The short-term spinal cord stimulation improves the rates of tracheal decannulation in patients of brain injury with disorders of consciousness

The short-term spinal cord stimulation improves the rates of tracheal decannulation in patients of brain injury with disorders of consciousness | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The short-term spinal cord stimulation improves the rates of tracheal decannulation in patients of brain injury with disorders of consciousness guanlin Huang, Dong Wang, Qiang Chen, Qi Zhong, Weilong Huang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4066057/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 May, 2025 Read the published version in BMC Neuroscience → Version 1 posted 4 You are reading this latest preprint version Abstract Objective: To investigate the effects of the short-term spinal cord stimulation (stSCS) on the rates of tracheal decannulation in patients of brain injury with disorders of consciousness (DoC). Methods: 81 patients of brain injury with DoC after tracheotomy treated in Ganzhou People’s hospital from June 2021 to June 2022 were retrospectively analyzed. Results: We divided the patients into two groups, 46 patients who underwent stSCS as observation group, and 35 patients who did not undergo stSCS under the same conditions as the control group. The rates of decannulation were compared between the two groups. The rates of decannulation were 50% in the observation group and 25.7% in the control group. There was significant difference between the two groups. Conclusion: stSCS can improve the rates of decannulation in patients of brain injury with DoC. the short-term spinal cord stimulation (stSCS) tracheal decannulation brain injury disorders of consciousness(DoC) tracheotomy Figures Figure 1 Introduction Tracheotomy is one of the most commonly performed procedures in critically sick patients. It plays an important role in relieving airway obstruction in critically sick patients, fully draining lower airway secretions, improving nursing quality, improving patient comfort, and reducing the use of sedative and analgesic drugs [1] . For some critically sick patients, tracheotomy cannot be removed in a short time because of various reasons. Studies have shown that 2.0%-5.0% of patients with tracheotomy will have difficulty in decannulation [2] . The long-term indwelling of tracheotomy is easy to lead to airway dryness, injury and bleeding, the decline of airway self-purification ability, and repeated lung infection, resulting in prolonged hospitalization, increased hospitalization costs, and increased nursing difficulty. How to improve the rates of decannulation is a difficulty in clinical practice [3] . This study retrospectively analyzed the effects of stSCS on the rates of decannulation in patients of brain injury with DoC. Data and Methods 1.1 Design:The study was a retrospective analysis, 81 patients of brain injury with DoC after tracheotomy treated in Ganzhou People’s hospital from June 2021 to June 2022 were retrospectively analyzed. 1.2 Treatments, intervention and data collection: All the patients were diagnosed with DOC less than 3 months, they can’t reach the standard of spinal cord stimulation (SCS). We have treated lots of patients with DOC less than 3 months with stSCS, in that case, 46 patients underwent stSCS, 35 patients did not undergo stSCS. For patients without stSCS, they were received inpatient rehabilitation (at least 3h daily,6 days a week, including physical therapy, speech therapy and occupational therapy).For patients with stSCS（some of the surgical procedures was show in Fig1）, the stSCS lasted two weeks, they were received inpatient rehabilitation the same to the patients without stSCS. All patients were adequately postured at least every 2-3h, daily basal stimulations was performed by means of oral hygiene, frequent aspirations of the tracheobronchial secretions, safe swallowing training as soon as possible, splinting of the limbs when needed, respiratory training, early recovery of assisted sitting and standing position. After that, We have the same standards and doctors to evaluate decannulation and then undergo decannulation. Demographic and clinical data were collected. The information also included age, etiology, type of disease, the rates of decannulation, prognosis, ect. 1.3 statistical analysis SPSS 20.0 statistical software was used for data processing. Use χ²test and Fisher exact probability method, P<0.05 means the difference is statistically significant. Results We divided the patients into two groups, 46 patients who underwent stSCS as observation group, and 35 patients who did not undergo stSCS under the same conditions as the control group.In the observation group, there were 29 males and 17 females; Average age was 62.2 years old; Disease type: brainstem hemorrhage in 12 cases, brain trauma in 19 cases, cerebral hemorrhage in 10 cases, cerebral infarction in 