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

Schneider, Hauke; Hertel, Franziska; Kühn, Matthias; Ragaller, M.; Gottschlich, Birgit; Trabitzsch, Anne; Dengl, Markus; Neudert, Marcus; Reichmann, Heinz; Wöpking, Sigrid

doi:10.1007/s12028-017-0390-y

Cited by 29 publications

(36 citation statements)

References 30 publications

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“…In the model, which included age, diagnosis, days until admission to rehabilitation, region, swallowing function, and functional ability after the injury, we found that age in particular and a combination of swallowing function and overall functional ability after the injury were highly associated with time to decannulation. Age as an inverse predictor of decannulation is in line with several previous studies investigating predictors of decannulation in either subjects with acquired brain injury or critically ill subjects in general, 9,10,20,31 and swallowing function has also been reported as a predictor of decannulation. 5,10,20,31 For illustrative purposes, we have presented probability curves for subgroups, to show that the model is able to Decannulation from a cuffed tube: n ¼ 520 subjects.…”

Section: Discussionsupporting

confidence: 90%

“…Several previous studies have investigated predictors of decannulation in subjects with acquired brain injury. However, many studies are of poor quality (eg, small study populations, or the use of univariate analyses), 4,5,7,8,20,[27][28][29] thus limiting the conclusions that may be drawn from those studies. 30 A few recent studies have investigated the prediction of decannulation in larger study populations of subjects with neurological diseases and acquired brain injury using routinely gathered clinical data and applying multivariable analytical methods.…”

Section: Discussionmentioning

confidence: 99%

“…19 All items are scored on a 5point Likert scale (1: no function; 2: severe disturbance; 3: moderate disturbance; 4: slight disturbance; 5: normal), with a total score ranging from 20 to 100. This score, along with the item score for swallowing function (ie, swallowing function vs no swallowing function), 5,10,20 were included in the prognostic model, with the following categories: (1) EFA 20-40 + no swallowing function, (2) EFA 20-40 + swallowing function, (3) EFA 41-60 + no swallowing function, (4) EFA 41-60 + swallowing function, (5) EFA 61-100 + no swallowing function, (6) EFA 61-100 + swallowing function, and (7) missing. The region from which the subject was referred was also included as a predictor, because the likelihood of being discharged with a tracheostomy tube was reduced in subjects from central Jutland (for organizational reasons) compared with the 4 other regions in Denmark, thus introducing systematically different right-censoring mechanisms of event times between regions.…”

Section: Clinical Predictorsmentioning

confidence: 99%

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Using Routinely Gathered Clinical Data to Develop a Prognostic Online Tool for Decannulation in Subjects With Acquired Brain Injury

Mortensen¹,

Kjeldsen²,

Honoré³

et al. 2020

Respir Care

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BACKGROUND: Clinicians are often required to provide a qualified guess on the probability of decannulation in estimating patients' rehabilitation potential and relaying information about prognosis to patients and next of kin. The objective of this study was to use routinely gathered clinical data to develop a prognostic model of time to decannulation in subjects with acquired brain injury, for direct implementation in clinical practice. METHODS: Data from a large cohort including 574 tracheostomized subjects admitted for neurorehabilitation were analyzed using discrete time-to-event analysis with logit-link. Within this model, a reference hazard function was modeled using restricted cubic splines, and estimates were presented using odds ratios (95% CIs). RESULTS: A total of 411 subjects (72%) were decannulated within a median of 27 d (interquartile range 16-49) at the rehabilitation hospital. The prognostic model for decannulation included age, diagnosis, days from injury until admission for rehabilitation, swallowing, and overall functional level measured with the Early Functional Abilities score. Among these, the strongest predictors for decannulation were age and a combination of overall functional abilities combined with swallowing ability. CONCLUSIONS: A prognostic model for decannulation was developed using routinely gathered clinical data. Based on the model, an online graphical user interface was applied, in which the probability of decannulation within x days is calculated along with the statistical uncertainty of the probability. Furthermore, a layman's interpretation is provided. The online tool was directly implemented in clinical practice at the rehabilitation hospital, and is available through this link: (

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Section: Clinical Predictorsmentioning

confidence: 99%

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Using Routinely Gathered Clinical Data to Develop a Prognostic Online Tool for Decannulation in Subjects With Acquired Brain Injury

