The Course of Rehabilitation of Ventilated and Tracheally Cannulated Patients in Neurological-Neurosurgical Early Rehabilitation

With optimized emergency, stroke, and intensive care management, a growing number of patients now survive major cerebral infarctions, intracranial hemorrhages, severe acute brain injuries, resuscitation, and critical care with subsequent neurological complications (1). Many require follow-up rehabilitation. Neurological rehabilitation in Germany follows the “Phase Model” developed by the Federal Association for Rehabilitation (BAR) (2): Phase A = primary treatment in a hospital for acute cases; Phase B = specialized early rehabilitation center for neurological-neurosurgical early rehabilitation (NNR); Phase C = follow-up rehabilitation (patients still need care but can already participate actively in [group] therapy). Not infrequently, patients transitioning to Phase B still have tracheostomy cannulas and, in some cases, require ongoing ventilation. Weaning from mechanical ventilation and decannulation are the main therapeutic goals of NNR, with the aim of establishing the requirements for Phase C. Weaning and decannulation are achieved in 65 to 82% and 52 to 54% of cases, respectively (3, 4). Patients who cannot be weaned from ventilation or decannulated receive care in out-of-hospital intensive care units (OOH-IC) or in Phase F (long-term) facilities. Against a background of increasing care demands, weaning from mechanical ventilation has become an integral part of NNR, accounting for approximately 25% of NNR patients (3). At the same time, the proportion of patients admitted from a non-neurological intensive care unit (ICU) to a NNF facility, who initially did not suffer from a neurological disorder but who have developed neurological complications during the ICU stay (post-intensive care syndrome), has increased markedly. The present observational study analyzed the success rates of ventilator weaning and decannulation, as well as changes in the Early Rehabilitation Barthel Index (ERBI) and type of follow-up care. Furthermore, with respect to the endpoint “decannulation,” we compared patients admitted solely for decannulation with those admitted for both weaning and decannulation.

Methods

Eleven NNR/Phase B facilities from seven federal states participated (specialized hospitals, certified by the German Society for Neurorehabilitation (DGNR) and the German Technical Inspection Agency (TÜV) of the Rhineland region as centers for weaning from mechanical ventilation) (5). Anonymized data were acquired from routine clinical practice for the period January 1 to December 31, 2023, and from one center for the period July 1 to December 31, 2023. All patients who had been admitted either for ventilator weaning and decannulation (WD group) or exclusively for decannulation (D group) were included. Eight centers included both groups; three centers had WD patients only. The WD group was subdivided into successfully weaned and decannulated (+W+D), weaned, but not decannulated (+W–D), and not successfully weaned patients (–W). The D group was stratified according to decannulation success in +D and –D. Primary endpoints were the success rates of ventilator weaning and decannulation. Changes in ERBI and type of follow-up care were also analyzed.

Figure

Course of rehabilitation with discharges/transfers

Results and Discussion

Results: Data from a total of 2435 patients were evaluated, of which 1703 were WD patients (64.7 ± 13.2 years) and 732 D patients (64.2 ± 14.3 years). Altogether, 1449 patients (85.1%) in the WD group were successfully weaned from mechanical ventilation. Of these, 852 patients (58.8%) were subsequently decannulated (+W+D), while decannulation was unsuccessful in 597 patients (41.2%) (+W–D). Weaning was unsuccessful in 14.9% (–W). The decannulation rate in the D group was 45.4% and was significantly lower as compared to the WD group. At the time of admission, there was no difference between the WD subgroups with regard to ERBI score (median: −220). Within the D Group, however, patients who were later successfully decannulated were shown to have higher ERBI scores at admission than non-decannulated patients. At discharge, the ERBI score of +D patients was lower than that of +W+D patients. Twenty-six percent of the initially ventilated patients (31% of the successfully weaned, 53% of the successfully weaned and decannulated patients) were discharged into continuing rehabilitative care. Fifteen percent of initially ventilated patients received ongoing care in OOH-IC. In the D group, 20% (40% of the +D patients) were discharged to follow-up rehabilitation and 15% to OOH-IC. Fifteen percent of patients in both groups died during rehabilitation.

Discussion: Eighty-five percent of ventilated patients were successfully weaned from mechanical ventilation. Decannulation and subsequent rehabilitative follow-up care were achieved more often in patients weaned during NNR than in patients who were already weaned at admission. Decannulation is the actual challenge in NNR: around 90% of ventilated patients present at admission with severe dysphagia requiring monitoring and still needing a tracheostomy cannula even after successful ventilator weaning. In NNR, swallowing rehabilitation begins in parallel with ventilator weaning and can also be provided during breaks from ventilation.

Table

Descriptive Statistics

The participating centers were required to document the involvement of respiratory and speech therapists, as well as their interdisciplinary collaboration, for certification by the DGNR. Coordinated high-intensity therapy that provides ventilator weaning and swallowing rehabilitation may facilitate decannulation; however, interpretation of these associations is limited by the lack of information on the preceding stay in the intensive care unit (duration, weaning process, dysphagia therapy). Yet this is the time when initial rehabilitative interventions begin, so further studies are needed to quantify these interventions and compare them across different treatment/rehabilitation phases.

Tobias Schmidt-Wilcke, Frederick Benjamin Junker, Andreas Bender, Vannessa Born, Christoph Bucka, Cay Cordes, Imanuel Dzialowski, Martin Gross, Christiane Haack, Michael Hartwich, Marcel Klimes, Sven Lukhaup, Jens Rollnik, Annette Schälich, Joachim Scheßl, Christian Weimar, Daniel Wertheimer, Thomas Platz, Marcus Pohl

Conflict of interest statement

MG received lecture fees from Löwenstein Medical and Aerogen.

MG, MP, TP, and TSW are members of the Certification Committee of the German Society for Interdisciplinary Neurological Rehabilitation (DGiNR).

AB, MP, and TP are members of the DGiNR executive committee. 

CC, CB, ID, MG, MH, JS, TSW, and CW are members of the DGiNR.

TSW is spokesperson of the Federal Working Group for Neurological–Neurosurgical Early Rehabilitation.

MH is spokesperson of the Neurological Early Rehabilitation Specialty Group of the Asklepios Group.

MG is President of the German Interdisciplinary Society for Out-of-Hospital Ventilation (DIGAB).

TP is Regional Vice President (Central and Western Europe) of the World Federation for Neurorehabilitation (WFNR) and receives personal funding from the Federal Association for Rehabilitation (BDH), for which he serves as Medical Director of Research.

AB received third-party funding for the OptiNIV project (“Optimization of posthospital intensive care for neurological patients”) through the Innovation Fund of the German Federal Joint Committee.

The other authors declare that no conflict of interest exists.

Manuscript received on July 29, 2024, revised version accepted on December 15, 2025

Translated from the original German by Dr. Grahame Larkin

Cite this as:
Schmidt-Wilcke T, Junker FB, Bender A, Born V, Bucka C, Cordes C, Dzialowski I, Gross M, Haack C, Hartwich M, Klimes M, Lukhaup S, Rollnik J, Schälich A, Scheßl J, Weimar C, Wertheimer D, Platz T, Pohl M: The course of rehabilitation of ventilated and tracheally cannulated patients in neurological-neurosurgical early rehabilitation. Dtsch Arztebl Int 2025; 122: 136–7. DOI: 10.3238/arztebl.m2025.0241

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