2 cases, aneurysm rupture and hemorrhage after operation in 3 cases. In the control group, there were 21 males and 14 females; Average age was 65.3 years old; Disease type: brainstem hemorrhage in 7 cases, brain trauma in 6 cases, cerebral hemorrhage in 13 cases, cerebral infarction in 1 case, aneurysm rupture and hemorrhage after operation in 8 cases (Table 1). There was no significant difference in gender, age and disease type between the two groups. In the observation group, there were 46 cases in total, decannulation was performed in 23 (50%) patients; Type of disease: 6 cases of brainstem hemorrhage were successfully decannulated, and the rates of decannulation was 50%; decannulation was performed in 10 (73.3%) of the brain trauma patients; 3 cases of intracerebral hemorrhage were successfully decannulated, and the rates of decannulation was 30%; decannulation was performed in 0 cases of the cerebral infarction; 1 (33.3%) case of aneurysm rupture and hemorrhage after operation were successfully decannulated. In the control group, decannulation was performed in 9 (25.7%) patients; Type of disease: 1 cases of brainstem hemorrhage were successfully decannulated, and the rates of decannulation was 14.3%; decannulation was performed in 3 (50%) of the brain trauma patients; 3 cases of intracerebral hemorrhage were successfully decannulated, and the rates of decannulation was 23.1%; decannulation was performed in 0 cases of cerebral infarction; 2 (25%) case of aneurysm rupture and hemorrhage after operation were successfully decannulated. Discussion The ventilation and air exchange functions of patients with brain injury are seriously damaged [4] . When oxygen supply, sputum suction, airway relaxation and other measures can not improve breathing, tracheotomy is a necessary measure. However, patients after tracheotomy are prone to complications such as pulmonary infection, respiratory tract stenosis, intratracheal hemorrhage, tracheoesophageal fistula, etc [5] . Decannulation should be carried out as early as possible [3] . However, the success rate of decannulation is often not high,especially in patients of brain injury with DOC. The failure of decannulation leads to long-term indwelling of tracheotomy. Long-term indwelling of tracheotomy tends to airway dryness, injury and bleeding, decline of airway self purification ability, and repeated lung infection leads to prolonged hospitalization, increased hospitalization costs, and increased nursing difficulties [6] . Patients of brain injury with DoC usually have decreased cough function, sputum cannot be fully drained, and a large amount of sputum accumulates in the airway, which affects the ventilation and exchange function, resulting in hypoxia and infection,which is difficult to control, and would leads to the failure of decannulation [7-9] . Tracheotomy also can lead to the increase of airway secretions. With the long-term indwelling of tracheotomy, bacteriaes can breed, in that case,the self purification, heating and humidification of the airway disappear, resulting in the increase of secretions. If the patient has poor cough function and a large amount of sputum in the airway cannot be fully drained, it will affect the respiratory function and even have the risk of asphyxia [10] . It can be seen that cough function is one of the clinical criteria for whether patients with tracheotomy can undergo decannulation [10, 11] . And lots of literatures have reported that cough function is one of the criteria for evaluating tracheal decannulation [10, 12] . In the observation group, the cough function of patients after stSCS was improved. Among them, 23 cases had improved cough function and reached the criteria for tracheal decannulation, while the remaining 23 cases had improved cough function but still did not reach the criteria for tracheal decannulation, leaving tracheotomy cannula. In the two groups,All patients were DoC caused by brain injury. After stSCS treatment, GCS scores of most patients were improved to varying degrees. However, literatures reported the level of consciousness cannot be used as one of the criteria for evaluating tracheal decannulation [4] . Among the cases in the observation group, 13 cases were still unconscious and were successfully decannulated. And other literatures have reported that the improvement of swallowing function is also one of the criteria for evaluating tracheal decannulation [2, 8, 9, 11-14] . In the observation group, the swallowing function of patients who successfully removed the tracheotomy cannula has been improved to varying degrees. In the remaining cases of decannulating failure, the swallowing function is still poor, and the gastric tube is still retained for a long time. Tracheal decannulation is still an challenging clinical problem. There are still many patients with poor prognosis due to long-term tracheotomy. Wahlster S ect. [2] reported, about one third of patients with