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Decannulation and Functional Outcome After Tracheostomy in Patients with Severe Stroke (DECAST): A Prospective Observational Study

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Abstract

Background

Tracheostomy is performed in ventilated stroke patients affected by persisting severe dysphagia, reduced level of consciousness, or prolonged mechanical ventilation. The study aim was to determine the frequency and predictors of successful decannulation and long-term functional outcome in tracheotomized stroke patients.

Methods

A prospective single-center observational study recruited ventilated patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. Follow-up visits were performed at hospital discharge, 3, and 12 months. Competing risk analyses were performed to identify predictors of decannulation.

Results

We included 53 ventilated stroke patients who had tracheostomy. One year after tracheostomy, 19 patients were decannulated (median [IQR] time to decannulation 74 [58–117] days), 13 patients were permanently cannulated, and 21 patients died without prior removal of the cannula. Independent predictors for decannulation in our cohort were patient age (HR 0.95 [95% CI: 0.92–0.99] per one year increase, p = 0.003) and absence of sepsis (HR 4.44 [95% CI: 1.33–14.80], p = 0.008). Compared to surviving patients without cannula removal, decannulated patients had an improved functional outcome after one year (median modified Rankin Scale score 4 vs. 5 [p < 0.001]; median Barthel index 35 vs. 5 [p < 0.001]).

Conclusions

Decannulation was achieved in 59.4% of stroke patients surviving the first 12 months after tracheostomy and was associated with better functional outcome compared to patients without decannulation. Further prospective studies with larger sample sizes are needed to confirm our results.

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Abbreviations

TS:

Tracheostomy

PDT:

Percutaneous dilational tracheostomy

MV:

Mechanical ventilation

NA:

Not applicable

References

  1. Berrouschot J, Rossler A, Koster J, Schneider D. Mechanical ventilation in patients with hemispheric ischemic stroke. Crit Care Med. 2000;28:2956–61.

    Article  CAS  PubMed  Google Scholar 

  2. Gujjar AR, Deibert E, Manno EM, Duff S, Diringer MN. Mechanical ventilation for ischemic stroke and intracerebral hemorrhage: indications, timing, and outcome. Neurology. 1998;51:447–51.

    Article  CAS  PubMed  Google Scholar 

  3. Steiner T, Mendoza G, De Georgia M, Schellinger P, Holle R, Hacke W. Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit. Stroke. 1997;28:711–5.

    Article  CAS  PubMed  Google Scholar 

  4. Santoli F, De Jonghe B, Hayon J, et al. Mechanical ventilation in patients with acute ischemic stroke: survival and outcome at one year. Intensive Care Med. 2001;27:1141–6.

    Article  CAS  PubMed  Google Scholar 

  5. Huttner HB, Kohrmann M, Berger C, Georgiadis D, Schwab S. Predictive factors for tracheostomy in neurocritical care patients with spontaneous supratentorial hemorrhage. Cerebrovasc Dis. 2006;21:159–65.

    Article  PubMed  Google Scholar 

  6. Pelosi P, Ferguson ND, Frutos-Vivar F, et al. Management and outcome of mechanically ventilated neurologic patients. Crit Care Med. 2011;39:1482–92.

    Article  PubMed  Google Scholar 

  7. Szeder V, Ortega-Gutierrez S, Ziai W, Torbey MT. The TRACH score: clinical and radiological predictors of tracheostomy in supratentorial spontaneous intracerebral hemorrhage. Neurocrit Care. 2010;13:40–6.

    Article  PubMed  Google Scholar 

  8. Bosel J, Schiller P, Hacke W, Steiner T. Benefits of early tracheostomy in ventilated stroke patients? Current evidence and study protocol of the randomized pilot trial SETPOINT (Stroke-related Early Tracheostomy vs. Prolonged Orotracheal Intubation in Neurocritical care Trial). Int J Stroke. 2012;7:173–82.

