale for the piriform sinus (without capping, 0.16±0.12; with capping, 0.10±0.07; p=0.015), and UES width (without capping, 3.32±1.61 mm; with capping, 4.61±1.95 mm; p=0.003). However, there were no statistically significant differences in laryngeal elevation (x-axis without capping, 2.48±1.45 mm; with capping, 3.26±2.37 mm; y-axis without capping, 11.11±5.24 mm; with capping, 12.64±6.16 mm), pharyngeal transit time (without capping, 9.19± 10.14 s; with capping, 9.09±10.21 s), and PAS score (without capping, 4.94±2.83; with capping, 4.18±2.24). Conclusion Tracheostomy tube capping is a useful way to reduce post-swallow remnants and it can be considered an alternative method for alleviating dysphagia in stroke patients who can tolerate tracheostomy tube capping when post-swallow remnants are observed.
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Affiliation(s)
- Yong Kyun Kim
- Department of Physical Medicine and Rehabilitation, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
| | - Sang-Heon Lee
- Department of Physical Medicine and Rehabilitation, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
| | - Jang-Won Lee
- Department of Physical Medicine and Rehabilitation, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
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Perin C, Meroni R, Rega V, Braghetto G, Cerri CG. Parameters Influencing Tracheostomy Decannulation in Patients Undergoing Rehabilitation after severe Acquired Brain Injury (sABI). Int Arch Otorhinolaryngol 2017; 21:382-389. [PMID: 29018503 PMCID: PMC5629091 DOI: 10.1055/s-0037-1598654] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 12/21/2016] [Indexed: 11/06/2022] Open
Abstract
Introduction
Tracheostomy weaning in patients who suffered a severe acquired brain injury is often a challenge and decannulation failures are not uncommon.
Objective
Our study objective is to describe the decannulation failure rate in patients undergoing rehabilitation following a severe acquired brain injury (sABI); to describe the factors associated with a successful tube weaning.
Methods
We conduct a retrospective analysis of charts, consecutively retrieved considering a 3-year window. Variables analyzed were: age, sex, body mass index (BMI), Glasgow Coma Scale (GCS), cause of hospitalization (stroke, trauma, cardiac arrest), date of the pathological event, gap between the index event and the first day of hospitalization, duration of Neurorehabilitation Ward hospitalization, comorbidities, chest morphological alteration, kind of tracheostomy tube used (overall dimension, cap, fenestration), SpO2, presentation and quantification of pulmonary secretion, maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP), respiratory frequency and pattern, cardiac frequency, presence of spontaneous cough, cough strength, and blood gas analysis.
Results
We analyzed 45 tracheostomised sABI patients following stroke, trauma, or cardiac arrest. The weaning success percentage was higher in Head Trauma patients and in patients presenting positive spontaneous cough. Failures seem to be associated with presence of secretions and anoxic brain damage. GCS seemed not related to the decannulation outcome.
Conclusions
Parameters that could be used as positive predictors of weaning are: mean expiratory pressure, presence of spontaneous cough, and cough strength. Provoked cough and GCS were not predictive of weaning success.
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Affiliation(s)
- Cecilia Perin
- Medicina e Chirurgia, Universita degli Studi di Milano-Bicocca Ringgold Standard Institution, Milano, Italy
| | - Roberto Meroni
- Medicina e Chirurgia, Universita degli Studi di Milano-Bicocca Ringgold Standard Institution, Milano, Italy
| | - Vincenzo Rega
- Riabilitazione Neurologica, Gruppo Ospedaliero San Donato Ringgold Standard Institution, Milano, Lombardia, Italy
| | - Giacomo Braghetto
- Medicina e Chirurgia, Universita degli Studi di Milano-Bicocca Ringgold Standard Institution, Milano, Italy
| | - Cesare Giuseppe Cerri
- Medicina e Chirurgia, Universita degli Studi di Milano-Bicocca Ringgold Standard Institution, Milano, Italy
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Abnormal Breathing Patterns Predict Extubation Failure in Neurocritically Ill Patients. Case Rep Crit Care 2017; 2017:9109054. [PMID: 28348899 PMCID: PMC5350289 DOI: 10.1155/2017/9109054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/03/2017] [Accepted: 02/07/2017] [Indexed: 02/05/2023] Open
Abstract
In neurologically injured patients, predictors for extubation success are not well defined. Abnormal breathing patterns may result from the underlying neurological injury. We present three patients with abnormal breathing patterns highlighting failure of successful extubation as a result of these neurologically driven breathing patterns. Recognizing abnormal breathing patterns may be predictive of extubation failure and thus need to be considered as part of extubation readiness.
