Preserved somatosensory discrimination predicts consciousness recovery in unresponsive wakefulness syndrome.

OBJECTIVE: To assess somatosensory discrimination and command following using a vibrotactile P300-based Brain-Computer Interface (BCI) in Unresponsive Wakefulness Syndrome (UWS), and investigate the predictive role of this cognitive process on the clinical outcomes. METHODS: Thirteen UWS patients and six healthy controls each participated in two experimental runs in which they were instructed to count vibrotactile stimuli delivered to the left or right wrist. A BCI determined each subject's task performance based on EEG measures. All of the patients were followed up six months after the BCI assessment, and correlations analysis between accuracy rates and clinical outcome were investigated. RESULTS: Four UWS patients demonstrated clear EEG-based indices of task following in one or both paradigms, which did not correlate with clinical factors. The efficacy of somatosensory discrimination strongly correlated (VT2: R = 0.89, p = 0.0000002, VT3: R = 0.81, p = 0.002) with the clinical outcome at 6-months. The BCI system also yielded the expected results with healthy controls. CONCLUSIONS: Neurophysiological correlates of somatosensory discrimination can be detected in clinically unresponsive patients and are associated with recovery of behavioural responsiveness at six months. SIGNIFICANCE: Quantitative measurements of somatosensory discrimination may increase the diagnostic accuracy of persons with DOCs and provide useful prognostic information.

Tracheostomy mechanical ventilation in patients with amyotrophic lateral sclerosis: clinical features and survival analysis.

BACKGROUND: Tracheostomy mechanical ventilation (TMV) is performed in amyotrophic lateral sclerosis (ALS) patients with a respiratory failure or when the non-invasive ventilation (NIV) is no longer effective. We evaluated the clinical characteristics and survival of a cohort of tracheostomized ALS patients, followed in a single ALS Clinical Center. METHODS: Between 2001 and 2010, 87 out of 279 ALS patients were submitted to TMV. Onset was spinal in 62 and bulbar in 25. After tracheostomy, most patients were followed up through telephone interviews to caregivers. A complete survival analysis could be performed in fifty-two TMV patients. RESULTS: 31.3% ALS patients underwent tracheostomy, with a male prevalence (M/F=1.69) and a median age of 61 years (interquartile range=47-66). After tracheostomy, nearly all patients were under home care. TMV ALS patients were more likely than non-tracheostomized (NT) patients to be implanted with a PEG device, although the bulbar-/spinal-onset ratio did not differ between the two groups. Kaplan-Meyer analysis showed that tracheostomy increases median survival (TMV, 47 months vs NT, 31 months, p=0.008), with the greatest effect in patients younger than 60 at onset (TMV ≤ 60 years, 57.5 months vs NT ≤ 60 years, 38.5 months, p=0.002). CONCLUSIONS: TMV is increasingly performed in ALS patients. Nearly all TMV patients live at home and most of them are fed through a PEG device. Survival after tracheostomy is generally increased, with the stronger effect in patients younger than 60. This survival advantage is apparently lost when TMV is performed in patients older than 60. The results of this study might be useful for the decision-making process of patients and their families about this advanced palliative care.

Increased number and expertise of italian respiratory high-dependency care units: the second national survey.

BACKGROUND: The imbalance between the increasing prevalence of acutely decompensated respiratory diseases and the shortage of intensive care unit beds has stimulated the growth of respiratory high-dependence care units (RHDCUs). METHODS: We conducted a national survey to analyze the changes, in the past 10 years, in the number, structures, staff, procedures, diagnoses, and outcomes in Italian RHDCUs that satisfy the European Respiratory Society's criteria (modified according to the Italian Association of Hospital Pneumologists) for high level (respiratory intensive care unit), intermediate level (respiratory intermediate intensive care unit), and low level (respiratory monitoring unit) RHDCU care. RESULTS: The number of RHDCUs increased from 26 to 44. The relative prevalence among all the RHDCUs increased only for the low-level units (P = .03). Compared to 1997, in 2007 a higher percentage of Italian RHDCUs were located within respiratory wards than located outside of respiratory wards (P = .03), and the physician-to-patient mean ratio and the nurse-to-patient mean ratio per shift were lower (P = .001 and P = .002, respectively). Admissions for only monitoring decreased (P < .001), and admissions for active interventions increased: noninvasive ventilation (P = .002), invasive ventilation (P < .001), weaning from invasive ventilation (P < .001), and tracheal decannulation (P < .001). The complexity of RHDCU patients' conditions increased: there was a reduction in the percentage of COPD patients (P < .001) and an increase in the percentage of patients with neuromyopathies (P < .001) and de novo hypoxemia (P = .006). CONCLUSIONS: Between 1997 and 2007 there was an increase in the number and expertise of Italian RHDCUs, with a shift toward less expensive care, and greater complexity of interventions and patient dysfunctions. These findings support the crucial role of RHDCUs in the management of respiratory critical patients.