    Article  PubMed  Google Scholar 

  9. Schonenberger S, Al-Suwaidan F, Kieser M, Uhlmann L, Bosel J. The SETscore to predict tracheostomy need in cerebrovascular neurocritical care patients. Neurocrit Care. 2016;25:94–104.

    Article  PubMed  Google Scholar 

  10. Young D, Harrison DA, Cuthbertson BH, Rowan K, TracMan C. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309:2121–9.

    Article  CAS  PubMed  Google Scholar 

  11. McCredie VA, Alali AS, Scales DC, et al. Effect of early versus late tracheostomy or prolonged intubation in critically ill patients with acute brain injury: a systematic review and meta-analysis. Neurocrit Care. 2017;26(1):14–25.

    Article  Google Scholar 

  12. Meng L, Wang C, Li J, Zhang J. Early vs late tracheostomy in critically ill patients: a systematic review and meta-analysis. Clin Respir J. 2016;10:684–92.

    Article  PubMed  Google Scholar 

  13. Rabinstein AA, Wijdicks EF. Outcome of survivors of acute stroke who require prolonged ventilatory assistance and tracheostomy. Cerebrovasc Dis. 2004;18:325–31.

    Article  PubMed  Google Scholar 

  14. Bosel J, Schiller P, Hook Y, et al. Stroke-related Early Tracheostomy versus Prolonged Orotracheal Intubation in Neurocritical Care Trial (SETPOINT): a randomized pilot trial. Stroke. 2013;44:21–8.

    Article  PubMed  Google Scholar 

  15. Kothari RU, Brott T, Broderick JP, et al. The ABCs of measuring intracerebral hemorrhage volumes. Stroke. 1996;27:1304–5.

    Article  CAS  PubMed  Google Scholar 

  16. Coplin WM, Pierson DJ, Cooley KD, Newell DW, Rubenfeld GD. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J Respir Crit Care Med. 2000;161:1530–6.

    Article  CAS  PubMed  Google Scholar 

  17. Manno EM, Rabinstein AA, Wijdicks EF, et al. A prospective trial of elective extubation in brain injured patients meeting extubation criteria for ventilatory support: a feasibility study. Crit Care. 2008;12:R138.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Walts PA, Murthy SC, DeCamp MM. Techniques of surgical tracheostomy. Clin Chest Med. 2003;24:413–22.

    Article  PubMed  Google Scholar 

  19. Scrucca L, Santucci A, Aversa F. Competing risk analysis using R: an easy guide for clinicians. Bone Marrow Transplant. 2007;40:381–7.

    Article  CAS  PubMed  Google Scholar 

  20. Choate K, Barbetti J, Currey J. Tracheostomy decannulation failure rate following critical illness: a prospective descriptive study. Aust Crit Care. 2009;22:8–15.

    Article  PubMed  Google Scholar 

  21. Warnecke T, Suntrup S, Teismann IK, Hamacher C, Oelenberg S, Dziewas R. Standardized endoscopic swallowing evaluation for tracheostomy decannulation in critically ill neurologic patients. Crit Care Med. 2013;41:1728–32.

    Article  PubMed  Google Scholar 

  22. Hales PA, Drinnan MJ, Wilson JA. The added value of fibreoptic endoscopic evaluation of swallowing in tracheostomy weaning. Clin Otolaryngol. 2008;33:319–24.

    Article  CAS  PubMed  Google Scholar 

  23. Foerch C, Lang JM, Krause J, et al. Functional impairment, disability, and quality of life outcome after decompressive hemicraniectomy in malignant middle cerebral artery infarction. J Neurosurg. 2004;101:248–54.

    Article  PubMed  Google Scholar 

  24. Bosel J. Tracheostomy in stroke patients. Curr Treat Options Neurol. 2014;16:274.

    Article  PubMed  Google Scholar 

  25. Walcott BP, Kamel H, Castro B, Kimberly WT, Sheth KN. Tracheostomy after severe ischemic stroke: a population-based study. J Stroke Cerebrovasc Dis. 2014;23:1024–9.

