A stepwise decannulation pathway for patients with prolonged disorders of consciousness after brain injury: a retrospective feasibility study

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Objective: Structured tracheostomy decannulation pathways specifically tailored to patients with prolonged disorders of consciousness (pDoC) after brain injury remain limited. We aimed to describe a stepwise decannulation pathway and evaluate its feasibility and safety in this population. Methods: We retrospectively reviewed consecutive tracheostomized patients with pDoC after brain injury admitted to a single rehabilitation center. The pathway integrated flexible laryngoscopy for assessment of airway patency and secretion burden using the Murray Secretion Scale (MSS), assessment of airway protection using the Semi-quantitative Cough Strength Score (SCSS), and a monitored 48-h capping trial. The primary outcomes were feasibility (decannulation rate), early safety (reintubation or transfer to the ICU within 48 h), and short-term safety (reintubation within 3 months). Secondary outcomes included time from referral to decannulation, airway findings, and MSS grades on flexible laryngoscopy, SCSS score, and reasons for non-decannulation. Results: Among 61 included patients, 35 (57.4%) were successfully decannulated. No patient required reintubation or transfer to the ICU within 48 h after decannulation. One patient underwent reintubation approximately 1 month later because of severe liver failure rather than airway compromise. The mean time to decannulation was 19.8 ± 8.2 days. Airway lesions were identified in 54 patients (88.5%), and 31 (50.8%) had MSS ≥ 2. Twelve patients (19.7%) had SCSS < 3. The main barriers to decannulation were airway stenosis ≥50%, uncontrolled secretion burden, inadequate cough-mediated airway protection, and worsening pulmonary infection during capping. Conclusion: In this single-center retrospective study, the stepwise decannulation pathway appeared feasible and was associated with favorable short-term safety outcomes in patients with pDoC after brain injury. The pathway may provide a structured framework for decannulation decision-making in this population. Further prospective, multicenter studies are needed to validate these findings.

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