Respiratory Management Following Spinal Cord Injury - 16

RESPIRATORY MANAGEMENT FOLLOWING SPINAL CORD INJURY

Surfactant, PositiveEnd Expiratory Pressure (PEEP), and Atelectasis
13. Recognize the role of surfactant in atelectasis, especially when the patient is on the ventilator.
(Scientific evidence–None; Grade of recommendation–NA; Strength of panel opinion–Strong)

Atelectasis is more common in the left lower lobe than in the right. Therefore, when the patient is first intubated, some areas of the lungs may be more aerated than other areas. In this situation, it is more difficult to inflate the atelectatic lung by recruiting alveolar elements and easier to inflate the already partially inflated lung. Atelectatic lung produces no surfactant, but hyperinflation enhances surfactant production. Positive-end expiratory pressure does not stimulate surfactant production (Nicholas and Barr, 1981). Also consider which medications stimulate surfactant production. The only medications known to stimulate surfactant production are longacting beta agonists, short-acting beta agonists, and theophyllines (Nicholas and Barr, 1981).

may also develop a pneumothorax as a result of mechanical ventilation. Many physicians are reluctant to use large ventilator tidal volumes; however, Peterson et al. (1999) and Peterson et al. (1997) demonstrated no increase in barotrauma or pneumothorax in patients ventilated with very high tidal volumes when the large volumes were achieved using a protocol (see Appendix A on page 31). Some patients may develop an empyema from pneumonia or as a result of infection of the pleural space related to contamination of this space at the time of the original injury. Patients with pneumothorax, hemothorax, or empyema may require a chest tube. In some of these patients, the presence of blood or empyema in the pleural space or the presence of a chest tube may result in deformity of the lung, adhesions between the lung and the chest wall, or a trapped lung. Because these patients are weak, the lung constriction of the trapping, or the deformity, may interfere with total weaning from the ventilator. Surgical treatment and high postoperative tidal volumes should reexpand the affected lung and allow easier weaning.

Pneumonia
15. Employ active efforts to prevent pneumonia, atelectasis, and aspiration.
(Scientific evidence–IV/V; Grade of recommendation–C; Strength of panel opinion–Strong)

Complications of Short-Term and LongTerm Ventilation
Atelectasis
14. Use a protocol for ventilation that guards against high ventilator peak inspiratory pressures. Consider the possibility of a “trapped” or deformed lung in individuals who have trouble weaning and have had a chest tube or chest surgery.
(Scientific evidence–V; Grade of recommendation–C; Strength of panel opinion–Strong)

Reducing the incidence of atelectasis for people on a ventilator should reduce the incidence of pneumonia because the bacteria will not have the medium of secretions for their growth. Pneumonia is common in tetraplegia, although it is sometimes difficult to sort out whether the patient has pneumonia, atelectasis, or both. The underlying problem is paralysis of the respiratory muscles, which leads to poor mobilization of secretions, bacterial accumulation in the secretions, and the resultant respiratory infection. Therefore, the goal for prevention and treatment of pneumonia is to mobilize the secretions. Prevention and Treatment of Atelectasis and Pneumonia (see page 9) details treatments that can be considered to accomplish this goal. If the patient is on a ventilator, some of these treatments can also be used. However, the most important goal is to prevent the accumulation of secretions and the formation of atelectasis. If the patient develops respiratory infection and pneumonia, the result is likely to be a cascade effect of bacteria that are more and more resistant to antibiotics. Therefore, vigorous treatment to clear secretions and clear atelectasis must be instituted. The best data on clearing atelectasis and improving weaning

Ventilation with low ventilator tidal volumes will allow lung deformity or lung entrapment if adhesions have formed between the visceral and parietal pleura. If the lung deformity or entrapment occurs at a low ventilator tidal volume, this may cause great difficulty in weaning the patient from the ventilator later. Some patients have chest injury or placement of central lines associated with their spinal cord injury. These associated injuries may result in pneumothorax or hemothorax. The individual

Respiratory Management Following Spinal Cord Injury

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