brain injury after tracheotomy can undergo decannulation,and then achieved independence,about one third of patients survived in a dependent state with the tracheal tube, and the remaining one third of patients will die due to various complications with the tracheal tube.In the observation group, after stSCS, 23 cases (50%) successfully removed the tracheal tube and survived in independence, while the remaining patients still survived in a dependent state with tracheal tube. In the control group, 9 cases were successfully removed the tracheal tube and survived in independence. In the comparison of the two groups of cases, the success rates of tracheal decannulation in the observation group was significantly higher than that in the control group, p=0.027 (Table 2), and the difference was statistically significant.stSCS therapy can treat DoC, it can improve the cerebral blood flow by stimulation therapy [15] . In this group of cases in the observation group, we can see that patients treated by stSCS have faster and deeper breathing, and cough more effectively. The reason why stSCS can improve breathing, cough, swallowing is unclear, which may be related to the stimulation of respiratory center by stSCS while improving cerebral blood flow, further research is needed. Conclusion stSCS can improve the rates of decannulation in patients of brain injury with DoC. Declarations Ethics approval and consent to participate Patient consent was obtained from the family members of patients in this study, and the decision as to whether to receive short-term spinal cord stimulation was at the discretion of the family of the patients.The ethical approval was obtained from the Ethics Committee of Ganzhou People’s Hospital. Consent for publication The authors are consent for publication. Availability of data and materials Not applicable. Competing interests The authors report no conflicts of interest in this work. Funding This work was supported by grants from the Natural Science Foundation of Jiangxi Province’s (20224BAB206041). Acknowledgements Not applicable. References Abe T, Madotto F, Pham T, et al. Epidemiology and patterns of tracheostomy practice in patients with acute respiratory distress syndrome in ICUs across 50 countries. Crit Care. 2018. 22(1): 195. Wahlster S, Sharma M, Chu F, et al. Outcomes After Tracheostomy in Patients with Severe Acute Brain Injury: A Systematic Review and Meta-Analysis. Neurocrit Care. 2021. 34(3): 956-967. Bösel J, Niesen WD, Salih F, et al. Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation: The SETPOINT2 Randomized Clinical Trial. JAMA. 2022. 327(19): 1899-1909. Perin C, Meroni R, Rega V, Braghetto G, Cerri CG. Parameters Influencing Tracheostomy Decannulation in Patients Undergoing Rehabilitation after severe Acquired Brain Injury (sABI). Int Arch Otorhinolaryngol. 2017. 21(4): 382-389. Christiansen KJ, Devantier L, Pasgaard T, et al. Tracheostomy healing time after decannulation. Multidiscip Respir Med. 2022. 16(1): 822. Avesani R, Roncari L, Khansefid M, et al. The Italian National Registry of severe acquired brain injury: epidemiological, clinical and functional data of 1469 patients. Eur J Phys Rehabil Med. 2013. 49(5): 611-8. Enrichi C, Battel I, Zanetti C, et al. Clinical Criteria for Tracheostomy Decannulation in Subjects with Acquired Brain Injury. Respir Care. 2017. 62(10): 1255-1263. Muhle P, Suntrup-Krueger S, Burkardt K, et al. Standardized Endoscopic Swallowing Evaluation for Tracheostomy Decannulation in Critically Ill Neurologic Patients - a prospective evaluation. Neurol Res Pract. 2021. 3(1): 26. Warnecke T, Suntrup S, Teismann IK, Hamacher C, Oelenberg S, Dziewas R. Standardized endoscopic swallowing evaluation for tracheostomy decannulation in critically ill neurologic patients. Crit Care Med. 2013. 41(7): 1728-32. Rose L, Adhikari NK, Leasa D, Fergusson DA, McKim D. Cough augmentation techniques for extubation or weaning critically ill patients from mechanical ventilation. Cochrane Database Syst Rev. 2017. 1(1): CD011833. Zanata Ide L, Santos RS, Hirata GC. Tracheal decannulation protocol in patients affected by traumatic brain injury. Int Arch Otorhinolaryngol. 2014. 18(2): 108-14. Reverberi C, Lombardi F, Lusuardi M, Pratesi A, Di Bari M. Development of the Decannulation Prediction Tool in Patients With Dysphagia After Acquired Brain Injury. J Am Med Dir Assoc. 2019. 20(4): 470-475.e1. Kim YK, Choi JH, Yoon JG, Lee JW, Cho SS. Improved Dysphagia After Decannulation of Tracheostomy in Patients With Brain Injuries. Ann Rehabil Med. 2015. 39(5): 778-85. Martin KA, Cole T, Percha CM, et al. Standard versus Accelerated Speaking Valve Placement after Percutaneous Tracheostomy: A Randomized Controlled Feasibility Study. Ann Am Thorac Soc. 2021. 18(10): 1693-1701. Wu M, Linderoth B, Foreman RD. Putative mechanisms behind effects of spinal cord stimulation on vascular diseases: a review of experimental studies. Auton Neurosci. 2008. 