Predictive Factors for Successful Decannulation in Patients with Tracheostomies and Brain Injuries: A Systematic Review.

Neurological patients frequently have disorders of consciousness, swallowing disorders, or neurological states that are incompatible with extubation. Therefore, they frequently require tracheostomies during their stay in an intensive care unit. After the acute phase, tracheostomy weaning and decannulation are generally expected to promote rehabilitation. However, few reliable predictive factors (PFs) for decannulation have been identified in this patient population. We sought to identify PFs that may be used during tracheostomy weaning and decannulation in patients with brain injuries. We conducted a systematic review of the literature regarding potential PFs for decannulation; searches were performed on 16 March 2021 and 1 June 2022. The following databases were searched: MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, PEDro, OPENGREY, OPENSIGLE, Science Direct, CLINICAL TRIALS and CENTRAL. We searched for all article types, except systematic reviews, meta-analyses, abstracts, and position articles. Retrieved articles were published in English or French, with no date restriction. In total, 1433 articles were identified; 26 of these were eligible for inclusion in the review. PFs for successful decannulation in patients with acquired brain injuries (ABIs) included high neurological status, traumatic brain injuries rather than stroke or anoxic brain lesions, younger age, effective swallowing, an effective cough, and the absence of pulmonary infections. Secondary PFs included early tracheostomy, supratentorial lesions, the absence of critical illness polyneuropathy/myopathy, and the absence of tracheal lesions. To our knowledge, this is the first systematic review to identify PFs for decannulation in patients with ABIs. These PFs may be used by clinicians during tracheostomy weaning.

A Pluridisciplinary Tracheostomy Weaning Protocol for Brain-Injured Patients, Outside of the Intensive Care Unit and Without Instrumental Assessment: Results of Pilot Study.

Concurrently to the recent development of percutaneous tracheostomy techniques in the intensive care unit (ICU), the amount of tracheostomized brain-injured patients has increased. Despites its advantages, tracheostomy may represent an obstacle to their orientation towards conventional hospitalization or rehabilitation services. To date, there is no recommendation for tracheostomy weaning outside of the ICU. We created a pluridisciplinary tracheostomy weaning protocol relying on standardized criteria but adapted to each patient's characteristics and that does not require instrumental assessment. It was tested in a prospective, single-centre, non-randomized cohort study. Inclusion criteria were age > 18 years, hospitalized for an acquired brain injury (ABI), tracheostomized during an ICU stay, and weaned from mechanical ventilation. The exclusion criterion was severe malnutrition. Decannulation failure was defined as recannulation within 96 h after decannulation. Thirty tracheostomized ABI patients from our neurosurgery department were successively and exhaustively included after ICU discharge. Twenty-six patients were decannulated (decannulation rate, 90%). None of them were recannulated (success rate, 100%). Two patients never reached the decannulation stage. Two patients died during the procedure. Mean tracheostomy weaning duration (inclusion to decannulation) was 7.6 (standard deviation [SD]: 4.6) days and mean total tracheostomy time (insertion to decannulation) was 42.5 (SD: 24.8) days. Our results demonstrate that our protocol might be able to determine without instrumental assessment which patient can be successfully decannulated. Therefore, it may be used safely outside ICU or a specialized unit. Moreover, our tracheostomy weaning duration is very short as compared to the current literature.

Expert Consensus on Clinical Decision Making in the Disease Trajectory of Oropharyngeal Dysphagia in Adults: An International Delphi Study.

To date, no consensus exists on the complex clinical decision-making processes involved in oropharyngeal dysphagia, or swallowing disorders. This study aimed to develop an international consensus on a clinical decision tree for the disease trajectory of oropharyngeal dysphagia in adults, taking into account physiological impairments of swallowing, risk factors for the development of complications from oropharyngeal dysphagia, and prognostic factors for treatment outcomes. Using the Delphi technique, consensus was achieved among dysphagia experts across 31 countries, resulting in a total of 10 physiological impairments, 23 risk factors and 21 prognostic factors identified as relevant factors in the clinical decision-making process. Factors most contributing to the severity of oropharyngeal dysphagia were 'Aspiration', 'Incomplete ejection or failure to eject aspirated materials from the airways', 'Weak or absent cough', 'Choking' and 'Sensory deficits in the oropharynx'. To connect the existing theoretical framework to clinical practice, future research will develop the current findings by corroborating the domains based on relevant factors for clinical decision making and those that contribute to the severity of oropharyngeal dysphagia.

