Clinical Criteria for Tracheostomy Decannulation in Subjects with Acquired Brain Injury

Prognostic factors for tracheostomy early decannulation in acquired brain injury patients

After severe brain injuries, a tracheostomy tube is usually inserted for respiratory support. This study aimed to clarify the prognostic factors for tracheostomy early decannulation in patients with acquired brain injuries. We retrospectively reviewed the medical records of inpatients with acquired brain injuries who underwent successful tracheostomy decannulation between March 2021 and June 2022. Fifty-six patients were included; median age was 68 (59-72) years; 28 (50%) were men; 28 (50%) underwent tracheostomy due to stroke. The median time to decannulation was 47 days. The patients were divided into the early and the late decannulation groups based on the median time, and compared. In univariate analysis, the early decannulation group had a higher BMI, peak cough flow, and acquired brain injuries due to trauma, and a lower penetration-aspiration scale score, duration of antibiotic use, and duration of oxygen use. Multivariate Cox regression analysis revealed that a higher initial peak cough flow [hazard ratio (HR) 1.142; 95% confidence interval (CI) 0.912-0.954; P  < 0.001] and lower duration of oxygen use (HR 0.930; 95% CI 0.502-0.864; P  = 0.016) were independent factors for early tracheostomy decannulation, with each unit increase in peak cough flow corresponding to a 14.2% increase and each additional day of duration of oxygen use corresponding to a 7.0% decrease in the likelihood of early decannulation. In conclusion, key prognostic factors for early tracheostomy decannulation were identified as the initial cough strength and duration of oxygen use. These results could play important role in decannulation plans for patients with tracheostomy tube.

Increased physiotherapy capacity reduces duration of tracheostomy in situ, reduces hospital length of stay and improves functional outcomes for people with an acquired brain injury (ABI): a service review

PURPOSE

To assess the impact of increased physiotherapy capacity in an acute regional Neurosurgery Centre on outcomes for people with an acquired brain injury (ABI) requiring a tracheostomy.

MATERIALS AND METHODS

A service review of patients undergoing active tracheostomy weaning, admitted over two 15-week time periods; normal physiotherapy staffing with enhanced physiotherapy staffing.

RESULTS

With a 50% increase in staffing, physiotherapy rehabilitation sessions increased from 2 to 4 times weekly. A mean improvement was found for patient outcomes; time with a tracheostomy in situ reduced by 11 days and the length of hospital stay reduced by 19 days. Functional status on discharge also improved, with 33% of patients able to mobilise on discharge with normal staffing levels and 77% of patients able to mobilise on discharge with enhanced staffing levels.

CONCLUSION

A temporary increase in physiotherapy capacity gave the opportunity to evaluate the impact on physiotherapy rehabilitation frequency and patient outcomes. Results demonstrate the positive impact for this complex patient group on outcomes including rehabilitation frequency, length of stay, time to decannulation, and functional status on discharge. Early access to high-frequency specialist physiotherapy rehabilitation is a critical component of improving functional independence in people with an ABI requiring a tracheostomy.

A Simplified Protocol for Tracheostomy Decannulation in Patients Weaned off Prolonged Mechanical Ventilation

Introduction  The criteria for the removal of the tracheostomy tube (decannulation) vary from center to center. Some perform an endoscopic evaluation under anesthesia or computed tomography, which adds to the cost and discomfort. We use a simple two-part protocol to determine the eligibility and carry out the decannulation: part I consists of airway and swallowing assessment through an office-based flexible laryngotracheoscopy, and part II involves a tracheostomy capping trial. Objective  The primary objective was to determine the safety and efficacy of the simplified decannulation protocol followed at our center among the patients who were weaned off the mechanical ventilator and exhibited good swallowing function clinically. Methods  Of the patients considered for decannulation between November 1st, 2018, and October 31st, 2020, those who had undergone tracheostomy for prolonged mechanical ventilation were included. The efficacy to predict successful decannulation was calculated by the decannulation rate among patients who had been deemed eligible for decannulation in part I of the protocol, and the safety profile was defined by the protocol's ability to correctly predict the chances of risk-free decannulation among those submitted to part II of the protocol. Results  Among the 48 patients included (mean age: 46.5 years; male-to-female ratio: 3:1), the efficacy of our protocol in predicting the successful decannulation was of 87.5%, and it was was safe or reliable in 95.45%. Also, in our cohort, the decannulation success and the duration of tracheotomy dependence were significantly affected by the neurological status of the patients. Conclusion  The decannulation protocol consisting of office-based flexible laryngotracheoscopy and capping trial of the tracheostomy tube can safely and effectively aid the decannulation process.

Development and Effect Evaluation of an Action-Oriented Interdisciplinary Weaning Protocol for Cuffed Tracheostomy Tubes in Patients with Acquired Brain Injury

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.

Impact of Vertical and Horizontal Skin Incisions on Outcome Measures in Tracheostomies

Tracheostomy is a life-saving procedure in which an opening is created in the anterior wall of the trachea. Different skin incision types are administered in tracheostomy procedures, predominantly vertical and horizontal. Various literature on the skin incision types in tracheostomy had contradictory findings, with different studies observing that one skin incision type had better outcomes than its counterpart. Hence the objective of this study was to compare the outcomes associated with vertical and horizontal skin incisions in patients undergoing tracheostomy. Method The present study assessed the outcome measures between the two incision types (vertical and horizontal) in tracheostomy. A prospective longitudinal study was done based on an academic tertiary hospital in Bhopal, Madhya Pradesh. Participants above 18 years who underwent tracheostomy were enrolled in the study and followed up over six months during intraoperative, immediate, within seven days, and long-term periods. Result In intraoperative complications, bleeding was most common (n = 15, 16.7%), followed by passage of tube into false tract (n = 6, 6.7%) and saturation drop (n = 2, 2.2%). Immediate complications comprised T-tube blockage (n = 4, 4.4%) and bleeding (n = 1, 1.1%). Complications within seven days occurred only in the horizontal group in which stomal site ulceration (n = 4, 6.7%) and delayed bleeding (n = 2, 3.3%) was seen, and one participant had unintended decannulation. In the long term, complications observed were stomal granulation (n = 9, 19.1%), dysphagia (n = 7, 14.9%), and unintended decannulation (n = 4, 8.5%). Conclusion In the current study, the most common intraoperative complication was bleeding, the immediate complication was tube dislodgement, and tracheostomy site ulcer was the most common complication within seven days, similar to the literature findings.