138(1-2): 9-23. Tables Table 1 Characteristics of the patients characteristics the observation group the control group sex male 29 21 female 17 14 Age, years mean 62.2 65.3 range 19-75 18-79 disease types brainstem hemorrhage 12 7 brain trauma 19 6 cerebral hemorrhage 10 13 cerebral infarction 2 1 aneurysm rupture and hemorrhage after operation 3 8 Table 2 Comparison of decannulation between the two groups Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 May, 2025 Read the published version in BMC Neuroscience → Version 1 posted Editorial decision: Revision requested 26 Mar, 2024 Submission checks completed at journal 22 Mar, 2024 Editor assigned by journal 22 Mar, 2024 First submitted to journal 10 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4066057","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":284249107,"identity":"8595cfc7-4932-4915-9e8a-f9aa345de15b","order_by":0,"name":"guanlin Huang","email":"","orcid":"","institution":"Ganzhou People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"guanlin","middleName":"","lastName":"Huang","suffix":""},{"id":284249109,"identity":"7b75023f-242a-40b9-b9b8-37fce59d3eac","order_by":1,"name":"Dong Wang","email":"","orcid":"","institution":"Ganzhou People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dong","middleName":"","lastName":"Wang","suffix":""},{"id":284249111,"identity":"d8d08dd5-2897-4d09-9b27-84c4a6b0b459","order_by":2,"name":"Qiang Chen","email":"","orcid":"","institution":"Ganzhou People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qiang","middleName":"","lastName":"Chen","suffix":""},{"id":284249112,"identity":"02ff8c18-be56-495d-9da1-49080eed8701","order_by":3,"name":"Qi Zhong","email":"","orcid":"","institution":"Ganzhou People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Qi","middleName":"","lastName":"Zhong","suffix":""},{"id":284249113,"identity":"3e87c71b-77e5-41bb-b417-6d80f62c5fa3","order_by":4,"name":"Weilong Huang","email":"","orcid":"","institution":"Ganzhou People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Weilong","middleName":"","lastName":"Huang","suffix":""},{"id":284249114,"identity":"ee88102c-6d69-4597-81a9-b12413ef21cc","order_by":5,"name":"Xiaoping Zhou","email":"","orcid":"","institution":"Ganzhou People's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Xiaoping","middleName":"","lastName":"Zhou","suffix":""},{"id":284249115,"identity":"44d83f4d-2eef-4382-98e4-86e0dc408a8b","order_by":6,"name":"Qiuhua Jiang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYBACxmYwdYCHn7354IOEChvitchI9hxLNnhwJo1oyw7YGNzwMZN82HaIsFrmduZnD7+U3eExuMGWVpHAdoCBv707gYDD2MyNZc4945G83XzsRgLPHQaJM2c3ENDCYCYt2XaYh+/OsbQbCRLPGAwkcglpYf8G1sJwI8esIMHgMDFaeMwkPwK1CAC1MCQkEKelTJrh3GEeUCBLJBxI4yHoF8P+49skf5QdtgdF5cef/2zk+Nt7CWhpAAY0DxtCgAevchCQBznuBxtBdaNgFIyCUTCSAQCeWE6RuRnATQAAAABJRU5ErkJggg==","orcid":"","institution":"Ganzhou People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Qiuhua","middleName":"","lastName":"Jiang","suffix":""}],"badges":[],"createdAt":"2024-03-10 15:44:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4066057/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4066057/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12868-025-00951-x","type":"published","date":"2025-05-26T15:57:02+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":53581182,"identity":"45297359-94d5-4d2a-a4d6-ed89b7991568","added_by":"auto","created_at":"2024-03-27 17:32:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":382426,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative images of the surgical positioning and interoperative digital subtraction angiography (DSA). (A) A patient in the prone position, with point of puncture markings at the T8-9 vertebra thoracalis. (B-I) Representative images of the electrode array in the coronal (B), horizontal (G-I) (at the most cephalic contact level), and sagittal (C-F) DSA views\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4066057/v1/c86adebb9d384b57d5afdaee.png"},{"id":83783123,"identity":"a283a72c-b0f0-4b26-bb00-fbd1ea515030","added_by":"auto","created_at":"2025-06-02 16:10:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":837236,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4066057/v1/35e2ab5a-bceb-490c-873a-6320011cbfc0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The short-term spinal cord stimulation improves the rates of tracheal decannulation in patients of brain injury with disorders of consciousness","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTracheotomy is one of the most commonly performed procedures in critically sick patients. It plays an important role in relieving airway obstruction in critically sick patients, fully draining lower airway secretions, improving nursing quality, improving patient comfort, and reducing the use of sedative and analgesic drugs\u003csup\u003e[1]\u003c/sup\u003e. For some critically sick patients, tracheotomy cannot be removed in a short time because of various reasons. Studies have shown that 2.0%-5.0% of patients with tracheotomy will have difficulty in decannulation\u003csup\u003e[2]\u003c/sup\u003e. The long-term indwelling of tracheotomy is easy to lead to airway dryness, injury and bleeding, the decline of airway self-purification ability, and repeated lung infection, resulting in prolonged hospitalization, increased hospitalization costs, and increased nursing difficulty. How to improve the rates of decannulation is a difficulty in clinical practice\u003csup\u003e[3]\u003c/sup\u003e. This study retrospectively analyzed the effects of stSCS on the rates of decannulation in patients of brain injury with DoC.