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Mitton K, Walton K, Sivan M. Tracheostomy weaning outcomes in relation to the site of acquired brain injury: A retrospective case series. Brain Inj 2017; 31:267-271. [PMID: 28102699 DOI: 10.1080/02699052.2016.1250951] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To analyse whether the outcome of tracheostomy weaning is influenced by the site of injury in acquired brain injury. METHODS A retrospective case review of all the consecutive admissions to an acute neurorehabilitation unit in a 2-year period was performed. Patients with a diagnosis of acquired brain injury and tracheostomy in situ were included in this study. RESULTS One hundred and six patients were included in the analysis. They were considered in two groups based on the site of brain injury: Group S, those with supratentorial brain injury only; and Group I, those with any injury with infratentorial involvement. Fifty-one (82%) patients in Group S were successfully weaned from the tracheostomy, compared to only 27 (61%) of patients in Group I. In other words, the proportion of unsuccessful weans (long-term tracheostomy) was 11 (18%) in Group S compared to 17 (39%) in Group I. The statistical significance of successful weans between the groups was p = 0.01 (Chi-square test). The common reasons for unsuccessful weaning were excessive secretion load and recurrent aspiration pneumonia. CONCLUSIONS Patients with isolated supratentorial brain injury have a statistically significant higher chance of successful decannulation when compared to those patients with any infratentorial brain injury involvement.
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Affiliation(s)
- Kay Mitton
- a Department of Rehabilitation Medicine (Neurorehabilitation) , Salford Royal NHS Foundation Trust , Salford , UK
| | - Krystyna Walton
- a Department of Rehabilitation Medicine (Neurorehabilitation) , Salford Royal NHS Foundation Trust , Salford , UK
| | - Manoj Sivan
- a Department of Rehabilitation Medicine (Neurorehabilitation) , Salford Royal NHS Foundation Trust , Salford , UK.,b Institute of Brain, Behaviour and Mental Health , University of Manchester , Manchester , UK
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Seo HG, Kim JG, Nam HS, Lee WH, Han TR, Oh BM. Swallowing Function and Kinematics in Stroke Patients with Tracheostomies. Dysphagia 2016; 32:393-400. [PMID: 28013388 DOI: 10.1007/s00455-016-9767-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 12/03/2016] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to compare the swallowing function and kinematics in stroke patients with and without tracheostomies. In this retrospective matched case-control study, we compared stroke patients with (TRACH group, n = 24) and without (NO-TRACH group, n = 24) tracheostomies. Patients were matched for age, sex, and stroke-type. Swallowing function was evaluated using the videofluoroscopic dysphagia scale (VDS) and functional oral intake scale (FOIS) obtained from videofluoroscopic swallow study (VFSS) images. Swallowing kinematics were evaluated using a two-dimensional kinematic analysis of the VFSS images. Mean duration of tracheostomy was 132.38 ± 150.46 days in the TRACH group. There was no significant difference in the total VDS score between the TRACH (35.17 ± 15.30) and NO-TRACH groups (29.25 ± 16.66, p = 0.247). FOIS was significantly lower in the TRACH group (2.33 ± 1.40) than in the NO-TRACH group (4.33 ± 1.79, p = 0.001). The TRACH group had a significantly lower maximum vertical displacement (15.23 ± 7.39 mm, p = 0.011) and velocity (54.99 ± 29.59 mm/s, p = 0.011), and two-dimensional velocity (61.07 ± 24.89 mm/s, p = 0.013) of the larynx than the NO-TRACH group (20.18 ± 5.70 mm, 82.23 ± 37.30 mm/s, and 84.40 ± 36.05 mm/s, respectively). Maximum horizontal velocity of the hyoid bone in the TRACH group (36.77 ± 16.97 mm/s) was also significantly lower than that in the NO-TRACH group (47.49 ± 15.73 mm/s, p = 0.032). This study demonstrated that stroke patients with tracheostomies had inferior swallowing function and kinematics than those without tracheostomies. A prospective longitudinal study is needed to elucidate the effect of a tracheostomy on swallowing recovery in stroke patients.
