Implications of the consciousness state on decannulation in patients with a prolonged Disorder of Consciousness

Francesca Draghi; Silvia Pancani; Agnese De Nisco; Anna Maria Romoli; Daniela Maccanti; Rachele Burali; Antonello Grippo; Claudio Macchi; Francesca Cecchi; Bahia Hakiki

doi:10.1016/j.apmr.2024.05.006

Implications of the consciousness state on decannulation in patients with a prolonged Disorder of Consciousness

Arch Phys Med Rehabil. 2024 May 9:S0003-9993(24)00994-8. doi: 10.1016/j.apmr.2024.05.006. Online ahead of print.

Affiliations

¹ IRCCS Fondazione Don Carlo Gnocchi Onlus, Via di Scandicci, 269, 50143, Florence, Italy.
² IRCCS Fondazione Don Carlo Gnocchi Onlus, Via di Scandicci, 269, 50143, Florence, Italy. Electronic address: spancani@dongnocchi.it.
³ IRCCS Fondazione Don Carlo Gnocchi Onlus, Via di Scandicci, 269, 50143, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3, 50134 Florence, Italy.

PMID: 38734048
DOI: 10.1016/j.apmr.2024.05.006

Abstract

Objective: to prospectively investigate the evolution of the consciousness state and the cannula-weaning progression in patients with prolonged Disorders of Consciousness (pDoC).

Design: non-concurrent cohort study SETTING: rehabilitation unit of the Fondazione Don Gnocchi, Florence PARTICIPANTS: adult patients, with a pDoC following a sABI admitted between 06.2020 and 09.2022 INTERVENTIONS: not applicable MAIN OUTCOME MEASURES: consciousness state was assessed by repeated Coma Recovery Scale-Revised (CRS-R) administration at admission, and weekly afterwards. The dates of the first improvement of consciousness state and the achievement of decannulation were recorded. Decannulation followed an internal protocol of multi-professional rehabilitation.

Results: 144 patients were included: age: 69 years, 64 (44.4%) with hemorrhagic etiology, time post-onset: 40 days, CRS-R at admission: 9, median length of stay: 90 days. Seventy-three (50.7%) patients were decannulated. They showed a significantly higher CRS-R (p<0.001) and states of consciousness (p<0.001) at admission, at the first improvement of the consciousness state (p=0.003), and discharge (p<0.001), a lower severity in the Cumulative Illness Rating Scale at admission (p=0.01), and a lower rate of pulmonary infections with recurrence (p=0.021), compared to non-decannulated patients. Almost all decannulated patients (97.3%) improved their consciousness before decannulation. Consciousness states at decannulation were: Unresponsive wakefulness Syndrome: 0 (0%), Minimally conscious state (MCS) minus: 4 (5.5%), MCS plus: 7 (9.6%), 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<0.001).

Conclusion: 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.

Keywords: Brain Injury; Consciousness Disorders; Deglutition; Rehabilitation; Tracheostomy.