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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:S0003-9993(24)00994-8. [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] [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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Ge J, Niu G, Li Q, Li Y, Yang B, Guo H, Wang J, Zhang B, Zhang C, Zhou T, Zhao Z, Jiang H. Cough flows as a criterion for decannulation of autonomously breathing patients with tracheostomy tubes. Respir Res 2024; 25:128. [PMID: 38500141 PMCID: PMC10949589 DOI: 10.1186/s12931-024-02762-w] [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: 10/15/2023] [Accepted: 03/08/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Adequate cough or exsufflation flow can indicate an option for safe tracheostomy decannulation to noninvasive management. Cough peak flow via the upper airways with the tube capped is an outcome predictor for decannulation readiness in patients with neuromuscular impairment. However, this threshold value is typically measured with tracheotomy tube removed, which is not acceptable culturally in China. The aim of this study was to assess the feasibility and safety of using cough flow measured with tracheostomy tube and speaking valve (CFSV) > 100 L/min as a cutoff value for decannulation. STUDY DESIGN Prospective observational study conducted between January 2019 and September 2022 in a tertiary rehabilitation hospital. METHODS Patients with prolonged tracheostomy tube placement were referred for screening. Each patient was assessed using a standardized tracheostomy decannulation protocol, in which CFSV greater than 100 L/min indicated that the patients' cough ability was sufficient for decannulation. Patients whose CFSV matched the threshold value and other protocol criteria were decannulated, and the reintubation and mortality rates were followed-up for 6 months. RESULTS A total of 218 patients were screened and 193 patients were included. A total of 105 patients underwent decannulation, 103 patients were decannulated successfully, and 2 patients decannulated failure, required reinsertion of the tracheostomy tube within 48 h (failure rate 1.9%). Three patients required reinsertion or translaryngeal intubation within 6 months. CONCLUSIONS CFSV greater than 100 L/min could be a reliable threshold value for successful decannulation in patients with various primary diseases with a tracheostomy tube. TRIAL REGISTRATION This observational study was not registered online.
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Affiliation(s)
- Jingyi Ge
- Department of Respiratory Rehabilitation Center, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, China
| | - Guangyu Niu
- Department of Respiratory Rehabilitation Center, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, China
| | - Qing Li
- Department of Respiratory Rehabilitation Center, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, China
| | - Yi Li
- Department of Respiratory Rehabilitation Center, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, China
| | - Bo Yang
- Department of Respiratory Rehabilitation Center, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, China
| | - Haiming Guo
- Department of Respiratory Rehabilitation Center, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, China
| | - Jianjun Wang
- Department of Respiratory Rehabilitation Center, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, China
| | - Bin Zhang
- Department of Respiratory Rehabilitation Center, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, China
| | - Chenxi Zhang
- Department of Respiratory Rehabilitation Center, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, China
| | - Ting Zhou
- Department of Respiratory Rehabilitation Center, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, China
| | - Zhanqi Zhao
- School of Biomedical Engineering, Guangzhou Medical University, Guangzhou, China
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Hongying Jiang
- Department of Respiratory Rehabilitation Center, Beijing Rehabilitation Hospital of Capital Medical University, Beijing, China.
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Chen Y, Aishan G, Fan S, Wang T, Wu J, Chia C, Liu G, Wang L, Hu R. Predictors of long-term decannulation in patients with disorders of consciousness. Front Neurol 2023; 14:1099307. [PMID: 37849837 PMCID: PMC10577412 DOI: 10.3389/fneur.2023.1099307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 08/21/2023] [Indexed: 10/19/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ruiping Hu
- Department of Rehabilitation Medicine, Huashan Hospital, Fudan University, Shanghai, China
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Liuzzi P, Grippo A, Campagnini S, Scarpino M, Draghi F, Romoli A, Bahia H, Sterpu R, Maiorelli A, Macchi C, Cecchi F, Carrozza MC, Mannini A. Merging Clinical and EEG Biomarkers in an Elastic-Net Regression for Disorder of Consciousness Prognosis Prediction. IEEE Trans Neural Syst Rehabil Eng 2022; 30:1504-1513. [PMID: 35635833 DOI: 10.1109/tnsre.2022.3178801] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Patients with Disorder of Consciousness (DoC) entering Intensive Rehabilitation Units after a severe Acquired Brain Injury have a highly variable evolution of the state of consciousness which is a complex aspect to predict. Besides clinical factors, electroencephalography has clearly shown its potential into the identification of prognostic biomarkers of consciousness recovery. In this retrospective study, with a dataset of 271 patients with DoC, we proposed three different Elastic-Net regressors trained on different datasets to predict the Coma Recovery Scale-Revised value at discharge based on data collected at admission. One dataset was completely EEG-based, one solely clinical data-based and the last was composed by the union of the two. Each model was optimized, validated and tested with a robust nested cross-validation pipeline. The best models resulted in a median absolute test error of 4.54 [IQR = 4.56], 3.39 [IQR = 4.36], 3.16 [IQR = 4.13] for respectively the EEG, clinical and hybrid model. Furthermore, the hybrid model for what concerns overcoming an unresponsive wakefulness state and exiting a DoC results in an AUC of 0.91 and 0.88 respectively. Small but useful improvements are added by the EEG dataset to the clinical model for what concerns overcoming an unresponsive wakefulness state. Data-driven techniques and namely, machine learning models are hereby shown to be capable of supporting the complex decision-making process the practitioners must face.