\u003c/p\u003e"},{"header":"Data and Methods","content":"\u003cp\u003e1.1 Design:The study was a retrospective analysis, 81 patients of brain injury with DoC after tracheotomy treated in Ganzhou People’s hospital from June 2021 to June 2022 were retrospectively analyzed.\u003c/p\u003e\n\u003cp\u003e1.2 Treatments, intervention and data collection: All the patients were diagnosed with DOC less than 3 months, they can’t reach the standard of spinal cord stimulation (SCS). We have treated lots of patients with DOC less than 3 months with stSCS, in that case, 46 patients underwent stSCS, 35 patients did not undergo stSCS. For patients without stSCS, they were received inpatient rehabilitation (at least 3h daily,6 days a week, including physical therapy, speech therapy and occupational therapy).For patients with stSCS（some of the surgical procedures was show in Fig1）, the stSCS lasted two weeks, they were received inpatient rehabilitation the same to the patients without stSCS. All patients were adequately postured at least every 2-3h, daily basal stimulations was performed by means of oral hygiene, frequent aspirations of the tracheobronchial secretions, safe swallowing training as soon as possible, splinting of the limbs when needed, respiratory training, early recovery of assisted sitting and standing position. After that, We have the same standards and doctors to evaluate decannulation and then undergo decannulation. Demographic and clinical data were collected. The information also included age, etiology, type of disease, the rates of decannulation, prognosis, ect.\u003c/p\u003e\n\u003cp\u003e1.3 statistical analysis\u003c/p\u003e\n\u003cp\u003eSPSS 20.0 statistical software was used for data processing. Use χ²test and Fisher exact probability method, P\u0026lt;0.05 means the difference is statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe divided the patients into two groups, 46 patients who underwent stSCS \u0026nbsp;as observation group, and 35 patients who did not undergo stSCS under the same conditions as the control group.In the observation group, there were 29 males and 17 females; Average age was 62.2 years old; Disease type: brainstem hemorrhage in 12 cases, brain trauma in 19 cases, cerebral hemorrhage in 10 cases, cerebral infarction in 2 cases, aneurysm rupture and hemorrhage after operation in 3 cases. In the control group, there were 21 males and 14 females; Average age was 65.3 years old; Disease type: brainstem hemorrhage in 7 cases, brain trauma in 6 cases, cerebral hemorrhage in 13 cases, cerebral infarction in 1 case, aneurysm rupture and hemorrhage after operation in 8 cases (Table 1). There was no significant difference in gender, age and disease type between the two groups.\u003c/p\u003e\n\u003cp\u003eIn the observation group, there were 46 cases in total, decannulation was performed in 23 (50%) patients; Type of disease: 6 cases of brainstem hemorrhage \u0026nbsp; were successfully decannulated, and the rates of decannulation was 50%; decannulation was performed in 10 (73.3%) of the brain trauma patients; 3 cases of intracerebral hemorrhage were successfully decannulated, and the rates of decannulation was 30%; decannulation was performed in 0 cases of the cerebral infarction; 1 (33.3%) case of aneurysm rupture and hemorrhage after operation were successfully decannulated. In the control group, decannulation was performed in 9 (25.7%) patients; Type of disease: 1 cases of brainstem hemorrhage were successfully decannulated, and the rates of decannulation was 14.3%; decannulation was performed in 3 (50%) of the brain trauma patients; 3 cases of intracerebral hemorrhage were successfully decannulated, and the rates of decannulation was 23.1%; decannulation was performed in 0 cases of cerebral infarction; 2 (25%) case of aneurysm rupture and hemorrhage after operation were successfully decannulated.