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Gallice T, Cugy E, Germain C, Barthélemy C, Laimay J, Gaube J, Engelhardt M, Branchard O, Maloizel E, Frison E, Dehail P, Cuny E. A Pluridisciplinary Tracheostomy Weaning Protocol for Brain-Injured Patients, Outside of the Intensive Care Unit and Without Instrumental Assessment: Results of Pilot Study. Dysphagia 2024; 39:608-622. [PMID: 38062168 PMCID: PMC11239749 DOI: 10.1007/s00455-023-10641-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/06/2023] [Indexed: 07/12/2024]
Abstract
Concurrently to the recent development of percutaneous tracheostomy techniques in the intensive care unit (ICU), the amount of tracheostomized brain-injured patients has increased. Despites its advantages, tracheostomy may represent an obstacle to their orientation towards conventional hospitalization or rehabilitation services. To date, there is no recommendation for tracheostomy weaning outside of the ICU. We created a pluridisciplinary tracheostomy weaning protocol relying on standardized criteria but adapted to each patient's characteristics and that does not require instrumental assessment. It was tested in a prospective, single-centre, non-randomized cohort study. Inclusion criteria were age > 18 years, hospitalized for an acquired brain injury (ABI), tracheostomized during an ICU stay, and weaned from mechanical ventilation. The exclusion criterion was severe malnutrition. Decannulation failure was defined as recannulation within 96 h after decannulation. Thirty tracheostomized ABI patients from our neurosurgery department were successively and exhaustively included after ICU discharge. Twenty-six patients were decannulated (decannulation rate, 90%). None of them were recannulated (success rate, 100%). Two patients never reached the decannulation stage. Two patients died during the procedure. Mean tracheostomy weaning duration (inclusion to decannulation) was 7.6 (standard deviation [SD]: 4.6) days and mean total tracheostomy time (insertion to decannulation) was 42.5 (SD: 24.8) days. Our results demonstrate that our protocol might be able to determine without instrumental assessment which patient can be successfully decannulated. Therefore, it may be used safely outside ICU or a specialized unit. Moreover, our tracheostomy weaning duration is very short as compared to the current literature.
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Affiliation(s)
- Thomas Gallice
- Neurosurgery Unit B, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France.
- Bordeaux Research Center for Population Health (BPH), Team: ACTIVE, University Bordeaux Segalen, UMR_S 1219, 33000, Bordeaux, France.
- Physical and Rehabilitation Medicine Unit, Swallowing Evaluation Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France.
- Neurological ICU, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France.
| | - Emmanuelle Cugy
- Physical and Rehabilitation Medicine Unit, Swallowing Evaluation Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
- Arcachon Hospital, Physical and Rehabilitation Medicine Unit, 33260, La Teste de Buch, France
| | - Christine Germain
- Medical Information Unit, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Clément Barthélemy
- Neurological ICU, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Julie Laimay
- Neurosurgery Unit B, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
- Neurological ICU, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Julie Gaube
- Neurological ICU, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Mélanie Engelhardt
- 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, Cognition and Language Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
- Neuro-Vascular Unit, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Olivier Branchard
- Neurosurgery Unit B, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Elodie Maloizel
- Neurosurgery Unit B, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Eric Frison
- Medical Information Unit, 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
| | - Emmanuel Cuny
- Neurological ICU, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
- Neurodegenerative Diseases Institute, CNRS, UMR 5293, 33000, Bordeaux, France
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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: 0] [Impact Index Per Article: 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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Spicer L, Stephenson E, Tate L, van Hille L, Kenny M, Ross D. 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. Disabil Rehabil 2024; 46:2065-2068. [PMID: 37233604 DOI: 10.1080/09638288.2023.2216027] [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: 09/27/2022] [Accepted: 05/14/2023] [Indexed: 05/27/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Madeleine Kenny
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Faculty of Health Studies, University of Bradford, Bradford, UK
| | - Denise Ross
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