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Affiliation(s)
- Han Gil Seo
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Jeong-Gil Kim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Hyung Seok Nam
- Department of Biomedical Engineering, Seoul National University College of Medicine, 103 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Woo Hyung Lee
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
- Department of Biomedical Engineering, Seoul National University College of Medicine, 103 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Tai Ryoon Han
- Department of Rehabilitation Medicine, Gangwon Do Rehabilitation Hospital, 24-16 Chungyeol-ro 142beon-gil, Chuncheon-si, Gangwon-do, 200-939, Republic of Korea
| | - Byung-Mo Oh
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea.
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Dziewas R, Mistry S, Hamdy S, Minnerup J, Van Der Tweel I, Schäbitz W, Bath PM. Design and implementation of Pharyngeal electrical Stimulation for early de-cannulation in TRACheotomized (PHAST-TRAC) stroke patients with neurogenic dysphagia: a prospective randomized single-blinded interventional study. Int J Stroke 2016; 12:430-437. [PMID: 27807279 DOI: 10.1177/1747493016676618] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Rationale Ongoing dysphagia in stroke patients weaned from mechanical ventilation often requires long-term tracheotomy to protect the airway from aspiration. In a recently reported single-centre pilot study, a significantly larger proportion (75%) of tracheotomized dysphagic stroke patients regained sufficient control of airway management allowing tracheotomy tube removal (decannulation) 24-72 h after pharyngeal electrical stimulation (PES) compared to controls who received standard therapy over the same time period (20%). Aim To assess the safety and efficacy of PES in accelerating dysphagia rehabilitation and enabling decannulation of tracheotomized stroke patients. Design International multi-centre prospective randomized controlled single-blind trial in approximately 126 ICU patients (the 90th percentile of the calculated maximum sample size). Study outcomes Primary outcome: proportion of stroke patients considered safe for decannulation 24-72 h after PES compared to control patients who do not receive PES. Key secondary outcomes focus on: dysphagia severity, decannulation rates, decannulation rate after a repeat PES treatment in patients persistently dysphagic after an initial PES treatment, stroke severity, duration of ICU-stay, occurrence of adverse events including pneumonia and need for recannulation over 30 days or until hospital discharge (if earlier). Discussion Dysphagia and related airway complications are reported as one of the main reasons for stroke patients remaining tracheotomized once successfully weaned from ventilation. This study will evaluate if PES can improve airway safety sufficiently enough to allow earlier tracheotomy tube removal.
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Affiliation(s)
- Rainer Dziewas
- 1 Department of Neurology, University Hospital Münster, Münster, Germany
| | - Satish Mistry
- 2 Department for Clinical Research, Phagenesis Limited, Manchester, UK
| | - Shaheen Hamdy
- 3 Centre for Gastrointestinal Sciences, University of Manchester, Manchester, UK
| | - Jens Minnerup
- 1 Department of Neurology, University Hospital Münster, Münster, Germany
| | - Ingeborg Van Der Tweel
- 4 Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, the Netherlands
| | - Wolf Schäbitz
- 5 Department of Neurology, Bethel-EvK Bielefeld, Bielefeld, Germany
| | - Philip M Bath
- 6 Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
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Lioutas VA, Hanafy KA, Kumar S. Predictors of extubation success in acute ischemic stroke patients. J Neurol Sci 2016; 368:191-4. [PMID: 27538631 DOI: 10.1016/j.jns.2016.07.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 06/07/2016] [Accepted: 07/08/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Acute ischemic stroke (AIS) patients often undergo intubation and mechanical ventilation (MV). Prolonged intubation and MV have disadvantages and complications. Conventional extubation criteria based only on respiratory parameters are insufficient to guide extubation practices in stroke patients where capacity for airway protection is a major concern. OBJECTIVE To identify clinical and neuroanatomical markers of successful extubation in AIS patients requiring MV. METHODS Retrospective review of tertiary care hospital patient database from May 2009-November 2012 to identify consecutive patients with AIS intubated during hospitalization. We assessed the effect of age, sex, baseline National Institutes of Health Stroke Scale (NIHSS) score, level of consciousness, facial weakness, dysarthria, neglect, infarct location, dysphagia, respiratory parameters and history of pneumonia on successful extubation by hospital discharge using multivariate logistic regression analysis. RESULTS 112 subjects met study criteria and were included in the analysis. Age and NIHSS scores (mean±standard deviation) were 74.5±16.1years and 19±9.8, respectively; 56% were women. In multivariate analysis, NIHSS score≤15 (Odds Ratio 4.6, 95% Confidence Interval 1.9-11.3, p<0.001) and absence of dysarthria prior to intubation (Odds Ratio 3.0, 95% Confidence interval 1.1-8.3, p=0.04) were independently associated with successful extubation. Conventional respiratory parameters had no effect on extubation success in this cohort. CONCLUSIONS Milder stroke and absence of dysarthria prior to intubation were independently associated with extubation success. Our findings could help inform extubation practices in patients with AIS though prospective validation is necessary.