    Article  PubMed  Google Scholar 

  26. Schonenberger S, Niesen WD, Fuhrer H, et al. Early tracheostomy in ventilated stroke patients: study protocol of the international multicentre randomized trial SETPOINT2 (Stroke-related Early Tracheostomy vs. Prolonged Orotracheal Intubation in Neurocritical care Trial 2). Int J Stroke. 2016;11:368–79.

    Article  PubMed  Google Scholar 

  27. Seder DB, Lee K, Rahman C, et al. Safety and feasibility of percutaneous tracheostomy performed by neurointensivists. Neurocrit Care. 2009;10:264–8.

    Article  PubMed  Google Scholar 

  28. Brass P, Hellmich M, Ladra A, Ladra J, Wrzosek A. Percutaneous techniques versus surgical techniques for tracheostomy. Codschrane Database Syst Rev. 2016;7:CD008045.

    Google Scholar 

  29. Johnson-Obaseki S, Veljkovic A, Javidnia H. Complication rates of open surgical versus percutaneous tracheostomy in critically ill patients. Laryngoscope. 2016;126:2459–67.

    Article  PubMed  Google Scholar 

  30. Dettmer MR, Damuth E, Zarbiv S, Mitchell JA, Bartock JL, Trzeciak S. prognostic factors for long-term mortality in critically ill patients treated with prolonged mechanical ventilation: a systematic review. Crit Care Med. 2017;45:69–74.

    Article  PubMed  Google Scholar 

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Acknowledgements

We would like to thank Michael Hanna, PhD, for proof reading the manuscript.

Authors’ Contributions

HS designed and coordinated the study, performed statistical analyses, interpreted results, and drafted the manuscript. FH acquired data, interpreted results, and revised the manuscript for content. MK performed statistical analyses and revised the manuscript for content. MR interpreted results and revised the manuscript for content. BG interpreted results and revised the manuscript for content. AT interpreted results and revised the manuscript for content. MD interpreted results and revised the manuscript for content. MN designed the study and revised the manuscript for content. HR interpreted results and revised the manuscript for content. SW designed the study, acquired and interpreted data, and revised the manuscript for content. All authors read and approved the final manuscript.

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Authors and Affiliations

  1. Department of Neurology and Dresden University Stroke Center, University Hospital, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany

    Hauke Schneider, Franziska Hertel, Heinz Reichmann & Sigrid Wöpking

  2. Institute for Medical Informatics and Biometry, Technische Universität Dresden, Dresden, Germany

    Matthias Kuhn

  3. Department of Anesthesiology and Intensive Care Medicine, University Hospital, Technische Universität Dresden, Dresden, Germany

    Maximilian Ragaller & Birgit Gottschlich

  4. Surgery Center, University Hospital, Technische Universität Dresden, Dresden, Germany

    Anne Trabitzsch

  5. Department of Neurosurgery, University Hospital, Technische Universität Dresden, Dresden, Germany

    Markus Dengl

  6. Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Technische Universität Dresden, Dresden, Germany

    Marcus Neudert

Authors
  1. Hauke Schneider
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  2. Franziska Hertel
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  3. Matthias Kuhn
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  4. Maximilian Ragaller
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  5. Birgit Gottschlich
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  6. Anne Trabitzsch
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  7. Markus Dengl
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  8. Marcus Neudert
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  9. Heinz Reichmann
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  10. Sigrid Wöpking
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Corresponding author

Correspondence to Hauke Schneider.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Statement

The study was approved by our institutional review board (Ethikkommission an der TU Dresden; OHRP IRB00001473; EK 101042013). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study or their legal representatives.

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Schneider, H., Hertel, F., Kuhn, M. et al. Decannulation and Functional Outcome After Tracheostomy in Patients with Severe Stroke (DECAST): A Prospective Observational Study. Neurocrit Care 27, 26–34 (2017). https://doi.org/10.1007/s12028-017-0390-y

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  • DOI: https://doi.org/10.1007/s12028-017-0390-y

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