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe ventilation and air exchange functions of patients with brain injury are seriously damaged\u003csup\u003e[4]\u003c/sup\u003e. When oxygen supply, sputum suction, airway relaxation and other measures can not improve breathing, tracheotomy is a necessary measure. However, patients after tracheotomy are prone to complications such as pulmonary infection, respiratory tract stenosis, intratracheal hemorrhage, tracheoesophageal fistula, etc\u003csup\u003e[5]\u003c/sup\u003e. Decannulation should be carried out as early as possible\u003csup\u003e[3]\u003c/sup\u003e. However, the success rate of decannulation is often not high,especially in patients of brain injury with DOC. The failure of decannulation leads to long-term indwelling of tracheotomy. Long-term indwelling of tracheotomy tends to airway dryness, injury and bleeding, decline of airway self purification ability, and repeated lung infection leads to prolonged hospitalization, increased hospitalization costs, and increased nursing difficulties\u003csup\u003e[6]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Patients of brain injury with DoC usually have decreased cough function, sputum cannot be fully drained, and a large amount of sputum accumulates in the airway, which affects the ventilation and exchange function, resulting in hypoxia and infection,which is difficult to control, and would leads to the failure of decannulation\u003csup\u003e[7-9]\u003c/sup\u003e. Tracheotomy also can lead to the increase of airway secretions. With the long-term indwelling of tracheotomy, bacteriaes can breed, in that case,the self purification, heating and humidification of the airway disappear, resulting in the increase of secretions. If the patient has poor cough function and a large amount of sputum in the airway cannot be fully drained, it will affect the respiratory function and even have the risk of asphyxia\u003csup\u003e[10]\u003c/sup\u003e. It can be seen that cough function is one of the clinical criteria for whether patients with tracheotomy can \u0026nbsp;undergo decannulation\u003csup\u003e[10, 11]\u003c/sup\u003e. And lots of literatures have reported that cough function is one of the criteria for evaluating tracheal decannulation\u003csup\u003e[10, 12]\u003c/sup\u003e. In the observation group, the cough function of patients after stSCS was improved. Among them, 23 cases had improved cough function and reached the criteria for tracheal decannulation, while the remaining 23 cases had improved cough function but still did not reach the criteria for tracheal decannulation, leaving tracheotomy cannula. In the two groups,All patients were DoC caused by brain injury. After stSCS treatment, GCS scores of most patients were improved to varying degrees. However, literatures reported the level of consciousness cannot be used as one of the criteria for evaluating tracheal decannulation\u003csup\u003e[4]\u003c/sup\u003e. Among the cases in the observation group, 13 cases were still unconscious and were successfully decannulated. And other literatures have reported that the improvement of swallowing function is also one of the criteria for evaluating tracheal decannulation\u003csup\u003e[2, 8, 9, 11-14]\u003c/sup\u003e. In the observation group, the swallowing function of patients who successfully removed the tracheotomy cannula has been improved to varying degrees. In the remaining cases of decannulating failure, the swallowing function is still poor, and the gastric tube is still retained for a long time.\u003c/p\u003e\n\u003cp\u003eTracheal decannulation is still an challenging clinical problem. There are still many patients with poor prognosis due to long-term tracheotomy. Wahlster S ect.\u003csup\u003e[2]\u003c/sup\u003ereported, about one third of patients with brain injury after tracheotomy can undergo decannulation,and then achieved independence,about one third of patients survived in a dependent state with the tracheal tube, and the remaining one third of patients will die due to various complications with the tracheal tube.In the observation group, after stSCS, 23 cases (50%) successfully removed the tracheal tube and survived in independence, while the remaining patients still survived in a dependent state with tracheal tube. In the control group, 9 cases were successfully removed the tracheal tube and survived in independence. In the comparison of the two groups of cases, the success rates of tracheal decannulation in the observation group was significantly higher than that in the control group, p=0.027 (Table 2), and the difference was statistically significant.stSCS therapy can treat DoC, it can improve the cerebral blood flow by stimulation therapy\u003csup\u003e[15]\u003c/sup\u003e. In this group of cases in the observation group, we can see that patients treated by stSCS have faster and deeper breathing, and cough more effectively. The reason why stSCS can improve breathing, cough, swallowing is unclear, which may be related to the stimulation of respiratory center by stSCS while improving cerebral blood flow, further research is needed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003estSCS can improve the rates of decannulation in patients of brain injury with DoC.