Decannulation Potential After Acquired Brain Injury in Rehabilitation-Oriented Outpatient Intensive Care

Outpatient intensive care for severely injured patients after discharge from the acute medical setting or early rehabilitation treatment presents substantial challenges for the outpatient care setting (1). In 2020, the statutory health insurers spent more than €2bn on outpatient intensive care services (of about 20 000 treatment cases). In a recent analysis of AOK billing data for such patients, a need for mechanical ventilation was coded for 20–25%; 60–70% of this clientele required a tracheostomy and had dysphagia (2). Little is known to date, however, about the subgroup of patients with a tracheostomy who are not mechanically ventilated—especially their decannulation potential. This seems to be a relevant figure in outpatient intensive care. The newly established Intensive Care and Rehabilitation Strengthening Act (GKV-IPReG) requires regular checks for possible decannulation potential. It is not clear, however, how this potential can be influenced in the outpatient setting (3). The following sections describe the setting and success rate of a rehabilitation-focused institution of outpatient intensive care with the objective of decannulation.

Methods

In 2014 the outpatient nursing service of the Fürst Donnersmarck Foundation, in collaboration with the P.A.N. Center for post-acute neurorehabilitation (4), started an outpatient intensive care service with the focus on rehabilitation. The service is intended for people with a tracheal cannula with and without ventilation after acquired brain injury in whom no short-term decannulation potential was perceived in the context of pre-treatment—usually because of neurogenic dysphagia—when they were clinically and paraclinically assessed. The intention was to evaluate and therapeutically support these patients’ decannulation or weaning potential over a time period of up to 18 months. On the basis of individual case decisions, patients with progressive neurologic disorders or diagnoses outside the neurologic spectrum are also included. Once patients achieved a positive decannulation prognosis (among others, on the basis of the FEES examinations carried out on site), they are referred to inpatient clinical institutions for the purpose of decannulation. Decannulation on site is undertaken only in individual cases because no timely emergency care can be guaranteed in the outpatient setting should decannulation related complications occur.

The present analysis included all cases whose treatment was concluded between 1 July 2014 and 31 December 2022. The diagnosis, age at admission, sex, treatment duration, ventilation status, and tracheal cannula status at the time of admission, as well as follow-on care after the end of treatment were retrospectively collected. According to § 5 section 1 No 2 of the Church law on data protection of the Protestant Church in Germany (EKD Data Protection Act—DSG-EKD) and after approval of the local data protection officer, patients’ approval was not required. The patients were categorized into three groups—“acquired brain injury,” “other neurologic diagnoses,” and “non-neurologic diagnoses”—on the basis of their primary diagnosis. For the group of patients with acquired brain injuries (the primary target group of the institution), a descriptive analysis was carried out with the software package SPSS 29.0 with median (m) and interquartile ranges (IQR); for interval scaled data the Mann-Whitney-U test was used to undertake an unpaired group comparison.

Results

Over the observation period, a total of 43 persons with a tracheal cannula were admitted and discharged, of whom 29 had a diagnosis of an acquired brain injury. The diagnoses of these 29 patients are listed in the Table. It was possible to decannulate 13 patients (45%); four patients died during the observation period. If decannulation was successful, the median time period to decannulation was 11 months after the tracheal cannula had been placed. None of the decannulated patients required further outpatient intensive care. Three returned to their domiciles and four were looked after in outpatient care institutions. For six persons, subsequent neurologic long-term rehabilitation (4) was initiated; after its conclusion a further four patients were discharged to their homes. Four non-decannulated persons were discharged to domestic intensive care and eight patients with a tracheal cannula were transferred to other institutions of outpatient intensive care.

Table. Characteristics of cannulated and non-cannulated patients with acquired brain injury.

	All patients	Decannulation successful	Decannulation unsuccessful	Significance (Mann-Whitney-U test)
Number	n = 29	n = 13	n = 16	–
Age at admission/years (median. IQR)	55 [46.6; 65]	52 [42; 56.5]	60.5 [48.25; 74.5]	p = 0.050
Sex (male/female)	23 / 6	10 / 3	13 / 3	–
Latency placement of tracheal cannula to admission/days (median. IQR)	179 [121; 233]	170 [111; 215]	193.5 [121.5; 240.75]	p = 0.531
Diagnoses
– Cerebral ischemia	10	5	5	–
– Hemorrhage	10	4	6	–
– Traumatic brain injury	5	1	4	–
– Hypoxia	2	1	1	–
– Other	2	2	–	–
Additional diagnoses
– Initial respiratory failure	24	11	13	–
– Prolonged weaning	12	4	8	–
– Aspiration pneumonia	10	3	7	–
– Reduced vigilance	5	1	4	–
– Initial dysphagia	15	9	6	–
Ventilation at admission	1	–	1	–
Enteral feeding via PEG at admission	29	13	16	–
Duration of stay/days (median. IQR)	365 [199; 553]	210 [157.5; 355.5]	471 [354.5; 622]	p = 0.022
Time from admission to decannulization/days (median. IQR)	–	155 [100; 321.5]	–	–
Ventilation at discharge	–	–	–	–
Oral feeding/nutrition at discharge	13	11	2	–

IQR. interquartile range; PEG. percutaneous endoscopic gastrostomy

The Table shows the comparison between decannulated and non-decannulated persons. The successfully decannulated patients were significantly younger and were cannulated for a non-significantly shorter time before admission. Of the patients with other neurologic diagnoses, decannulation was successful in two out of six cases, in non-neurologic diagnoses in one of eight cases.

Discussion

Our data show that decannulation can be achieved even under outpatient conditions in about half of surviving patients with acquired brain injury. With about 11 months, decannulation took notably longer than in institutions providing early neurologic-neurosurgical rehabilitation (about 2 months) (5). Ongoing outpatient intensive care was avoided in all decannulated patients. The crucial factors for success are probably the rehabilitation focus with consistent care by qualified doctors, nurses, and therapists, as well as a regular interprofessional exchange. Because of the selection process before admission, the present data cannot be considered as representative for the entire patient population receiving outpatient intensive care. Further limitations of this analysis are the absence of a control group, as for ethical reasons a randomized trial was not possible. Furthermore, data are lacking regarding other clinical parameters—such as cognition, motor skills, or activities of daily life, as well as follow-up interviews about the long-term course. Including the named factors may help in future studies to capture the effects of this treatment approach in greater precision.