Respiratory Management Following Spinal Cord Injury - 18

RESPIRATORY MANAGEMENT FOLLOWING SPINAL CORD INJURY

Cuff Deflations
Bach and Alba (1990b) studied the efficacy of deflated cuffs and cuffless tracheostomy tubes. Ninety-one of 104 patients were able to be converted to tracheostomy tubes with no cuffs or to have the cuffs deflated; 38 of the 104 patients were high-level tetraplegics. This study also included people with other diagnoses, such as postpolio or myopathies. The study did not indicate what percentage of the 38 tetraplegic patients were able to convert to deflated cuffs or cuffless tubes. When the patient is doing well and improvement is seen in any pneumonia or atelectasis, the cuff on the tracheostomy tube can be deflated on a part-time basis. This allows the patient to talk. Also, sometimes the patient’s appetite improves with the cuff deflated and swallowing becomes easier. With the cuff deflated, if there is a one-way speaking valve in place, the patient will have a more effective cough, especially with the use of assisted coughing. A survey of Craig Hospital, Kessler Institute for Rehabilitation, and the Institute for Rehabilitation and Research resulted in the following list of basic discharge equipment required for a spinal cord injured person with apnea to live at home. Portable vent, bedside. Portable vent, wheelchair. External battery and charger. Vent circuits. Heated humidifier. Auxiliary power source. Nebulizer. Connecting tubing. Portable suction machine. Bedside suction machine. Tracheostomy tubes and care kits. Manual resuscitator. Oxygen source prn. Pulse oximeter pm. Remote external vent alarm. An auxiliary power supply is recommended because a prolonged power outage—with the potential for fatal consequences in an apneic patient—may occur at any time. Other equipment

items and supplies will also be necessary, depending upon the individual’s needs and the health-care team’s recommendations.

Weaning from the Ventilator
18. Consider using progressive ventilator-free breathing (PVFB) over synchronized intermittent mandatory ventilation (SIMV).
(Scientific evidence–V; Grade of recommendation–C; Strength of panel opinion–Strong)

The survival rate for seriously ill ventilated patients has increased dramatically over the past several decades, increasing the importance of weaning from mechanical ventilation. DeVivo and Ivie (1995) note progressive improvement in the survival rate of SCI patients who were ventilator dependent at the time of discharge from a rehabilitation center, or who died during their hospitalization while ventilator dependent. They compared the time periods 1973–79, 1980–85, and 1986–92. DeVivo et al. (1995) note that life expectancies for SCI individuals are considerably improved for those who have been totally weaned from the ventilator when compared to those who have not been weaned from the ventilator. Although some reports indicate at least part-time long-term ventilatory support for 100% (7 of 7) patients with C4 and C5 level tetraplegics (Sortor, 1992), other reports indicate that up to 83% of C3 and C4 tetraplegic patients can be successfully weaned from mechanical ventilation (Peterson et al., 1994). Hall et al. (1999) found that hours per month of paid attendant services for ventilatorassisted patients were 135.25 hours versus 64.74 hours of paid attendant services for ventilatorindependent patients.

PVFB Versus SIMV
Only two articles report on the weaning of spinal cord injured people with well-defined levels of injury. Both studies concerned C3 and C4 tetraplegia, because these are the people in whom there is a possibility of total weaning, although success would be difficult. Peterson et al. (1994) found that for C3 and C4 individuals with tetraplegia, PVFB provides a greater chance for successful weaning from the ventilator than does IMV The . success rate was 67.6% for each period of attempted weaning using PVFB, as compared to the 34.6% success rate for each period of attempted weaning using IMV In this study, some people . had more than one attempt at weaning, and the overall success rate for total weaning from the

Respiratory Management Following Spinal Cord Injury

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