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Patient consent was obtained from the family members of patients in this study, and the decision as to whether to receive short-term spinal cord stimulation was at the discretion of the family of the patients.The ethical approval was obtained from the Ethics Committee of Ganzhou People\u0026rsquo;s Hospital.\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eThe authors are consent for publication.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eThe authors report no conflicts of interest in this work.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThis work was supported by grants from the Natural Science Foundation of Jiangxi Province\u0026rsquo;s (20224BAB206041).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAbe T, Madotto F, Pham T, et al. Epidemiology and patterns of tracheostomy practice in patients with acute respiratory distress syndrome in ICUs across 50 countries. Crit Care. 2018. 22(1): 195.\u003c/li\u003e\n \u003cli\u003eWahlster S, Sharma M, Chu F, et al. Outcomes After Tracheostomy in Patients with Severe Acute Brain Injury: A Systematic Review and Meta-Analysis. Neurocrit Care. 2021. 34(3): 956-967.\u003c/li\u003e\n \u003cli\u003eB\u0026ouml;sel J, Niesen WD, Salih F, et al. Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation: The SETPOINT2 Randomized Clinical Trial. JAMA. 2022. 327(19): 1899-1909.\u003c/li\u003e\n \u003cli\u003ePerin C, Meroni R, Rega V, Braghetto G, Cerri CG. Parameters Influencing Tracheostomy Decannulation in Patients Undergoing Rehabilitation after severe Acquired Brain Injury (sABI). Int Arch Otorhinolaryngol. 2017. 21(4): 382-389.\u003c/li\u003e\n \u003cli\u003eChristiansen KJ, Devantier L, Pasgaard T, et al. Tracheostomy healing time after decannulation. Multidiscip Respir Med. 2022. 16(1): 822.\u003c/li\u003e\n \u003cli\u003eAvesani R, Roncari L, Khansefid M, et al. The Italian National Registry of severe acquired brain injury: epidemiological, clinical and functional data of 1469 patients. Eur J Phys Rehabil Med. 2013. 49(5): 611-8.\u003c/li\u003e\n \u003cli\u003eEnrichi C, Battel I, Zanetti C, et al. Clinical Criteria for Tracheostomy Decannulation in Subjects with Acquired Brain Injury. Respir Care. 2017. 62(10): 1255-1263.\u003c/li\u003e\n \u003cli\u003eMuhle P, Suntrup-Krueger S, Burkardt K, et al. Standardized Endoscopic Swallowing Evaluation for Tracheostomy Decannulation in Critically Ill Neurologic Patients - a prospective evaluation. Neurol Res Pract. 2021. 3(1): 26.\u003c/li\u003e\n \u003cli\u003eWarnecke T, Suntrup S, Teismann IK, Hamacher C, Oelenberg S, Dziewas R. Standardized endoscopic swallowing evaluation for tracheostomy decannulation in critically ill neurologic patients. Crit Care Med. 2013. 41(7): 1728-32.\u003c/li\u003e\n \u003cli\u003eRose L, Adhikari NK, Leasa D, Fergusson DA, McKim D. Cough augmentation techniques for extubation or weaning critically ill patients from mechanical ventilation. Cochrane Database Syst Rev. 2017. 1(1): CD011833.\u003c/li\u003e\n \u003cli\u003eZanata Ide L, Santos RS, Hirata GC. Tracheal decannulation protocol in patients affected by traumatic brain injury. Int Arch Otorhinolaryngol. 2014. 18(2): 108-14.\u003c/li\u003e\n \u003cli\u003eReverberi C, Lombardi F, Lusuardi M, Pratesi A, Di Bari M. Development of the Decannulation Prediction Tool in Patients With Dysphagia After Acquired Brain Injury. J Am Med Dir Assoc. 2019. 20(4): 470-475.e1.\u003c/li\u003e\n \u003cli\u003eKim YK, Choi JH, Yoon JG, Lee JW, Cho SS. Improved Dysphagia After Decannulation of Tracheostomy in Patients With Brain Injuries. Ann Rehabil Med. 2015. 39(5): 778-85.\u003c/li\u003e\n \u003cli\u003eMartin KA, Cole T, Percha CM, et al. Standard versus Accelerated Speaking Valve Placement after Percutaneous Tracheostomy: A Randomized Controlled Feasibility Study. Ann Am Thorac Soc. 2021. 18(10): 1693-1701.\u003c/li\u003e\n \u003cli\u003eWu M, Linderoth B, Foreman RD. Putative mechanisms behind effects of spinal cord stimulation on vascular diseases: a review of experimental studies. Auton Neurosci. 2008. 138(1-2): 9-23.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 \u0026nbsp;Characteristics of the patients\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003echaracteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003ethe observation group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003ethe control group\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.492957746478874%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003esex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.50704225352113%\" valign=\"top\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.583333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.583333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.492957746478874%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAge,\u003c/p\u003e\n \u003cp\u003eyears\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.50704225352113%\" valign=\"top\"\u003e\n \u003cp\u003emean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e62.