Predictive Factors for Successful Decannulation in Patients with Tracheostomies and Brain Injuries: A Systematic Review

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.

Tracheostomy decannulation in severe acquired brain injury patients: The role of flexible bronchoscopy

INTRODUCTION AND OBJECTIVES

Subjects with severe acquired brain injury (sABI) require long-term mechanical ventilation and, as a consequence, the tracheostomy tube stays in place for a long time. In this observational study, we investigated to what extent the identification of late tracheostomy complications by flexible bronchoscopy (FBS) might guide clinicians in the treatment of tracheal lesions throughout the weaning process and lead to successful decannulation.

SUBJECTS AND METHODS

One hundred and ninety-four subjects with sABI admitted to our rehabilitation unit were enrolled in the study. All subjects received FBS and tracheal lesions were treated either by choosing a more suitable tracheostomy tube, or by laser therapy, or by steroid therapy, or by a combination of the above treatments.

RESULTS

Overall, 122 subjects (63%) were decannulated successfully. Our subjects received 495 FBSs (2.55 per subject) and as many as 270 late tracheostomy complications were identified. At least one complication was found in 160 subjects (82%). In only 11 subjects, late tracheostomy complications did not respond to the treatment and were the cause of decannulation failure.

CONCLUSIONS

In conclusion, in sABI patients FBS is able to guide successful tracheostomy weaning in the presence of late tracheostomy complications that could get in the way decannulation.

Predictors of long-term decannulation in patients with disorders of consciousness

Purpose

The predictors of tracheostomy decannulation in patients with disorders of consciousness (DOC) are not comprehensively understood, making prognosis difficult. The primary objective of this study was to identify predictors of tracheostomy decannulation in patients with disorders of consciousness (DOC). The secondary aim was to evaluate the feasibility and safety of the modified Evans blue dye test (MEBDT) in tracheostomized DOC patients.

Methods

This retrospective study included all patients with disorders of consciousness (DOC) who underwent tracheostomy and were admitted between January 2016 and September 2022. Age, sex, etiology, initial Glasgow coma scale (GCS), initial Coma Recovery Scale-Revised (CRS-R), diagnosis of unresponsive wakefulness syndrome (UWS) or minimal consciousness state (MCS), MEBDT, initial modified Rankin scale (mRS), and initial Functional Oral Intake Scale (FOIS) were collected upon study enrollment. The relationship between clinical characteristics and cannulation status was investigated through a Cox regression model.

Results

A total of 141 patients were included in the study. The average age of these patients was 52.5 ± 16.7 years, with 42 (29.8%) being women. During the study period, 86 subjects (61%) underwent successful decannulation. Univariate analysis revealed that decannulated patients exhibited a significantly better conscious state compared to those without decannulation (CRS-R: p < 0.001; GCS: p = 0.023; MCS vs. UWS: p < 0.001). Additionally, a negative modified Evans blue dye test (MEBDT) result was significantly associated with tracheostomy decannulation (p < 0.001). In the multivariate analysis, successful decannulation was associated with a higher level of consciousness (MCS vs. UWS, p < 0.001, HR = 6.694) and a negative MEBDT result (negative vs. positive, p = 0.006, HR = 1.873). The Kaplan-Meier analysis further demonstrated that MEBDT-negative patients and those in the MCS category had a higher probability of decannulation at 12 months (p < 0.001).

Conclusion

The findings of this study indicate that a negative MEBDT result and a higher level of consciousness can serve as predictive factors for successful tracheostomy decannulation in DOC patients.

Rehabilitative intervention for successful decannulation in adult patients with acquired brain injury and tracheostomy: a systematic review

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.

A Study of Difficulty in Decannulation of Tracheostomized Head Injury Patients

A prospective observational study was done with the aim to analyze the difficulties during decannulation of tracheostomized head injury patients and to devise a sound protocol for decannulation. It was done over 2 years in a tertiary care Army Hospital with 40 tracheostomized head injury cases in the age group of 10-70 years. Once the indication of tracheostomy was over, their Glasgow Coma Scale score, airway adequacy, phonation, swallowing, cough reflex, and lung pathology were assessed. Fit patients were decannulated if they tolerated tube capping for 3 days. Data was statistically analyzed. Road traffic accident was the cause of head injury in 90% cases. 45% patients had traumatic brain injury. All the cases required ventilatory support. 80% patients required neurosurgery. Tracheostomy was done between 5th to 10th day. Decannulation could be achieved in 75% patients. Factors like neurological status, duration of ventilatory need, number of days on T piece, cough reflex, suction requirement, phonation, consistency of tracheal secretion, lung condition, and three days? capping of tracheostomy tube were significantly associated with outcome of decannulation trial (p <0.05). Factors like mode of injury, neurosurgical intervention, absence of phonation, and downsizing of tube did not affect the outcome significantly (p >0.05). The factors like strong cough reflex, thin minimal tracheal secretion, aspiration free swallowing, better GCS score, early weaning from ventilator and younger age favour early successful decannulation. Gradual downsizing of tube or presence of phonation are not essential prerequisites for decannulation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03504-y.

Characterizing Swallowing Impairment in a Post-Lung Transplant Population

BACKGROUND

Lung transplant recipients carry significant pre- and post-lung transplant dysphagia risk factors related to altered respiratory-swallow coordination as well as acute injury and decompensation resulting in the acute post-lung transplant recovery period. However, we are only beginning to understand the potential physiological contributors to altered swallowing in this population.

METHOD

A retrospective, cross-sectional, cohort study of post-lung transplant patients was performed. All participants received a modified barium swallow study (MBSS) as part of standard care during their acute hospitalization using the Modified Barium Swallow Impairment Profile (MBSImP) protocol and scoring metric. A combination of MBSImP scores, Penetration-Aspiration Scale (PAS) scores, Functional Oral Intake Scale (FOIS) scores, International Dysphagia Diet Standardization Initiative (IDDSI) scale levels, and the time from lung transplant to MBSS was collected, as well as measures of swallowing impairment and swallowing-related outcomes. Differences in swallowing physiology and swallowing-related outcomes between participants with typical versus atypical PAS were explored.

