| Coma & Chronic Disorders of Consciousness  

Implications of the Consciousness State on Decannulation in Patients With a Prolonged Disorder of Consciousness

This study explored the link between the evolution of consciousness and the advancement of the decannulation protocol in patients with prolonged disturbance of consciousness during their stay in an early intensive rehabilitation setting. Higher levels of consciousness on admission, as measured by the Coma Recovery Scale-Revised, were shown to be associated with higher rates of successful decannulation. Patients who had improved consciousness (transition between Unresponsive Wakefulness Syndrome (UWS) and Minimally Consciouss State "minus" and "plus" (MCS-/+) or between MCS- and MCS + or between MCS and emergence from MCS) were more likely to achieve decannulation. Importantly, the presence of even subtle signs of consciousness was observed in all patients who reached the decannulated . Therefore, all patients who persisted in a UWS during the rehabilitation stay failed decannulation. These results underscore the importance of monitoring the progress of consciousness during weaning from the tracheal cannula. They also confirm, in line with previous work (3), the impact of consciousness in the swallowing process closely related to weaning from the cannula.

Background: Up to 70% of severe Acquired Brain Injury (sABI) survivors admitted to rehabilitation are tracheostomized. A link between consciousness state and decannulation has been suggested, but is scarcely understood (1).

Objective: To investigate the evolution of consciousness state and cannula weaning in patients with prolonged Disorders of Consciousness admitted in an early intensive rehabilitation setting.

Methods: The analysis was conducted as part of the PRABI study (2). Adult patients with sABI admitted to the early intensive rehabilitation unit of IRCSS Fondazione Don Gnocchi, Florence, from June 2020 to September 2022, were enrolled.
Consciousness state was assessed using the Coma Recovery Scale-Revised (CRS-R) at admission and weekly afterward. Dates of first consciousness improvement and decannulation were recorded.

Results: One hundred forty-four patients were included: mean 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. Decannulated patients had significantly higher CRS-R scores (P<.001) at admission, first consciousness improvement (P=.003), and discharge (P<.001). They also had a lower severity on the Cumulative Illness Rating Scale (P=.01) and fewer recurrent pulmonary infections (P=.021). Almost all decannulated patients (97.3%) improved their consciousness before decannulation, and none were in Unresponsive Wakefulness Syndrome (UWS) at decannulation. Kaplan-Meier analysis showed a higher probability of decannulation in patients who improved consciousness (P<.001)

Conclusion: The presence of signs of consciousness, even subtle, is a necessary condition or decannulation. Consciousness may influence some of the components implied in the decannulation process.

Key Points:

Tracheostomy; Early intensive Rehabilitation; Severe Acquired Brain Injury; Consciousness Disorders; Swallowing

References:

  1. Hakiki B et al. Decannulation and improvement of responsiveness in patients with disorders of consciousness. Neuropsychol Rehabil. 2022 May;32(4):520-536. doi: 10.1080/09602011.2020.1833944. .
  2. Hakiki B et al. 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 Feb 28;13:711312. doi: 10.3389/fneur.2022.711312.
  3. Mélotte E et al. Links Between Swallowing and Consciousness: A Narrative Review. Dysphagia. 2023 Feb;38(1):42-64. doi: 10.1007/s00455-022-10452-2.

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