Effect of mechanical insufflation-exsufflation for ineffective cough on weaning duration in diseases of the peripheral or central nervous system (MEDINE): study protocol for a randomised controlled trial in a neurological weaning centre.

INTRODUCTION: Patients with neurological or neurosurgical disease can suffer from impaired cough, which may result in life-threatening retention of tracheobronchial secretions, atelectasis, pneumonia and finally death. Due to a lack of alternatives and pathophysiological plausibility, the application of mechanical insufflation-exsufflation (MI-E) has already become international standard care in neuromuscular disease and spinal cord injury although a lack of evidence for efficacy. High-quality studies to support the use of MI-E in neurological and neurosurgical patients during weaning from mechanical ventilation are missing. The goal of this exploratory study is to display the effect size of MI-E intervention on the duration of mechanical ventilation and additional outcomes. METHODS AND ANALYSIS: One hundred adult patients with a cough deficiency or retention of secretion admitted to a neurological intensive care unit (ICU) are planned to be recruited for this randomised controlled trial. Patients are randomised 1:1 to receive either MI-E or best standard care. Observation will take place until discharge from the hospital, death or end of the study period. The primary endpoint of this trial is the duration of mechanical ventilation from randomisation until successful weaning. The outcome will be analysed with Kaplan-Meier estimation and competing risks analyses. Secondary endpoint is the proportion of patients with successful weaning. Further outcomes will include the incidence of hospital-acquired pneumonia, mortality, decannulation rate, length of stay on the ICU and the total score of the Glasgow Coma Scale. ETHICS AND DISSEMINATION: The study was approved by the Medical Ethics Committee of the University of Oldenburg. The findings of this study will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: DRKS00020981.

Central Bradypnea and Ataxic Breathing in Myotonic Dystrophy Type 1 - A Clinical Case Report.

BACKGROUND: The occurrence of obstructive and central sleep apnea syndromes, ventilator pump failure and reduced hypercapnic ventilatory drive in myotonic dystrophy type 1 (DM1) is well established, and there are indications for an impairment of the hypoxic ventilator drive, too. Yet, it is still unknown, to which extent the respiratory rhythm is affected by DM1, thus if a central bradypnea, cluster breathing or ataxic ("Biot's") breathing can occur. Additionally, the causes of the impairment of the central respiratory drive in DM1 are not known. CASE PRESENTATION: We present the case of a tracheotomized female patient with DM1 with central bradypnea and ataxic breathing. A 57-year-old woman with DM1 was admitted to our Neurointensive Care Unit (NICU) due to refractory tracheobronchial retention of secretions resulting from aspiration of saliva. Due to a combination of chronic hypercapnic respiratory failure, severe central bradypnea with a minimal breathing frequency of 3 per minute and ataxic breathing a pressure-controlled home ventilation was initiated. CONCLUSIONS: In our patient central bradypnea and ataxic breathing possibly were respiratory sequale of DM1, that may have been caused by pontine white matter lesions affecting the pontine respiratory nuclei. From a clinical viewpoint, polygraphy is a suitable tool to objectify disorders of the respiratory rhythm in DM1 even in tracheotomized patients. Clinical studies combining respiratory diagnostics as polygraphy, transcutaneous capnometry and blood gas analysis with brain magnetic resonance imaging (MRI) are required to better understand disorders of respiratory regulation in DM1, and to identify their anatomical correlates.

Psychophysiological Effects of Biographical Interventions in People With Unresponsive Wakefulness Syndrome and Minimally Conscious State.

Background: Various music interventions can evoke favorable behavioral responses or physiological reactions in people with disorders of consciousness (DOC), such as coma, unresponsive wakefulness syndrome (UWS), and minimally conscious state (MCS). However, it appears that no study thus far has investigated the effects of music on the endocrine system of people with DOC. Objective: This explorative study aimed to investigate the effects of biographical music and biographical language on the physiological and endocrine systems of people with UWS and MCS. Method: A cohort of 20 people with DOC (10 women, 10 men; age range 19-77) received 20 min of biographical music and biographical language. Before and afterward, they were exposed to silence. Physiological and hormonal measurements were conducted before, during, and after the interventions. Results: Paired t-tests showed a significant decrease of salivary cortisol in the condition with biographical language interventions. Conclusion: Biographical interventions can modulate reactions in the endocrine system in people with DOC. Further studies are needed to establish whether and how individuals living with DOC show psychoneuroendocrine responses to music and other arts-based interventions.

Music interventions in disorders of consciousness (DOC) - a systematic review.

OBJECTIVES: The effects of music interventions including active and receptive music therapy for people living with neurogenic disorders of consciousness (DOC) have been subject to empirical studies in the past. The aim of this systematic review was to find and analyse the current research about the effects of musical interventions on people with DOC. METHODS: For this purpose, studies with music interventions and patients with DOC from the year 1900 to 2017 were searched in English, German, and French in different databases. Risk-of-bias-analyses were conducted for each study that fulfilled the inclusion criteria. RESULTS: Twenty-two quantitative studies (three randomised controlled trials with more than 10 participants) were found eligible for review. They include a total of 329 participants living with either coma, unresponsive wakefulness syndrome, or minimally conscious state. Music interventions were associated with favourable behavioural and physiological responses in several studies, but methodological quality and outcomes were heterogeneous. CONCLUSIONS: More studies with a larger number of participants are needed as well as a consensus on key characteristics of effective short-term and long-term music interventions for DOC.