RESULTS

Forty-two participants met our prespecified inclusion criteria. We identified atypical laryngeal penetration and/or aspiration in 52.4% of our post-lung transplant cohort. Silent aspiration occurred in 75% of those patients who aspirated. Comparing typical versus atypical PAS scores, we found statistically significant associations with laryngeal elevation (Component 8), p < .0001; anterior hyoid excursion (Component 9), p = .0046; epiglottic movement (Component 10), p = .0031; laryngeal vestibule closure (Component 11), p < .0001; pharyngeal stripping (Component 12), p = .0058; pharyngeal total scores, p = .0001; FOIS scores, p = .00264; and IDDSI liquid levels, p = .0009.

CONCLUSIONS

Swallowing impairment resulting in abnormal bolus invasion is prevalent in post-lung transplant patients. Airway invasion in this cohort was related to pharyngeal swallow impairment and resulted in modified oral intake. Our findings help expand upon prior literature, which only reported the incidence of aspiration and pathological laryngeal penetration. Our results suggest that the potential for aerodigestive system impairment and negative sequela should not be underestimated in the post-lung transplant population.

Does a decannulation protocol exist in COVID-19 patients? The importance of working in a multiprofessional team

As a Covid Hub in Emilia Romagna, we have experienced an increasing number of tracheostomized patients, prompting us to develop a standardized decannulation protocol for COVID-19 ARDS patients. Currently, there are no guidelines or protocols for decannulation in this population, and few studies have investigated the early outcomes of tracheostomy in COVID-19 patients, with no detailed analysis of the decannulation process. We recognized the importance of mutual reliance among our team members and the significant achievements we made compared to previous decannulation methods. Through the optimization of the decannulation process, we identified a clear, safe, and repeatable method based on clinical best practice and literature evidence. We decided to implement an existing standardized decannulation protocol, which was originally designed for severe brain-damaged patients, due to the growing number of COVID-19 patients with tracheostomy. This protocol was designed for daily practice and aimed to provide a uniform approach to using devices like fenestrated cannulas, speaking valves, and capping. The results of our implementation include:expanding the applicability of the protocol beyond severe brain-damaged patients to different populations and settings (in this case, patients subjected to a long period of sedation and invasive ventilation)early activation of speech therapy to facilitate weaning from the cannula and recovery of physiological swallowing and phonationearly activation of otolaryngologist evaluation to identify organic problems related to prolonged intubation, tracheostomy, and ventilation and address proper speech therapy treatmentactivation of more fluid and effective management paths for decannulation with a multiprofessional team.

Prognostic variables and decannulation of tracheostomy in the long-term acute care environment: a case for clinician-driven decision-making

Purpose

Tracheostomy is a necessary procedure required for prolonged mechanical ventilation in long-term acute care hospitals (LTACH). Many factors influence successful decannulation, or tracheostomy removal, and it is unclear what factors are essential for determining decannulation. The purpose of this study was to determine retrospective performance of single prognostic variables for successful decannulation, like peak expiratory flow measurement, overnight oximetry testing, and blood gas analysis.

Methods

A retrospective analysis of a three-year period to investigate the association between peak flow (PF) measurements ≥160 L/min, successful overnight oximetry (ONO), sex, and decannulation success. Average PF measurements, arterial blood gas (ABG), days on mechanical ventilation, LTACH length of stay (LOS), and age were also investigated.

Results

We examined the records of 135 patients, 127 of which were successfully decannulated. PF measurements ≥160 L/min (p=0.16), sex (p<0.05) and passing ONO (p<0.05) were significantly different between successfully and unsuccessfully decannulated patients; mean ABG (pH, pCO2, pO2), mechanical ventilation days, LOS, and age were not significantly different (p>0.05).

Conclusions

These results suggest no single prognostic variable can predict decannulation outcomes. Rather, clinical judgment of experienced medical professionals appears sufficient to achieve a 94% decannulation success rate. Additional investigation is required to determine what metrics are necessary, or if clinical judgment alone can predict decannulation success.

How the work of respiratory physiotherapists changes the tracheostomy management and decannulation in a NICU department: an Italian experience

Tracheotomy is a clinical procedure that is often necessary though not without complications, hence the need for appropriate and timely decannulation. The inclusion of trained respiratory physiotherapists (RPT) in the staff and the use of shared protocols could help the team to manage the patient with tracheotomy cannula. The objective of this study was to describe the difference in the rate of decannulation and clinical outcomes of tracheostomized patients admitted to a NeuroIntensive Care Unit (NICU) team after the inclusion of a group of physiotherapists specialized in respiratory physiotherapy and a new phoniatric protocol. It is a 6-year retrospective study, in which two periods of 3 years each were compared: in the first period (P1: September 2013-August 2016) physiotherapists were called to treat NICU patients on a consultative basis (2 hours/day for 5 days a week); in the second period (P2: September 2016-August 2019) two full-time respiratory physiotherapists were present on the ward (7 hours/day, 6/7 days/week). In P2 period, a decannulation protocol was used. Patients who had undergone a tracheotomy procedure and who were alive at the time of discharge were retrospectively evaluated. We described the number of decannulations, the length of stay in NICU and decannulation time; the diagnosis of decannulated patients and the number of deaths. 928 total patients were analysed: 468 in P1, 460 in P2. Total length of stay or number of deaths did not change significantly between the two periods, while the number of decannulated patients before the discharge was higher in P2 143 (64%), compared with P1 79 (36%) p<0.001. More patients with neurological pathologies involving possible swallowing disorders, such as cerebral haemorrhage, head trauma and stroke, have been successfully decannulated in P2 than in P1 (120 patients in P2 vs 54 in P1). A multidisciplinary approach, including respiratory physiotherapist, dedicated to tracheostomy management, decannulation and early mobilization in NICU is safe, feasible and seems to improve the number of severe patients decannulated, even if no change was observed in NICU length of stay or deaths. Further studies must confirm our results in other ICU settings.