European Survey: Dysphagia Management in Patients with Neuromuscular Diseases.

Dysphagia is common in patients with neuromuscular diseases (NMDs). Its management differs by country and clinical setting. The purpose of this study was to describe current practices in the management of dysphagia in NMDs across Europe. An online survey of sixteen questions was developed, including basic information on facilities, existence of a management protocol, availability of dedicated therapists, tools used during screening, assessment, treatment stages, and treatment strategies. The survey was rolled out to European healthcare facilities providing care for NMDs. A total of 140 facilities across 25 European countries completed the survey. Substantial discrepancies in dysphagia management were identified among respondents. Seventy-two percent of the facilities reported having a protocol for at least one of the three management stages whereas only 39% had one for all. Speech and language therapists were reported as involved throughout the entire management stage while participation of other members from multidisciplinary teams varied depending on the stage. Clinical swallowing assessment was the most frequently reported tool in the assessment and treatment stages. For screening, questionnaires were the most frequently used while instrumental examinations were mainly reported in the assessment stage. For the treatment stage, adaptation strategies (diet, food, and posture) were the most reported approaches. In conclusion, the survey highlighted the absence of a defined protocol concerning the management of dysphagia in most of the surveyed healthcare facilities. Standardized training strategies and guidelines are necessary in the future to familiarize clinicians with each stage of the management of dysphagia.

The Athletics Injury Prevention Programme Can Help to Reduce the Occurrence at Short Term of Participation Restriction Injury Complaints in Athletics: A Prospective Cohort Study.

We aimed to determine whether an Athletics Injury Prevention Programme (AIPP), targeting the most common athletics injuries, can reduce the occurrence of injury complaints that lead to restrictions in athletics participation (participation restriction injury complaints) in the short (12 weeks) and long (40 weeks) terms. For our 40-week prospective cohort study (level of evidence 2), we invited inter-regional and national-level athletes to regularly perform the AIPP, which included 8 exercises addressing core stability, hamstring, leg and pelvic muscles strengthening and stretching, and balance exercises. A Cox regression was used to analyse the influence of AIPP on the occurrence of participation restriction injury complaint, adjusted to sex, age, height, body mass, discipline, and history of injury complaints during the preceding season, individual response rate, mean weekly training time, mean weekly number of competition, presented by hazard ratio (HR) with 95% confidence interval (95% CI). At 12 weeks (n = 62 athletes), the AIPP was significantly associated with a lower risk of participation restriction injury complaint HR = 0.36 (95%CI: 0.15 to 0.86), p = 0.02 and HR = 0.29 (95%CI: 0.12 to 0.73), p = 0.009, with cumulative weeks and cumulative training time as time scale, respectively, while at 40 weeks (n = 53 athletes) there was no significant association. An 8-exercise injury prevention programme can effectively help to reduce occurrence of injury complaints that would restrict an athlete's participation in athletics in the short term.

Stroke-Associated Pneumonia Risk Score: Validity in a French Stroke Unit.

BACKGROUND: Stroke-associated pneumonia is a leading cause of in-hospital death and post-stroke outcome. Screening patients at high risk is one of the main challenges in acute stroke units. Several screening tests have been developed, but their feasibility and validity still remain unclear. OBJECTIVE: The aim of our study was to evaluate the validity of four risk scores (Pneumonia score, A2DS2, ISAN score, and AIS-APS) in a population of ischemic stroke patients admitted in a French stroke unit. METHODS: Consecutive ischemic stroke patients admitted to a stroke unit were retrospectively analyzed. Data that allowed to retrospectively calculate the different pneumonia risk scores were recorded. Sensitivity and specificity of each score were assessed for in-hospital stroke-associated pneumonia and mortality. The qualitative and quantitative accuracy and utility of each diagnostic screening test were assessed by measuring the Youden Index and the Clinical Utility Index. RESULTS: Complete data were available for only 1960 patients. Pneumonia was observed in 8.6% of patients. Sensitivity and specificity were, respectively, .583 and .907 for Pneumonia score, .744 and .796 for A2DS2, and .696 and .812 for ISAN score. Data were insufficient to test AIS-APS. Stroke-associated pneumonia risk scores had an excellent negative Clinical Utility Index (.77-.87) to screen for in-hospital risk of pneumonia after acute ischemic stroke. CONCLUSION: All scores might be useful and applied to screen stroke-associated pneumonia in stroke patients treated in French comprehensive stroke units.