Tracheostomy in patients with long-term mechanical ventilation: a survey.

BACKGROUND: Tracheostomy is increasingly performed in intensive care units (ICU), with many patients transferred to respiratory ICU (RICU). Indications/timing for closing tracheostomy are discussed. AIM AND METHOD: We report results of a one-year survey evaluating: 1) clinical characteristics, types of tracheostomy, complications in patients admitted to Italian RICU in 2006; 2) clinical criteria and systems for performing decannulation, and outcome of patients undergoing tracheostomy (number decannulated; number non-decannulated/non-ventilated; number non-decannulated/ventilated; dead/lost patients). RESULTS: 22/32 RICUs replied. There were 846 admissions of 719 patients (Mean age 64,3 (+/-14.2) years, 489 (68%) males). Causes of admission were: acute respiratory failure with underlying chronic co-morbidities 176 (24.4%); exacerbation of Chronic Obstructive Pulmonary Disease 222 (34.4%); neuromuscular diseases 200 (27.8%); surgical patients 77 (10.7%); thoracic dysmorphism 28 (3.8%); obstructive sleep apnea syndrome 16 (2.2%). Percutaneous tracheostomies were 65.9%. Major complications after tracheostomy were 2%. 427 tracheostomies were evaluated for decannulation: 96 (22.5%) were closed; 175 patients (41%) were discharged with home mechanical ventilation; 114 patients (26.5%) maintained the tracheostomy despite weaning from mechanical ventilation and 42 patients (10%) died or lost. The clinical criteria chosen for decannulation were: stability of respiratory conditions, effective cough, underlying diseases and ability to swallow. The systems for evaluating feasibility of decannulation were: closure of tracheostomy tube; laryngo-tracheoscopy; use of tracheal button and down-sizing. CONCLUSIONS: There were few major complications of tracheostomy. A substantial proportion of patients maintain the tracheostomy despite not requiring mechanical ventilation. There was no agreement on indications and systems for closing tracheostomy.

Outcome and attitudes toward home tracheostomy ventilation of consecutive patients: a 10-year experience.

OBJECTIVES: To describe survival, predictors of long-term outcome and attitudes in patients treated at home by tracheostomy-intermittent positive-pressure ventilation (TIPPV) for respiratory failure during a 10-year period (1995-2004). METHODS: Seventy-seven consecutive patients were treated by TIPPV at home. Patients were divided into three groups: neuromuscular, pulmonary, and non-pulmonary patients. Effects of TIPPV on survival, factors influencing outcome after TIPPV, and attitudes of patients and caregivers regarding mechanical ventilation were studied. RESULTS: Forty-one patients (53%) were neuromuscular, 19 (25%) were affected by pulmonary diseases, and 17 (22%) by non-pulmonary diseases. The median survival time after TIPPV in the group was 49 months (range 3-149 months). There was statistically significant longer survival in neuromuscular compared to pulmonary patients (p=0.006), and a trend toward longer survival for non-pulmonary when compared to pulmonary patients (p=0.048). Chronic obstructive pulmonary disease (COPD) patients (n=14) showed the poorest outlook (median survival 26 months, range 3-45 months) and the highest number of emergency readmissions to hospital. The median survival in amyotrophic lateral sclerosis (ALS) patients was 49 months (range 30-61), lower than the whole group of neuromuscular patients. Major tracheostomy complications were low: 2.6%. Multivariate analysis showed that COPD and ALS patients had a three-fold higher risk of death than patients with other diagnoses. Lastly, 64 patients (83%) were pleased they had chosen TIPPV and 69 (90%) would choose it again. Forty-two caregivers (55%) were pleased the patients had chosen home ventilation, but 29 (38%) reported major burdens. CONCLUSIONS: TIPPV is well-received by the patients, is safe, and provides survival for long periods of time. Underlying conditions (COPD and ALS) might represent important prognostic factors for survival.

The amyotrophic lateral sclerosis functional rating scale predicts survival time in amyotrophic lateral sclerosis patients on invasive mechanical ventilation.