Biomechanical mechanism of reduced aspiration by the Passy-Muir valve in tracheostomized patients following acquired brain injury: Evidences from subglottic pressure

Objective

Aspiration is a common complication after tracheostomy in patients with acquired brain injury (ABI), resulting from impaired swallowing function, and which may lead to aspiration pneumonia. The Passy-Muir Tracheostomy and Ventilator Swallowing and Speaking Valve (PMV) has been used to enable voice and reduce aspiration; however, its mechanism is unclear. This study aimed to investigate the mechanisms underlying the beneficial effects of PMV intervention on the prevention of aspiration.

Methods

A randomized, single-blinded, controlled study was designed in which 20 tracheostomized patients with aspiration following ABI were recruited and randomized into the PMV intervention and non-PMV intervention groups. Before and after the intervention, swallowing biomechanical characteristics were examined using video fluoroscopic swallowing study (VFSS) and high-resolution manometry (HRM). A three-dimensional (3D) upper airway anatomical reconstruction was made based on computed tomography scan data, followed by computational fluid dynamics (CFD) simulation analysis to detect subglottic pressure.

Results

The results showed that compared with the non-PMV intervention group, the velopharynx maximal pressure (VP-Max) and upper esophageal sphincter relaxation duration (UES-RD) increased significantly (P < 0.05), while the Penetration-Aspiration Scale (PAS) score decreased in the PMV intervention group (P < 0.05). Additionally, the subglottic pressure was successfully detected by CFD simulation analysis, and increased significantly after 2 weeks in the PMV intervention group compared to the non-PMV intervention group (P < 0.001), indicating that the subglottic pressure could be remodeled through PMV intervention.

Conclusion

Our findings demonstrated that PMV could improve VP-Max, UES-RD, and reduce aspiration in tracheostomized patients, and the putative mechanism may involve the subglottic pressure.

Clinical trial registration

[http://www.chictr.org.cn], identifier [ChiCTR1800018686].

Development and validation of a nomogram for decannulation in patients with neurological injury: A prognostic accuracy study

Background

Tracheostomy is a lifesaving procedure provided for patients with severe neurological injury. However, there is a lack of clarity about whether patients can be decannulated within 6 months in those receiving tracheostomy and what factors can be detected as a predictor for decannulation.

Objective

The objective of this study was to explore predictive factors of decannulation in patients with neurological injury receiving tracheostomy within 6 months and construct a novel nomogram model for clinical diagnosis and treatment.

Methods

This retrospective observational study enrolled patients with neurological injury who were admitted to the ICU of neurosurgical department in the First Affiliated Hospital of Nanjing Medical University between January 2016 and March 2021. Patients were divided into decannulation group and cannulation group according to whether tracheostomy tube removal was performed within 6 months after tracheostomy. Multivariable logistic regression analysis was performed to determine associated risk factors with a bootstrap backward selection process. The nomogram to assess the probability of decannulation at 6 months was constructed based on the regression coefficients of the associated factors and validated by bootstrap resampling. Model performance was measured by examining discrimination (Harrell's C-index), calibration (calibration plots), and utility (Kaplan–Meier curves stratified by the tertile of the predicted probability calculated and subgroup analysis stratified by age and intervention).

Results

A total of 40.1% (147/367) of patients decannulated within 6 months. Significant variables in multivariable logistic regression analysis were age (odds ratio [OR], 0.972; 95% confidence interval [CI], 0.954–0.990), National Institutes of Health Stroke Scale (NIHSS) score (OR, 0.936; 95% CI, 0.911–0.963), early rehabilitation (OR, 5.062; 95% CI, 2.889–8.868), shock (OR, 0.175; 95% CI, 0.058–0.533), and secondary surgery (OR, 0.210; 95% CI, 0.078–0.566). The area under receiver operating characteristic curve estimated with these variables was of 0.793 (95% CI, 0.747–0.838; P &lt; 0.001). A nomogram prediction model was constructed to predict the probability of decannulation in tracheostomized patients with a concordance index of 0.788 after internal validation.

Conclusion

We developed a nomogram that can predict the probability of decannulation within 6 months in tracheostomized neurological injury patients. The nomogram, including age, NIHSS scores, early rehabilitation, shock, and secondary surgery, may assist clinicians in estimating patients' prognosis.

Tracheostomy decannulation protocol in patients with prolonged tracheostomy referred to a rehabilitation hospital: a prospective cohort study

Background

The aim of the study was to assess the feasibility of a standardized tracheostomy decannulation protocol in patients with prolonged tracheostomy referred to a rehabilitation hospital.

Methods

This prospective cohort study recruited conscious patients with prolonged tracheostomy who were referred to the pulmonary rehabilitation department of a tertiary rehabilitation hospital between January 2019 and December 2021. A pulmonary rehabilitation team used a standardized tracheostomy decannulation protocol developed by the authors. The primary outcome was the success rate of decannulation. Secondary outcomes included decannulation time from referral and reintubation rate after a follow-up of 3 months.

Results

Of the 115 patients referred for weaning from mechanical ventilation and tracheostomy decannulation over the study period, 80.0% (92/115) were finally evaluated for tracheostomy decannulation. The mean time of tracheostomy in patients transferred to our department was 70.6 days. After assessment by a multidisciplinary team, 57 patients met all the decannulation indications and underwent decannulation. Fifty-six cases were successful, and 1 case was intubated again. The median time to decannulation after referral was 42.7 days. Reintubation after a follow-up of 3 months did not occur in any patients.

Conclusions

A standardized tracheostomy decannulation protocol implemented by a pulmonary rehabilitation team is associated with successful tracheostomy decannulation in patients with prolonged tracheostomy. Not every tracheostomy patient must undergo upper airway endoscopy before decannulation. Tolerance of speaking valve continuously for 4 h can be used as an alternative means for tube occlusion. A swallow assessment was used to evaluate the feeding mode and did not affect the final decision to decannulate.

Trial registration: 2018bkky-121.