Mortensen¹,

Kjeldsen²,

Honoré³

et al. 2020

Respir Care

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“…Similarly, the low rate of spontaneous recovery in the control group is compatible with the "Decannulation and Functional Outcome After Tracheostomy in Patients with Severe Stroke" (DECAST) cohort study, where only 26% (14/53) of tracheotomised stroke patients could be decannulated within 3 months of stroke. 17 The relationship between treatment efficacy and short times to treatment is presumably related to the development of critical illness dysphagia due to critical illness polyneuropathy and myopathy in patients with prolonged ICU treatment and mechanical ventilation. 33,34 Apart from stroke-related impairment of the central swallowing network, polyneuropathy and myopathy will damage swallowing related cranial nerves and muscles, respectively.…”

Section: Discussionmentioning

confidence: 99%

“…15,16 In stroke patients, severe dysphagia with related insufficient airway protection is often the main reason why decannulation cannot be performed even three months post stroke. 12,17 Currently, treatment options for accelerating decannulation are very limited. 1 Pharyngeal electrical stimulation (PES) is a novel technique shown to enhance reorganisation of the swallow-related motor-cortex, facilitate activation of cortico-bulbar pathways, and increases salivary substance P levels, a swallow-related neurotransmitter.…”

Section: Introductionmentioning

confidence: 99%

Pharyngeal electrical stimulation for early decannulation in tracheotomised patients with neurogenic dysphagia after stroke (PHAST-TRAC): a prospective, single-blinded, randomised trial

Dziewas

Stellato

Tweel

et al. 2018

The Lancet Neurology

117

111

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Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation

Bösel

Niesen²,

Salih

et al. 2022

JAMA

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ImportanceMany patients with severe stroke have impaired airway protective reflexes, resulting in prolonged invasive mechanical ventilation.ObjectiveTo test whether early vs standard tracheostomy improved functional outcome among patients with stroke receiving mechanical ventilation.Design, Setting, and ParticipantsIn this randomized clinical trial, 382 patients with severe acute ischemic or hemorrhagic stroke receiving invasive ventilation were randomly assigned (1:1) to early tracheostomy (≤5 days of intubation) or ongoing ventilator weaning with standard tracheostomy if needed from day 10. Patients were randomized between July 28, 2015, and January 24, 2020, at 26 US and German neurocritical care centers. The final date of follow-up was August 9, 2020.InterventionsPatients were assigned to an early tracheostomy strategy (n = 188) or to a standard tracheostomy (control group) strategy (n = 194).Main Outcomes and MeasuresThe primary outcome was functional outcome at 6 months, based on the modified Rankin Scale score (range, 0 [best] to 6 [worst]) dichotomized to a score of 0 (no disability) to 4 (moderately severe disability) vs 5 (severe disability) or 6 (death).ResultsAmong 382 patients randomized (median age, 59 years; 49.8% women), 366 (95.8%) completed the trial with available follow-up data on the primary outcome (177 patients [94.1%] in the early group; 189 patients [97.4%] in the standard group). A tracheostomy (predominantly percutaneously) was performed in 95.2% of the early tracheostomy group in a median of 4 days after intubation (IQR, 3-4 days) and in 67% of the control group in a median of 11 days after intubation (IQR, 10-12 days). The proportion without severe disability (modified Rankin Scale score, 0-4) at 6 months was not significantly different in the early tracheostomy vs the control group (43.5% vs 47.1%; difference, −3.6% [95% CI, −14.3% to 7.2%]; adjusted odds ratio, 0.93 [95% CI, 0.60-1.42]; P = .73). Of the serious adverse events, 5.0% (6 of 121 reported events) in the early tracheostomy group vs 3.4% (4 of 118 reported events) were related to tracheostomy.Conclusions and RelevanceAmong patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy, compared with a standard approach to tracheostomy, did not significantly improve the rate of survival without severe disability at 6 months. However, the wide confidence intervals around the effect estimate may include a clinically important difference, so a clinically relevant benefit or harm from a strategy of early tracheostomy cannot be excluded.Trial RegistrationClinicalTrials.gov Identifier: NCT02377167

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

Abstract: 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.

Cited by 29 publications

References 30 publications

Using Routinely Gathered Clinical Data to Develop a Prognostic Online Tool for Decannulation in Subjects With Acquired Brain Injury

Using Routinely Gathered Clinical Data to Develop a Prognostic Online Tool for Decannulation in Subjects With Acquired Brain Injury

Pharyngeal electrical stimulation for early decannulation in tracheotomised patients with neurogenic dysphagia after stroke (PHAST-TRAC): a prospective, single-blinded, randomised trial

Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation

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