Respiratory Management Following Spinal Cord Injury - 21

CLINICAL PRACTICE GUIDELINE

cases; however, a normal study does not rule out sleep-disordered breathing, particularly if performed with a standard oximeter (Netzer et al., 2001; Wiltshire et al., 2001). Nocturnal oximetry, therefore, may be appropriate as a screening study in a setting where full polysomnography is not immediately available or as a follow-up study for monitoring sleep-disordered breathing. 22. Prescribe positive airway pressure therapy if sleep-disordered breathing is diagnosed.
(Scientific evidence–V; Grade of recommendation–C; Strength of panel opinion–Strong)

23. Evaluate the patient for the following risk factors: Supine position. Spinal shock. Slowing of gastrointestinal tract. Gastric reflux. Inability to turn the head to spit out regurgitated material. Medications that slow gastrointestinal activity or cause nausea and vomiting. Recent anterior cervical spine surgery. Presence of a tracheostomy. Advanced age.
(Scientific evidence–V; Grade of recommendation–C; Strength of panel opinion–Strong)

Continuous positive airway pressure (CPAP) therapy is the most commonly prescribed treatment for sleep-disordered breathing. In spite of severe sleep-disordered breathing, tetraplegic patients may have a relatively low rate of acceptance for CPAP (Burns et al., 2000; Burns et al., 2001). Bi-level positive airway pressure (BiPAP) therapy has not been evaluated for treatment of sleep-disordered breathing in people with tetraplegia, but it may be considered for patients who do not tolerate or do not show improvement with CPAP Other forms of treatment for sleep. disordered breathing, including oral appliances and airway surgery, such as uvulopalatopharyngoplasty, also have not been studied in people with tetraplegia. A patient with severe sleep-disordered breathing secondary to upper airway obstruction may choose to retain the tracheostomy tube and leave it open during sleep.

Dysphagia and Aspiration
The literature on the incidence of aspiration in spinal cord injury is limited. When it does occur, it is a serious risk for the individual with tetraplegia. It is a cause of aspiration pneumonia, in addition to being a cause of acute respiratory distress syndrome (ARDS). Although the risk and frequency of ARDS in people with tetraplegia has not been specifically studied, it would appear that it is not a common occurrence in this population. However, when it does occur, it greatly increases the risk of death. Recent literature on ARDS indicates that the death rate is 31–61% for people who have ARDS (Acute Respiratory Distress Syndrome Network, 2000; Bersten et al., 2002; Gattinoni et al., 2001).

Kirshblum et al. (1999) studied the incidence of aspiration in 187 patients with acute traumatic spinal cord injury. Forty-two patients had signs or symptoms suggestive of dysphagia; follow-up evaluation with videofluoroscopic swallowing study (VFSS) was positive in 31 of the 42 patients (73.8%). Spinal surgery via anterior cervical approach (p<0.016), tracheostomy with mechanical ventilation (p<0.01), and older age (p<0.028) were three independent predictors of dysphagia by VFSS. Tracheostomy at admission was the strongest single predictor of dysphagia. Patients with both tracheostomy and spine surgery via an anterior cervical approach were highly likely to demonstrate dysphagia (48%). Higher level of injury and increased time between injury and rehabilitation admission slightly increased the likelihood of dysphagia. Kirshblum and colleagues note that harmful sequelae of dysphagia in SCI patients can include transient hypoxemia, atelectasis, chemical pneumonitis, mechanical obstruction, bronchospasm, and pneumonia. Bellamy et al. (1973) also noted that patients with posterior cervical spine surgery had a slightly lower incidence of pulmonary complications and postoperative infection than anterior cervical fusion. According to Kirshblum et al. (1999), Wise and Milani (1987) found as causes of aspiration position, certain neurologic factors, surgical complications, and the inability to coordinate swallowing with ventilator cycling. They also noted that complications included the anterior spine approach, dislodged strut grafts, laryngeal nerve paralysis, and postoperative edema.

Respiratory Management Following Spinal Cord Injury

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