Gram-negative multidrug-resistant organisms were dominant in neurorehabilitation ward patients in a general hospital in southwest China

This study aimed to investigate the prevalence of and risk factors for multidrug-resistant organism (MDRO) infection in the rehabilitation ward of a general hospital in Southwest China. We analyzed rehabilitation patients with nosocomial infections caused by MDROs from June 2016 to June 2020. MDRO infection pathogens and associated antibiotic resistance were calculated. Possible risk factors for MDRO-related infection in the neurorehabilitation ward were analyzed using chi-square, and logistic regression. A total of 112 strains of MDRO were found positive from 96 patients. The MDRO test-positive rate was 16.70% (96/575). Ninety-five MDRO strains were detected in sputum, of which 84.82% (95/112) were gram-negative bacteria. Acinetobacter baumannii (A. Baumannii), Pseudomonas aeruginosa (P. aeruginosa), and Klebsiella pneumonia (K. pneumonia) were the most frequently isolated MDRO strains. The logistic regression model and multifactorial analysis showed that long-term (≥ 7 days) antibiotic use (OR 6.901), history of tracheotomy (OR 4.458), and a low albumin level (< 40 g/L) (OR 2.749) were independent risk factors for the development of MDRO infection in patients in the rehabilitation ward (all P < 0.05). Gram-negative MRDOs were dominant in rehabilitation ward patients. Low albumin, history of a tracheostomy, and long-term use of antibiotics were independent risk factors for MRDO infection and are worthy of attention.

Effects of a modified Singh's algorithm care bundle on cannulation success rate in patients with neurological sequelae

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.

ROLE OF ULTRASONOGRAPHY IN UPPER AIRWAY ASSESSMENT FOR DECANNULATING TRACHEOSTOMY IN ACQUIRED BRAIN INJURY - A PILOT STUDY

OBJECTIVE

To compare the findings of ultrasonography of the upper airway with flexible fiberoptic laryngoscopy and determine the efficacy of transcutaneous laryngeal ultrasonography for decannulation.

DESIGN

Prospective cross sectional study SETTING: Tertiary care referral centre in South India PARTICIPANTS: Twenty- four patients with acquired brain injury MAIN OUTCOME MEASURES: Participants underwent an airway assessment by ultrasonography followed by assessment of airway by flexible laryngoscopy done within the next 72 hours.

RESULTS

Vocal cord assessment by ultrasonography revealed a sensitivity of 81.2% and specificity of 87.5%. A statistically significant association between vocal cord mobility as assessed by ultrasonography and decannulation was observed (sensitivity of 81.25%, specificity of 87.5%, p= 0.002). Although aspiration was not assessed by ultrasonography, a statistically significant association was observed between vocal cord mobility on ultrasonography and aspiration as assessed by laryngoscopy (sensitivity of 81.25%, specificity of 87.5%, p= 0.011).

CONCLUSION

Laryngeal ultrasonography is an emerging diagnostic modality with a potential role for assessing vocal cord mobility and airway prior to decannulation in centres which lack the expertise and the infrastructure to perform a flexible laryngoscopy.

Tracheostomy decannulation outcomes in 131 consecutive neurosurgical patients

OBJECTIVES

This study was a retrospective study to investigate factors related to difficult tracheostomy decannulation, and to evaluate outcomes of tracheostomized neurosurgical patients.

METHODS

All consecutive tracheostomized neurosurgical patients in the Prince of Wales Hospital between 1st September 2016 and 31st August 2019 were reviewed retrospectively. Patients were grouped into easy decannulation and difficult decannulation groups using 3 months as cut-off time. Risk factors were analysed and outcomes were compared.

RESULTS

One hundred thirty-one patients were included. In univariate analyses, male gender, GCS less than or equal to 8 on admission, the presence of vocal cord palsy at 3 months, and pneumonia within 1-month post-tracheostomy were associated with difficult decannulation. In multivariable logistic regression for difficult decannulation, GCS on admission, the presence of vocal cord palsy at 3 months, and the presence of pneumonia within 1-month post-tracheostomy remained statistically significant. The easy decannulation group had a shorter length of in-patient stay, higher survival rate, and more favourable neurological outcome (GOS 4-5) than the difficult decannulation group at both 6 months and 1 year. The majority of easy decannulation group patients (54%) were discharged to home, while the majority of the difficult decannulation group (42%) of patients were discharged to the infirmary.

CONCLUSION

GCS less than or equal to 8 on admission, the presence of vocal cord palsy, and the presence of pneumonia were associated with difficult tracheostomy decannulation in neurosurgical patients. Difficult decannulation is associated with a longer length of in-patient stay and poor neurological outcomes.

Weaning from mechanical ventilation in neurocritical care

In the intensive care unit (ICU), weaning from mechanical ventilation follows a step-by-step process that has been well established in the general ICU population. However, little data is available in brain injury patients, who are often intubated to protect airways and prevent central hypoventilation. In this narrative review, we describe the general principles of weaning and how these principles can be adapted to brain injury patients. We focus on three major issues regarding weaning from mechanic ventilation in brain injury patients: (1) sedation protocol, (2) weaning and extubation protocol and criteria, (3) criteria, timing and technique for tracheostomy.

External Validation and Calibration of the DecaPreT Prediction Model for Decannulation in Patients with Acquired Brain Injury

We propose a new set of clinical variables for a more accurate early prediction of safe decannulation in patients with severe acquired brain injury (ABI), during a post-acute rehabilitation course. Starting from the already validated DecaPreT scale, we tested the accuracy of new logistic regression models where the coefficients of the original predictors were reestimated. Patients with tracheostomy were retrospectively selected from the database of the neurorehabilitation unit at the S. Anna Institute of Crotone, Italy. New potential predictors of decannulation were screened from variables collected on admission during clinical examination, including (a) age at injury, (b) coma recovery scale-revised (CRS-r) scores, and c) length of ICU period. Of 273 patients with ABI (mean age 53.01 years; 34% female; median DecaPreT = 0.61), 61.5% were safely decannulated before discharge. In the validation phase, the linear logistic prediction model, created with the new multivariable predictors, obtained an area under the receiver operating characteristics curve of 0.901. Our model improves the reliability of simple clinical variables detected at the admission of the post-acute phase in predicting decannulation of ABI patients, thus helping clinicians to plan better rehabilitation.

The tracheotomy tube weaning in patients with severe acquired brain injury: comparison of two operative procedures in a postacute rehabilitation hospital

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.