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Affiliation(s)
| | - Khalid A Hanafy
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Sandeep Kumar
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, United States
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Kim YK, Choi JH, Yoon JG, Lee JW, Cho SS. Improved Dysphagia After Decannulation of Tracheostomy in Patients With Brain Injuries. Ann Rehabil Med 2015; 39:778-85. [PMID: 26605176 PMCID: PMC4654085 DOI: 10.5535/arm.2015.39.5.778] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Accepted: 05/15/2015] [Indexed: 01/25/2023] Open
Abstract
Objective To investigate improved dysphagia after the decannulation of a tracheostomy in patients with brain injuries. Methods The subjects of this study are patients with brain injuries who were admitted to the Department of Rehabilitation Medicine in Myongji Hospital and who underwent a decannulation between 2012 and 2014. A video fluoroscopic swallowing study (VFSS) was performed in order to investigate whether the patients' dysphagia had improved. We measured the following 5 parameters: laryngeal elevation, pharyngeal transit time, post-swallow pharyngeal remnant, upper esophageal width, and semisolid aspiration. We analyzed the patients' results from VFSS performed one month before and one month after decannulation. All VFSS images were recorded using a camcorder running at 30 frames per second. An AutoCAD 2D screen was used to measure laryngeal elevation, post-swallow pharyngeal remnant, and upper esophageal width. Results In this study, a number of dysphagia symptoms improved after decannulation. Laryngeal elevation, pharyngeal transit time, and semisolid aspiration showed no statistically significant differences (p>0.05), however after decannulation, the post-swallow pharyngeal remnant (pre 37.41%±24.80%, post 21.02%±11.75%; p<0.001) and upper esophageal width (pre 3.57±1.93 mm, post 4.53±2.05 mm; p<0.001) showed statistically significant differences. Conclusion When decannulation is performed on patients with brain injuries who do not require a ventilator and who are able to independently excrete sputum, improved esophageal dysphagia can be expected.
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Affiliation(s)
- Yong Kyun Kim
- Department of Physical Medicine and Rehabilitation, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
| | - Jung-Hwa Choi
- Department of Physical Medicine and Rehabilitation, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
| | - Jeong-Gyu Yoon
- Department of Physical Medicine and Rehabilitation, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
| | - Jang-Won Lee
- Department of Physical Medicine and Rehabilitation, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
| | - Sung Sik Cho
- Department of Physical Medicine and Rehabilitation, Myongji Hospital, Seonam University College of Medicine, Goyang, Korea
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Suntrup S, Marian T, Schröder JB, Suttrup I, Muhle P, Oelenberg S, Hamacher C, Minnerup J, Warnecke T, Dziewas R. Electrical pharyngeal stimulation for dysphagia treatment in tracheotomized stroke patients: a randomized controlled trial. Intensive Care Med 2015; 41:1629-37. [PMID: 26077087 DOI: 10.1007/s00134-015-3897-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 05/22/2015] [Indexed: 11/27/2022]
Abstract
PURPOSE Treatment of post-stroke dysphagia is notoriously difficult with different neurostimulation strategies having been employed with a variable degree of success. Recently, electrical pharyngeal stimulation (EPS) has been shown to improve swallowing function and in particular decrease airway aspiration in acute stroke. We performed a randomized controlled trial to assess EPS effectiveness on swallowing function in severely dysphagic tracheotomized patients. METHODS All consecutive stroke patients successfully weaned from the respirator but with severe dysphagia precluding decannulation were screened for eligibility. Eligible patients were randomized to receive either EPS (N = 20) or sham stimulation (N = 10) over three consecutive days. Primary endpoint was ability to decannulate the patient. Swallowing function was assessed using fiberoptic endoscopy. Patients having received sham stimulation were offered EPS treatment during unblinded follow-up if required. Investigators were blinded to the patient's study group allocation. RESULTS Both groups were well matched for age, stroke severity, and lesion location. Decannulation after study intervention was possible in 75% of patients of the treatment group and in 20% of patients of the sham group (p < 0.01). Secondary outcome parameters did not differ. No adverse events occurred. CONCLUSION In this pilot study, EPS enhanced remission of dysphagia as assessed with fiberoptic endoscopic evaluation of swallowing (FEES), thereby enabling decannulation in 75% of patients.