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e65.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003erange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.583333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e19-75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.583333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e18-79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.492957746478874%\" rowspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003edisease types\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.50704225352113%\" valign=\"top\"\u003e\n \u003cp\u003ebrainstem hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003ebrain trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.583333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.583333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003ecerebral hemorrhage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.583333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.583333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003ecerebral infarction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.583333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.583333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"40.833333333333336%\" valign=\"top\"\u003e\n \u003cp\u003eaneurysm rupture and hemorrhage after operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.583333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.583333333333332%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2 \u0026nbsp;Comparison of decannulation between the two groups\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"data:image/png;base64,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more about [BMC Neuroscience](http://bmcneurosci.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nros/default.aspx","title":"BMC Neuroscience","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"the short-term spinal cord stimulation (stSCS), tracheal decannulation, brain injury, disorders of consciousness(DoC), tracheotomy","lastPublishedDoi":"10.21203/rs.3.rs-4066057/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4066057/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To investigate the effects of the short-term spinal cord stimulation (stSCS) on the rates of tracheal decannulation in patients of brain injury with disorders of consciousness (DoC).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e 81 patients of brain injury with DoC after tracheotomy treated in Ganzhou People’s hospital from June 2021 to June 2022 were retrospectively analyzed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e We divided the patients into two groups, 46 patients who underwent stSCS as observation group, and 35 patients who did not undergo stSCS under the same conditions as the control group. The rates of decannulation were compared between the two groups. The rates of decannulation were 50% in the observation group and 25.7% in the control group. There was significant difference between the two groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e stSCS can improve the rates of decannulation in patients of brain injury with DoC.\u003c/p\u003e","manuscriptTitle":"The short-term spinal cord stimulation improves the rates of tracheal decannulation in patients of brain injury with disorders of consciousness","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-27 17:31:55","doi":"10.21203/rs.3.rs-4066057/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-26T20:08:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-22T11:10:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-22T11:10:03+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neuroscience","date":"2024-03-10T15:04:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neuroscience","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nros","sideBox":"Learn more about [BMC Neuroscience](http://bmcneurosci.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nros/default.aspx","title":"BMC Neuroscience","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ba0e7bfd-3aa4-4f0f-8519-ff08a78e72a2","owner":[],"postedDate":"March 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-02T16:07:51+00:00","versionOfRecord":{"articleIdentity":"rs-4066057","link":"https://doi.org/10.1186/s12868-025-00951-x","journal":{"identity":"bmc-neuroscience","isVorOnly":false,"title":"BMC Neuroscience"},"publishedOn":"2025-05-26 15:57:02","publishedOnDateReadable":"May 26th, 2025"},"versionCreatedAt":"2024-03-27 17:31:55","video":"","vorDoi":"10.1186/s12868-025-00951-x","vorDoiUrl":"https://doi.org/10.1186/s12868-025-00951-x","workflowStages":[]},"version":"v1","identity":"rs-4066057","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4066057","identity":"rs-4066057","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}