Predicting postoperative tracheostomy requirement in children undergoing surgery for posterior fossa tumors

PURPOSE

Posterior fossa tumor (PFT) resection can be associated with postoperative respiratory failure. We aimed to identify risk factors predicting tracheostomy dependence in children after PFT resection.

METHODS

Retrospective chart review of all children undergoing PFT resection from April 2007 to May 2017 at our institution was performed.

RESULTS

A total of 197 patients were included; 12 (6.1%) required tracheostomy placement at a mean 69.1 days postoperatively (SD 112.7, range 7-388). Patients requiring tracheostomy were younger (3.4 vs. 6.8 years, p < 0.01), more likely to have postoperative dysphagia (91.7% vs. 17.3%, p < 0.01), and more likely to have an ependymoma (41.7% vs. 15.1%, p < 0.01) or astrocytoma (25.0% vs. 8.1%, p < 0.01). Patients with eventual tracheostomy were less likely extubated immediately postoperatively (45.5% vs. 79.6%, p < 0.01), had longer intubation duration postoperatively (5.7 vs. 0.5 days, p < 0.01), and had higher rates of reintubation within 48 h (63.6% vs. 1.3%, p < 0.01). Patients requiring tracheostomy had longer hospital length of stay (45.8 vs. 15.3 days, p < 0.01) and ICU stay postoperatively (13.5 vs. 2.1 days, p < 0.01). Of those requiring tracheostomy, three (25.0%) were decannulated by 1 year postoperatively. Decannulation rates did not vary by age (p < 0.47), extubation failure (p < 0.24), duration of intubation (p < 0.10), tumor histology (p < 0.23), or tumor grade (p < 0.13).

CONCLUSION

Lower cranial neuropathy following PFT resection is common. Identifying risk factors correlated with need for tracheostomy can help identify patients who may benefit from early tracheostomy, reducing prolonged intubation trauma, time on mechanical ventilation, and length of stay.

Tracheostomy decannulation methods and procedures for assessing readiness for decannulation in adults: a systematic scoping review

Despite the undisputable benefits of tracheostomy, it has been reported to have links with impaired communication, reduced quality of life and a risk of health complications such as bleeding, tracheal stenosis and in some cases resulting in mortality. There is a paucity of literature on tracheostomy decannulation methods and procedures, leaving the decision to expert opinion and institutional guidelines. This study aimed to map evidence on methods and procedures of tracheostomy decannulation in adults and assessment of readiness for decannulation, to reveal knowledge gaps and inform further research. We conducted a systematic search of peer reviewed and grey literature on PubMed/MEDLINE, Google Scholar, Union Catalogue of Theses and Dissertations via SABINET Online, World Cat Dissertations and Theses via OCLC, WHO library and governmental websites from 1985 to present. Following title screening, abstract and full article screening was performed by two independent reviewers guided by the eligibility criteria. Data from included studies were extracted, collated, summarized and synthesized into the following themes: assessment, removal, monitoring and definition of failure of decannulation. Quality of the included studies was assessed using the Mixed Methods Appraisal Tool version 2011. Twenty-five out of 51 screened articles were eligible for data extraction. There was wide variation in the assessment methods employed across and within similar patient groups. The common themes that emerged in the assessment for readiness for decannulation are informed consent, clinical stability, airway patency, physiological decannulation, swallowing assessment, level of consciousness, effectiveness of cough and clearance of secretions. In conclusion, the current body of evidence is inadequate and requires further research, particularly validation of different parameters used. A protocol approach to decannulation may be inappropriate but rather an algorithmic approach using validated parameters.

Mechanical ventilation in neurocritical care setting: A clinical approach

Neuropatients often require invasive mechanical ventilation (MV). Ideal ventilator settings and respiratory targets in neuro patients are unclear. Current knowledge suggests maintaining protective tidal volumes of 6-8 ml/kg of predicted body weight in neuropatients. This approach may reduce the rate of pulmonary complications, although it cannot be easily applied in a neuro setting due to the need for special care to minimize the risk of secondary brain damage. Additionally, the weaning process from MV is particularly challenging in these patients who cannot control the brain respiratory patterns and protect airways from aspiration. Indeed, extubation failure in neuropatients is very high, while tracheostomy is needed in one-third of the patients. The aim of this manuscript is to review and describe the current management of invasive MV, weaning, and tracheostomy for the main four subpopulations of neuro patients: traumatic brain injury, acute ischemic stroke, subarachnoid hemorrhage, and intracerebral hemorrhage.

Guidelines for Tracheostomy From the Korean Bronchoesophagological Society

The Korean Bronchoesophagological Society appointed a task force to develop a clinical practice guideline for tracheostomy. The task force conducted a systematic search of the Embase, Medline, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to key questions. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. An external expert review and a Delphi questionnaire were conducted to reach a consensus regarding the recommendations. Accordingly, the committee developed 18 evidence-based recommendations, which are grouped into seven categories. These recommendations are intended to assist clinicians in performing tracheostomy and in the management of tracheostomized patients.

Decannulation After a Severe Acquired Brain Injury

OBJECTIVE

To identify the effect of some clinical characteristics of severe acquired brain injury (sABI) patients on decannulation success during their intensive rehabilitation unit (IRU) stay.

DESIGN

Nonconcurrent cohort study.

SETTING

Don Gnocchi Foundation Institute.

PARTICIPANTS

Patients (N=351) with sABI and tracheostomy were retrospectively selected from the database of the IRU of the Don Gnocchi Foundation Institute.

MAIN OUTCOME MEASURES

Potential predictors of decannulation were screened from variables collected at admission during clinical examination, conducted by trained and experienced examiners. The association between clinical characteristics and decannulation status was investigated through a Cox regression model. Kaplan-Meier curves were then created for time-event analysis.

RESULTS

Among the patients (mean age, 64.1±15.5y), 54.1% were decannulated during their IRU stay. Absence of pulmonary infections (P<.001), sepsis (P=.001), tracheal alteration at the fibrobronchoscopy examination (P=.004) and a higher Coma Recovery Scale-Revised (CRS-R) score (P<.001) or a better state of consciousness at admission (P=.001) were associated with a higher probability of decannulation.