OBJECTIVE: To determine whether the amyotrophic lateral sclerosis functional rating scale (ALSFRS), which is a validated instrument that assesses the functional status and the disease progression in patients with amyotrophic lateral sclerosis (ALS), predicts hospital length of stay and survival time in ALS patients treated with tracheostomy-intermittent positive-pressure ventilation (TIPPV). METHODS: Thirty-three consecutive ALS patients with acute respiratory failure who received therapy with TIPPV were prospectively followed up from their admission to the hospital until death. The association of ALSFRS score at hospital admission with length of hospital stay and survival after TIPPV were examined using Cox proportional hazard models, adjusting for age at baseline, sex, and symptom duration. RESULTS: The median ALSFRS score of the ALS patients at hospital admission was 11 (range, 4 to 22). The median length of hospital stay was 55 days (range, 7 to 124 days), with a hospital mortality rate of 9%. For the 30 patients (91%) discharged from the hospital, the median survival time was 37 months (range, 2 to 64 months). The total ALSFRS score (above or below the median score) was a significant predictor of length of hospital stay (hazard ratio [HR], 2.86; 95% confidence interval [CI], 1.2 to 6.5; p = 0.003) and survival after TIPPV (HR, 3.76; 95% CI, 1.4 to 9.7; p = 0.002). The total ALSFRS score at hospital admission was also associated with length of hospital stay (HR, 2.1; 95% CI, 1.1 to 5.1; p = 0.005) and survival (HR, 0.52; 95% CI, 0.1 to 0.8; p = 0.002) when included in a Cox multivariable model together with the other demographic and clinical variables. CONCLUSION: In ALS patients with acute respiratory failure who have been treated with TIPPV, the total ALSFRS score may predict length of hospital stay and long-term survival after invasive mechanical ventilation.

Development of chronic hypoventilation in amyotrophic lateral sclerosis patients.

Early prediction of respiratory muscle involvement and chronic hypoventilation (CH) in amyotrophic lateral sclerosis (ALS) patients can help to plan mechanical ventilatory aids and palliative care interventions well before respiratory failure occurs. To describe the natural history of the progressive pulmonary dysfunction leading to CH, and to identify potential parameters associated with its development in ALS, we prospectively followed 38 ALS patients up to 26 months, starting from their first presentation at our Clinic. At study entry, median FVC was 87% (interquartile range: 72-104%) and declined by 10% after 6 months (range: 2-49%), showing a very high inter-patient variability. Over the 26-months follow-up, 19 patients (50%) presented CH in the first 12 months, and eight patients (21%) developed CH in the remaining 14 months of the study. The remaining 29% of patients did not show signs of CH during the whole period of observation. In the Cox model, the category of disease progression (rapid vs. intermediate and slow), assessed using the Appel ALS Rating Scale (AARS) in the first 3 months after presentation, was the only variable associated with a significantly increased likelihood of CH. We conclude that CH can occur within 1 year from presentation in a great proportion of patients, independently from their initial respiratory status. Including the patients in specific categories of early disease progression, as assessed with the AARS, could be a sensitive method to identify patients with different risk of developing CH, and may help physicians to more efficiently plan the frequencies of respiratory evaluations, initiate mechanical ventilation and discuss advance directives with the patients and their caregivers.

Iron lung vs mask ventilation in the treatment of acute on chronic respiratory failure in COPD patients: a multicenter study.

STUDY OBJECTIVES: Evaluation of the effectiveness of negative-pressure ventilation (NPV) with the use of the iron lung vs noninvasive positive-pressure ventilation (NIPPV) in the treatment of COPD patients with acute on chronic respiratory failure. DESIGN: A retrospective case-control study. SETTING: Four Italian respiratory intermediate ICUs. PATIENTS: Of a total of 393 COPD patients admitted to the ICU in 1996, 53 pairs were treated with the iron lung (NPV group). Patients treated with NIPPV (NIPPV group) were matched according to mean (+/- SD) age (70.3 +/- 7.1 vs 70.3 +/- 6.9 years, respectively), sex, causes of acute respiratory failure (ARF), APACHE (acute physiology and chronic health evaluation) II score (22.4 +/- 5.3 vs 22.1 +/- 4.6, respectively), pH (7.26 +/- 0.05 vs 7.27 +/- 0.04, respectively), and PaCO(2) (88.1 +/- 11.5 vs 85.1 +/- 13.5 mm Hg, respectively) on admission to the ICU. The effectiveness of matching was 98.4%. RESULTS: Five patients from the NPV group (9.4%) and seven patients from the NIPPV group (13.2%) needed endotracheal intubation (EI). The treatment failure rate (ie, death and/or need of EI) was 20.7% in the NPV group and 24.5% in the NIPPV group (difference was not significant). The mean duration of mechanical ventilation (29.6 +/- 28.6 vs 62.3 +/- 35.7 h, respectively) and length of hospital stay (10.4 +/- 4.3 vs 15 +/- 5.2 d, respectively) among the 35 concordant surviving pairs were significantly lower in the NPV group than in the NIPPV group (p = 0.001 and p = 0.001, respectively). CONCLUSIONS: These data suggest that both ventilatory techniques are equally effective in avoiding EI and death in COPD patients with ARF. Prospective trials are needed to confirm these preliminary results.