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Hakiki B, Donnini I, Romoli AM, Draghi F, Maccanti D, Grippo A, Scarpino M, Maiorelli A, Sterpu R, Atzori T, Mannini A, Campagnini S, Bagnoli S, Ingannato A, Nacmias B, De Bellis F, Estraneo A, Carli V, Pasqualone E, Comanducci A, Navarro J, Carrozza MC, Macchi C, Cecchi F. Clinical, Neurophysiological, and Genetic Predictors of Recovery in Patients With Severe Acquired Brain Injuries (PRABI): A Study Protocol for a Longitudinal Observational Study. Front Neurol 2022; 13:711312. [PMID: 35295839 PMCID: PMC8919857 DOI: 10.3389/fneur.2022.711312] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 01/13/2022] [Indexed: 01/03/2023] Open
Abstract
Background Due to continuous advances in intensive care technology and neurosurgical procedures, the number of survivors from severe acquired brain injuries (sABIs) has increased considerably, raising several delicate ethical issues. The heterogeneity and complex nature of the neurological damage of sABIs make the detection of predictive factors of a better outcome very challenging. Identifying the profile of those patients with better prospects of recovery will facilitate clinical and family choices and allow to personalize rehabilitation. This paper describes a multicenter prospective study protocol, to investigate outcomes and baseline predictors or biomarkers of functional recovery, on a large Italian cohort of sABI survivors undergoing postacute rehabilitation. Methods All patients with a diagnosis of sABI admitted to four intensive rehabilitation units (IRUs) within 4 months from the acute event, aged above 18, and providing informed consent, will be enrolled. No additional exclusion criteria will be considered. Measures will be taken at admission (T0), at three (T1) and 6 months (T2) from T0, and follow-up at 12 and 24 months from onset, including clinical and functional data, neurophysiological results, and analysis of neurogenetic biomarkers. Statistics Advanced machine learning algorithms will be cross validated to achieve data-driven prediction models. To assess the clinical applicability of the solutions obtained, the prediction of recovery milestones will be compared to the evaluation of a multiprofessional, interdisciplinary rehabilitation team, performed within 2 weeks from admission. Discussion Identifying the profiles of patients with a favorable prognosis would allow customization of rehabilitation strategies, to provide accurate information to the caregivers and, possibly, to optimize rehabilitation outcomes. Conclusions The application and validation of machine learning algorithms on a comprehensive pool of clinical, genetic, and neurophysiological data can pave the way toward the implementation of tools in support of the clinical prognosis for the rehabilitation pathways of patients after sABI.
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Affiliation(s)
- Bahia Hakiki
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Ida Donnini
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Anna Maria Romoli
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Francesca Draghi
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Daniela Maccanti
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Antonello Grippo
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Maenia Scarpino
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Antonio Maiorelli
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Raisa Sterpu
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Tiziana Atzori
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Andrea Mannini
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy.,The Biorobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Silvia Campagnini
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy.,The Biorobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Silvia Bagnoli
- Neuroscience Section, Department of Neurofarba, University of Florence, Firenze, Italy
| | - Assunta Ingannato
- Neuroscience Section, Department of Neurofarba, University of Florence, Firenze, Italy
| | - Benedetta Nacmias
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy.,Neuroscience Section, Department of Neurofarba, University of Florence, Firenze, Italy
| | - Francesco De Bellis
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Anna Estraneo
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Valentina Carli
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Eugenia Pasqualone
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy
| | - Angela Comanducci
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Milano, Italy
| | - Jorghe Navarro
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Milano, Italy
| | | | - Claudio Macchi
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | - Francesca Cecchi
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Don Carlo Gnocchi, Firenze, Italy.,Department of Experimental and Clinical Medicine, University of Florence, Firenze, Italy
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Critical Illness Polyneuropathy and Myopathy and Clinical Detection of the Recovery of Consciousness in Severe Acquired Brain Injury Patients with Disorders of Consciousness after Rehabilitation. Diagnostics (Basel) 2022; 12:diagnostics12020516. [PMID: 35204606 PMCID: PMC8870865 DOI: 10.3390/diagnostics12020516] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/07/2022] [Accepted: 02/14/2022] [Indexed: 01/25/2023] Open
Abstract
Background: Disorders of consciousness (DoCs) include unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS). Critical illness polyneuropathy and myopathy (CIPNM) is frequent in severe acquired brain injuries and impacts functional outcomes at discharge from the intensive rehabilitation unit (IRU). We investigated the prevalence of CIPNM in DoCs and its relationship with the consciousness assessment. Methods: Patients with DoCs were retrospectively selected from the database including patients admitted to the IRU of the IRCCS Don Gnocchi Foundation, Florence, from August 2012 to May 2020. Electroneurography/electromyography was performed at admission. Consciousness was assessed using the Coma Recovery Scale-Revised (CRS-R) at admission and discharge. Patients transitioning from a lower consciousness state to a higher one were classified as improved responsiveness (IR). Results: A total of 177 patients were included (UWS: 81 (45.8%); MCS: 96 (54.2%); 78 (44.1%) women; 67 years (IQR: 20). At admission, 108 (61.0%) patients had CIPNM. At discharge, 117 (66.1%) patients presented an IR. In the multivariate analysis, CRS-R at admission (p = 0.006; OR: 1.462) and CIPNM (p = 0.039; OR: −1.252) remained significantly associated with IR only for the UWS patients. Conclusions: CIPNM is frequent in DoCs and needs to be considered during the clinical consciousness assessment, especially in patients with UWS.
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External Validation and Calibration of the DecaPreT Prediction Model for Decannulation in Patients with Acquired Brain Injury. Brain Sci 2021; 11:brainsci11060799. [PMID: 34204352 PMCID: PMC8234369 DOI: 10.3390/brainsci11060799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/08/2021] [Accepted: 06/15/2021] [Indexed: 11/20/2022] Open
Abstract
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.
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