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Premraj L, Camarda C, White N, Godoy DA, Cuthbertson BH, Rocco PRM, Pelosi P, Robba C, Suarez JI, Cho SM, Battaglini D. Tracheostomy timing and outcome in critically ill patients with stroke: a meta-analysis and meta-regression. Crit Care 2023; 27:132. [PMID: 37005666 PMCID: PMC10068163 DOI: 10.1186/s13054-023-04417-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 03/27/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Stroke patients requiring mechanical ventilation often have a poor prognosis. The optimal timing of tracheostomy and its impact on mortality in stroke patients remains uncertain. We performed a systematic review and meta-analysis of tracheostomy timing and its association with reported all-cause overall mortality. Secondary outcomes were the effect of tracheostomy timing on neurological outcome (modified Rankin Scale, mRS), hospital length of stay (LOS), and intensive care unit (ICU) LOS. METHODS We searched 5 databases for entries related to acute stroke and tracheostomy from inception to 25 November 2022. We adhered to PRISMA guidance for reporting systematic reviews and meta-analyses. Selected studies included (1) ICU-admitted patients who had stroke (either acute ischaemic stroke, AIS or intracerebral haemorrhage, ICH) and received a tracheostomy (with known timing) during their stay and (2) > 20 tracheotomised. Studies primarily reporting sub-arachnoid haemorrhage (SAH) were excluded. Where this was not possible, adjusted meta-analysis and meta-regression with study-level moderators were performed. Tracheostomy timing was analysed continuously and categorically, where early (< 5 days from initiation of mechanical ventilation to tracheostomy) and late (> 10 days) timing was defined per the protocol of SETPOINT2, the largest and most recent randomised controlled trial on tracheostomy timing in stroke patients. RESULTS Thirteen studies involving 17,346 patients (mean age = 59.8 years, female 44%) met the inclusion criteria. ICH, AIS, and SAH comprised 83%, 12%, and 5% of known strokes, respectively. The mean time to tracheostomy was 9.7 days. Overall reported all-cause mortality (adjusted for follow-up) was 15.7%. One in five patients had good neurological outcome (mRS 0-3; median follow-up duration was 180 days). Overall, patients were ventilated for approximately 12 days and had an ICU LOS of 16 days and a hospital LOS of 28 days. A meta-regression analysis using tracheostomy time as a continuous variable showed no statistically significant association between tracheostomy timing and mortality (β = - 0.3, 95% CI = - 2.3 to 1.74, p = 0.8). Early tracheostomy conferred no mortality benefit when compared to late tracheostomy (7.8% vs. 16.4%, p = 0.7). Tracheostomy timing was not associated with secondary outcomes (good neurological outcome, ICU LOS and hospital LOS). CONCLUSIONS In this meta-analysis of over 17,000 critically ill stroke patients, the timing of tracheostomy was not associated with mortality, neurological outcomes, or ICU/hospital LOS. TRIAL REGISTRATION PROSPERO-CRD42022351732 registered on 17th of August 2022.
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Affiliation(s)
- Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, Queensland, Australia
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Queensland, Australia
| | | | - Nicole White
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Daniel Agustin Godoy
- Neurointensive Care Unit, Critical Care Department, Sanatorio Pasteur, Chacabuco 675, 4700, Catamarca, Argentina
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- University Department of Anaesthesiology in Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anaesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anaesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, USA
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Wang X, Wang L, Wang Z, Sun Y, Liu X, Li F, Zheng Y. Development and validation of a nomogram for decannulation in patients with neurological injury: A prognostic accuracy study. Front Neurol 2022; 13:979160. [PMID: 36341086 PMCID: PMC9630346 DOI: 10.3389/fneur.2022.979160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/03/2022] [Indexed: 06/07/2024] Open
Abstract
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 < 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.
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Affiliation(s)
- Xi Wang
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lu Wang
- Department of Rehabilitation Medicine, Qingdao Municipal Hospital, Qingdao, China
| | - Zeyu Wang
- Department of Rehabilitation Medicine, Shanghai Ruijin Rehabilitation Hospital, Shanghai, China
| | - Yi Sun
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xingdong Liu
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Feng Li
- Department of Neurological Rehabilitation, Wuxi Yihe Rehabilitation Hospital, Wuxi, China
| | - Yu Zheng
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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