Effect of submental sensitive transcutaneous electrical stimulation on virtual lesions of the oropharyngeal cortex.

OBJECTIVE: The aim of this study was to assess the effect of submental sensitive transcutaneous electrical stimulation (SSTES) on pharyngeal cortical representation after the creation of an oropharyngeal cortical virtual lesion in healthy subjects. METHODS: Motor-evoked potential amplitude of the mylohyoid muscles was measured with transcranial magnetic stimulation (TMS), the oropharyngeal cortex was mapped by cartography, and videofluoroscopic parameters of swallowing function were measured before and after SSTES (at the end of SSTES [0 min] and at 30 and 60 min), after the creation of a cortical virtual lesion (repetitive TMS, 1 Hz, 20 min on the dominant swallowing hemisphere). RESULTS: Nine subjects completed the study. After 20 min of SSTES, motor-evoked potential amplitude increased (P<0.05), as did swallow reaction time after repetitive TMS, as seen on videofluoroscopy, which was reversed after electrical stimulation. On cortical mapping, the number of points with a cortical response increased in the dominant lesioned hemisphere (P<0.05), remaining constant at 60 min (P<0.05). CONCLUSION: SSTES may be effective for producing cortical plasticity for mylohyoid muscles and reverses oropharyngeal cortical inhibition in healthy subjects. It could be a simple non-invasive way to treat post-stroke dysphagia.

Safety and self-reported efficacy of botulinum toxin for adult spasticity in current clinical practice: a prospective observational study.

OBJECTIVE: To determine the safety and the self-reported efficacy of botulinum toxin injections for adult spasticity in current clinical practice. DESIGN: A prospective observational study. SUBJECTS: A total of 406 adult patients with focal spasticity received of 1136 series botulinum toxin injections at Bordeaux University Hospital from January 2007 to December 2009. METHODS: Adverse events following botulinum toxin injections were reported. Their severity and the therapeutic efficacy of botulinum toxin injections were estimated with a four-point self-reporting scale (0 to 3). Latency and duration of adverse events and subjective improvement were also noted. RESULTS: The data of 640 series of injections were analyzed. Forty-six (7.2%) adverse events were reported, of which 36 (78%) were local. There were 18 (39%) cases of local muscular weakness with an average duration of 30.0 (SD 38.2) days, and an average severity score of 1.0 (SD 0.97). Among systemic adverse events, there were 8 (17%) cases of excessive fatigue without global muscular weakness and 2 (4%) cases of transitory generalized muscular weakness. The average subjective improvement score was 1.89 (SD 0.97) and was higher for upper, than for lower, limbs (P=0.007). CONCLUSION: Self-reported adverse events following botulinum toxin injections in spasticity are rare, often benign and of short duration in current clinical practice. Botulinum toxin is considered effective by patients in treating spasticity of the upper and lower limbs.

Botulinum toxin treatment in neurological practice: how much does it really cost? A prospective cost-effectiveness study.

Botulinum toxin (BTA) is a safe and effective therapeutic tool for many neurological conditions but few studies have investigated its real cost in neurological practice. We evaluated the daily cost of botulinum toxin type A (BTA) treatment through a cost effectiveness analysis alongside a prospective study of BTA injections at a French University Hospital over a 2-year follow-up period. The data of 3,108 BTA injections performed in 870 adult patients presenting with dystonia, facial hemispasm, or spasticity were entered in the database. Patients were questioned at each visit about the subjective effectiveness of the previous injection. The daily cost of BTA treatment was calculated as the ratio of each session's cost (including all additional costs) to the duration of subjective efficacy. The subjective rating of efficacy duration was 17.3 ± 7.7 weeks for facial hemispasm, 15.4 ± 7.7 for blepharospasm, 14.3 ± 6.7 for cervical dystonia, 14.5 ± 7.8 and 14.1 ± 7.4 weeks for upper and lower limb spasticity, respectively. The daily cost of BTA injections was 0.57 ± 0.20 for facial hemispasm, 0.95 ± 0.30 for blepharospasm, 2.85 ± 0.86 for cervical dystonia, 3.38 ± 1.49 and 3.62 ± 1.81 for upper and lower limb spasticity, respectively. When associated costs were considered, the daily cost of BTA injections was clearly increased (45-93%) in limb spasticity or rigidity but remained only modestly increased (15-37%) in other indications. These results obtained in a large cohort of patients show that BTA treatment has a low daily cost for a long-lasting effect, with a daily cost/benefit ratio that greatly depends on the indications.