CONCLUSIONS

Fibrobronchoscopy assessment of patency of airways and accurate evaluation of the state of consciousness using the CRS-R are relevant in this setting of care to better identify patients who are more likely to have the tracheostomy tube removed. These results may help clinicians choose the appropriate timing and intensity of rehabilitation interventions and plan for discharge.

Current Status of Indications, Timing, Management, Complications, and Outcomes of Tracheostomy in Traumatic Brain Injury Patients

Tracheostomy is the commonest bedside surgical procedure performed on patients needing mechanical ventilation with traumatic brain injury (TBI). The researchers made an effort to organize a narrative review of the indications, timing, management, complications, and outcomes of tracheostomy in relation to neuronal and brain-injured patients following TBI. The study observations were collated from the published literature, namely original articles, book chapters, case series, randomized studies, systematic reviews, and review articles. Information sorting was restricted to tracheostomy and its association with TBI. Care was taken to review the correlation of tracheostomy with clinical correlates including indications, scheduling, interventions, prognosis, and complications of the patients suffering from mild, moderate and severe TBIs using Glasgow Coma Scale, Glasgow Outcome Scale, intraclass correlation coefficient, and other internationally acclaimed outcome scales. Tracheostomy is needed to overcome airway obstruction, prolonged respiratory failure and as indispensable component of mechanical ventilation due to diverse reasons in intensive care unit. Researchers are divided over early tracheostomy or late tracheostomy from days to weeks. The conventional classic surgical technique of tracheostomy has been superseded by percutaneous techniques by being less invasive with lesser complications, classified into early and late complications that may be life threatening. Additional studies have to be conducted to validate and streamline varied observations to frame evidence-based practice for successful weaning and decannulation. Tracheostomy is a safer option in critically ill TBI patients for which a universally accepted protocol for tracheostomy is needed that can help to optimize indications and outcomes.

The assessment of the peak of reflex cough in subjects with acquired brain injury and tracheostomy and healthy controls

INTRODUCTION

There is no standard procedure to evaluated the peak of reflex cough flow (PCF-reflex) in the literature, which is important assessment in subjects with acquired brain injury and tracheostomy cannula. The present study aims to investigate the PCF of the reflex cough in a broad sample of healthy controls and, furthermore, the presence and the strength of voluntary and reflex cough in subjects with ABI with tracheostomy cannula.

MATERIALS AND METHODS

We recruited 147 participants including the healthy subjects (n = 105) and acquired brain injury subjects (n = 43), who underwent respiratory assessment: the Tidal Volume, Forced Vital Capacity, PCF of voluntary cough (PCF-voluntary) and PCF-reflex (using a spirometer connected with a nebulizer by a bidirectional).

RESULTS

The PCF-reflex of controls and subjects was significant lower than the PCF-voluntary (P < 0.01). The PCF-voluntary was not assessed in 26 (60.5 %) subjects due to severe cognitive deficit. In subjects without cognitive deficits (n = 17; 39.5 %), it was significantly lower than in healthy controls (p < 0.01). In contrast, the PCF-reflex was completed in all subjects and it was not significantly different from healthy controls. Furthermore, the strength of the PCF-reflex decreased with increasing inhalation numbers of nebulised air.

CONCLUSION

Reflex cough behaviour differs largely from voluntary cough and the PCF results reflect this great discrepancy. PCF-reflex could be useful parameter for assessing the airway protection whereas PCF-voluntary for measuring airway clearance.

Speech and language therapy best practice for patients in prolonged disorders of consciousness: a modified Delphi study

BACKGROUND

Research regarding speech and language therapy (SLT) for patients in prolonged disorders of consciousness (PDOC) is very limited. The Royal College of Physicians' (RCP) PDOC guideline provides recommendations regarding best practice, but does not give detail about many aspects of assessment and management. As a result, SLTs have little information regarding best practice for this complex patient group.

AIMS

To ascertain the degree of consensus amongst expert SLTs regarding SLT best practice for patients in PDOC in order to inform the future development of SLT guidelines.

METHODS & PROCEDURES

A two-round modified Delphi technique was used. Participants were recruited from major trauma centres and neurorehabilitation units in England and national SLT clinical excellence networks. To participate, SLTs had to be working on neurosciences, neurosurgery or neurorehabilitation wards that treat adult PDOC patients, or have ≥ 3 years' experience of working with PDOC. The Round 1 questionnaire was developed from the RCP's PDOC guideline and from existing research literature. It included ratings of statements regarding SLT best practice using Likert or temporal scales, with optional written justifications/comments and opportunities for participants to suggest additional statements. The percentage agreement amongst participants was calculated for each Round 1 statement. Written justifications for views were analysed using content analysis. The Round 2 questionnaire contained both quantitative and qualitative feedback from Round 1, allowing participants to reappraise their views. The final degree of consensus was then calculated after completion of both rounds.

OUTCOMES & RESULTS

A total of 40 SLTs completed Round 1, with 36 completing Round 2 (90% response rate). Consensus was achieved for 87% (67/77) of statements regarding best practice on a variety of topics including communication, tracheostomy, dysphagia and oral hypersensitivity. The statements represented assessment, management and service delivery components of SLT practice.

CONCLUSIONS & IMPLICATIONS

A total of 67 best practice statements were created. The statements provide a useful starting point for the creation of SLT guidelines to support best practice, and also have the potential to be used to advocate for the provision of SLT services for patients in PDOC. Future studies should focus on whether the expert opinion generated here can be borne out in experimental research.

Management of tracheostomized patients after poor grade subarachnoid hemorrhage: Disease related and pulmonary risk factors for failed and delayed decannulation

OBJECTIVE

Tracheostomy is often indicated in patients with spontaneous subarachnoid hemorrhage (sSAH). Decannulation is a major goal of neurorehabilitation, but cannot be achieved in all patients. The aim of this study was to describe the course of decannulation and to identify associated risk factors in a single-center collective.

PATIENTS AND METHODS

We retrospectively reviewed 87 sSAH patients with WFNS (World Federation of Neurosurgical Societies) grade III-IV, who received tracheostomy. Decannulation events and the time from tracheostomy to decannulation were recorded in a 200-days follow-up. Variables analyzed were: age, sex, WFNS grade, Fisher grade, the presence of intracerebral or intraventricular hematoma, acute hydrocephalus, aneurysm location, aneurysm obliteration (surgical vs. endovascular), treatment related complications, decompressive craniectomy, symptomatic cerebral vasospasm, vasospasm-related infarction and timing of tracheostomy. Further risk factors analyzed were preexisting chronic lung disease and pneumonia. Functional outcome was assessed by the modified Rankin Scale (mRS).