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Affiliation(s)
- Sonja Suntrup
- Department of Neurology, University Hospital Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany,
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Bösel J, Möhlenbruch M, Sakowitz OW. [News and perspectives in neurocritical care]. DER NERVENARZT 2015; 85:928-38. [PMID: 25096787 DOI: 10.1007/s00115-014-4040-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Neurocritical care is an ever-evolving discipline and its implementation in intensive care leads to reduction in mortality and to improvement of functional outcome in patients with devastating injuries to the nervous system. However, the decisive elements of the complete field of neurocritical care remain relatively unclear, as well as the exact ways to optimize them. During recent years new insights have been gained and new exciting studies have been initiated from which results are soon to be expected. This review focuses on the following management aspects: neuromonitoring, airway and ventilation, endovascular therapy, cerebrospinal fluid drainage, decompressive craniectomy, hematoma evacuation, blood pressure, and targeted temperature management. The application of these measures to brain diseases and injuries frequently treated in neurointensive care units will be addressed in the context of current studies.
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Affiliation(s)
- J Bösel
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland,
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Ponfick M, Wiederer R, Nowak DA. Outcome of Intensive Care Unit-Dependent, Tracheotomized Patients with Cerebrovascular Diseases. J Stroke Cerebrovasc Dis 2015; 24:1527-31. [PMID: 25881771 DOI: 10.1016/j.jstrokecerebrovasdis.2015.03.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 12/03/2014] [Accepted: 03/14/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Outcome studies in intensive care unit -dependent, tracheotomized, and mechanical ventilated patients with cerebrovascular disease (CVD) are scarce. METHODS In a retrospective approach, we analyzed the outcome of 143 patients with ischemic stroke (IS), primary intracerebral hemorrhage (PICH), and subarachnoid hemorrhage (SAH). To measure the potential benefit of in-patient rehabilitation, we used the Functional Independence Measure (FIM). In addition, weaning and rehabilitation duration, duration of mechanical ventilation (MV) in the acute care hospital (preweaning), and mortality rates were assessed. RESULTS Approximately 50% of all patients were transferred home. These patients were fully independent or under nursing support. We found no differences regarding weaning and rehabilitation durations, or FIM scores in between each entity. Log-regression analyses showed that every day on MV generates a 3.2% reduction of the possibility to achieve a beneficial outcome (FIM ≥ 50 points [only moderate assistance necessary]), whereas every day in-patient rehabilitation without MV increases the chance for favorable outcome by 1.9%. Mortality rates were 5% for IS and 10% for PICH and SAH, respectively. CONCLUSIONS This study shows that even severely affected, tracheotomized patients with CVD benefit from early in-patient rehabilitation, irrespective of the etiology of vascular brain injury. Mortality rates of early rehabilitation in CVD are low. Until no validated outcome predictors are available, all efforts should be undertaken to enable in-patient rehabilitation, even in severe cases of CVD to improve outcome and to prevent accommodation in long-time-care facilities.
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Affiliation(s)
- Matthias Ponfick
- Helios Klinik Kipfenberg, Kipfenberg, Germany; Neurologische Universitätsklinik Marburg, Philipps-Universität Marburg, Marburg, Germany.
| | | | - Dennis A Nowak
- Helios Klinik Kipfenberg, Kipfenberg, Germany; Neurologische Universitätsklinik Marburg, Philipps-Universität Marburg, Marburg, Germany
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The intensive care management of acute ischemic stroke: an overview. Intensive Care Med 2014; 40:640-53. [DOI: 10.1007/s00134-014-3266-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 03/11/2014] [Indexed: 01/21/2023]
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