RESULTS

The rate of successful decannulation was 84% after a median of 47 days. A higher WFNS grade and pneumonia were associated with both a prolonged time to decannulation (TTD) and decannulation failure (DF). Older age (> 60 years) and necessity for decompressive craniectomy were only associated with prolonged TTD. Outcome analysis revealed that patients with DF show a significantly (p < 0.01) higher rate of unfavorable outcome (mRS 3-6).

CONCLUSION

Successful decannulation is possible in the majority of sSAH patients and particularly, in all patients with WFNS grade III. WFNS grading, age, the necessity for decompressive craniectomy and pneumonia are significantly associated with the TTD. WFNS grade and pneumonia are significantly associated with DF. The mean cannulation time of sSAH patients is shorter in relation to stroke patients.

Roles of citric acid in conjunction with saline nebulization in experimental tracheostomy in guinea pigs

PURPOSE

Tracheostomy usually accompanied by the impairment of cough reflex, which may affect the clearance of secretions and result in the occurrence and development of pulmonary inflammation. Previous research has demonstrated that citric acid could effectively evoke cough. However, there are limited data available on this topic specific to the cough stimulation method, and the roles of citric acid in tracheostomy still remain obscure. The aims of present study were to identify the potential roles of citric acid in conjunction with saline nebulization in tracheostomy in guinea pigs.

MATERIALS AND METHODS

Experimental tracheostomy model was induced in guinea pigs, and different nebulization interventions were implemented. The expression of P-selectin and platelet count were analyzed by flow cytometer and automatic globulimeter, the histological changes in trachea and lung tissue were assessed by hematoxylin and eosin staining, and the inflammatory cytokines and substance P (SP) levels in bronchoalveolar lavage fluid were evaluated by enzyme-linked immunosorbent assay.

RESULTS

Tracheostomy resulted in the disorder of trachea mucosa and cilia, the inflammatory cell infiltration in lung tissue, the increase of IL-6, TNF-α levels and the decrease of SP level. Citric acid alone increase the SP level, and the joint action of citric acid and saline nebulization further showed significantly beneficial effects on pathological, inflammatory changes and SP level.

CONCLUSIONS

Citric acid combined with saline nebulization contributes to the alleviation of tracheotomy-induced tracheal damage and pulmonary inflammation in an experimental tracheostomy model in guinea pigs. This may provide novel insights into the inflammation management and cough recovery after tracheostomy.

Development of the Decannulation Prediction Tool in Patients With Dysphagia After Acquired Brain Injury

OBJECTIVES

Patients with acquired brain injuries (ABIs) often need tracheostomy because of dysphagia. However, many of them may recover over time and be eventually decannulated during post-acute rehabilitation. We developed the Decannulation Prediction Tool (DecaPreT) to identify, early in the post-acute course, patients with ABIs who can be safely decannulated.

DESIGN

Nonconcurrent cohort study.

SETTING AND PARTICIPANTS

Patients with ABI, as well as with dysphagia and tracheostomy, were retrospectively selected from the database of a neurorehabilitation unit in Correggio, Reggio Emilia, Italy.

MEASURES

Potential bivariate predictors of decannulation were screened from variables collected on admission during clinical examination, conducted by an expert speech therapist. Multivariable prediction was then obtained in 2 separate random subsamples to develop and validate the logistic regression model of the DecaPreT.

RESULTS

Of 463 patients with ABI (mean age 52.2 years) selected, 73.0% could be safely decannulated before discharge. After bivariate screening, multivariable predictors of decannulation were identified in the development subsample and confirmed in the validation subsample, each with its odds ratio and 95% confidence interval as follows: age tertile (1.77, 1.08-2.89; P = .024), no saliva aspiration (3.89, 1.73-8.64; P = .001), pathogenesis of ABI (trauma vs other causes vs stroke vs anoxia: 2.23, 1.41-3.54; P = .001), no vegetative status (8.47; 2.91-24.63; P < .001), and coughing score (voluntary and reflex vs voluntary vs reflex vs neither voluntary nor reflex cough: 2.62, 1.70-4.05; P < .001). In the validation subsample, the predicting equation obtained an area under the receiver operating characteristics curve of 0.836.

IMPLICATIONS

The DecaPreT predicts safe decannulation in patients with dysphagia and tracheostomy, using simple clinical variables detected early in the post-acute phase of ABI. The tool can help clinicians choose timing and intensity of rehabilitation interventions and plan discharge.

Changes in Swallowing and Cough Functions Among Stroke Patients Before and After Tracheostomy Decannulation

We investigated the functional changes in swallowing and voluntary coughing before and after tracheostomy decannulation among stroke patients who had undergone a tracheostomy. We also compared these functions between stroke patients who underwent tracheostomy tube removal and those who did not within 6 months of their stroke. Seventy-seven stroke patients who had undergone a tracheostomy were enrolled. All patients were evaluated by videofluoroscopic swallowing studies and a peak flow meter through the oral cavity serially until 6 months after their stroke. During the intensive rehabilitation period, if a patient satisfied the criteria for tracheostomy tube removal, the tube was removed. The patients were divided into the 'decannulated' group and the 'non-decannulated' group according to their tracheostomy tube removal status. In the decannulated group, swallowing function did not change before and after tracheostomy decannulation; however, cough function was significantly improved after decannulation. Although both groups exhibited functional improvement in swallowing and coughing over time, the improvement in the decannulated group was more significant than the improvement in the non-decannulated group. Our results revealed that stroke patients who had better functional improvement in swallowing and coughing were more likely to be potential candidates for tracheostomy decannulation. Stroke patients who recovered from neurogenic dysphagia, they were no longer affected by the mechanical effect of the tracheostomy tube on swallowing function. This study suggests that if patients show improvement in swallowing and coughing after their stroke, a multidisciplinary approach to tracheostomy decannulation would be needed to achieve better rehabilitation outcomes.