Respiratory Management Following Spinal Cord Injury - 9

CLINICAL PRACTICE GUIDELINE

Monitoring oxygen saturation is a noninvasive way of following the quality of gas exchange. This can be a means of identifying changes in function and developing pathologies early before they become clinically urgent. Consider arterial blood gas depending on patient complaints and deterioration in oxygen saturation. Decline in oxygen saturation and increased requirement for O2 supplementation may be associated with CO2 retention and herald the need for initiation of mechanical ventilation.

Prevention and Treatment of Atelectasis and Pneumonia
Pneumonia, atelectasis, and other respiratory complications, reported to occur in 40–70% of patients with tetraplegia, are the leading cause of mortality (Bellamy et al., 1973; Carter, 1987; Kiwerski, 1992; Reines and Harris, 1987). In one study, 60% of C3 and C4 patients on a ventilator who were transferred to a tertiary care facility had atelectasis (Peterson et al., 1999). 5. Monitor indicators for development of atelectasis or infection, including: Rising temperature. Change in respiratory rate. Shortness of breath. Increasing pulse rate. Increasing anxiety. Increased volume of secretions, frequency of suctioning, and tenacity of secretions. Declining vital capacity. Declining peak expiratory flow rate, especially during cough.
Note: If atelectasis or pneumonia is present on the chest x-ray, institute additional treatment and follow serial chest radiographs. If temperature, respiratory rate, vital capacity, or peak expiratory flow rate is trending in an adverse direction, obtain a chest radiograph. (Scientific evidence–V; Grade of recommendation–C; Strength of panel opinion–Strong)

the patient for these complications. The most common location for atelectasis is the left lower lobe. The physician should attempt to roll the patient to the side or sit him or her up to fully evaluate the left lower lobe, often missed when auscultating over the anterior chest wall (Sugarman, 1985). Other methods of evaluating the patient should be used, including the serial determination of the vital capacity, the peak expiratory flow rate, the negative inspiratory force (NIF), and oximetry. These should be followed on an individual flow sheet designed for this purpose or on a graph. If any of these measures are deteriorating, a chest radiograph should be performed. A chest radiograph should also be performed if the vital signs are deteriorating, if subjective dyspnea increases, or if the quantity of sputum changes. The higher the level of spinal cord injury, the greater the risk of pulmonary complications. Wang et al. (1997) documented a reduction in peak expiratory flow rate in tetraplegic patients. Because peak expiratory flow rate is important in cough, it would be expected that the higher the level of SCI, the greater the likelihood of retention of secretions and atelectasis. 6. Intubate the patient for the following reasons: Intractable respiratory failure, especially if continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) or noninvasive ventilation has failed. Demonstrable aspiration or high risk for aspiration plus respiratory compromise.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Because the incidence of atelectasis and pneumonia is so high in the tetraplegic patient, special attention needs to be given to monitoring

The decision to intubate the SCI patient is often difficult. There is evidence that patients have fewer respiratory complications on noninvasive ventilation than with invasive ventilation (Bach et al., 1998). However, unless the physicians and other staff caring for the patient have adequate experience in caring for tetraplegic patients who are not on a ventilator, it may be safer for the patient to be intubated and ventilated using the protocol outlined in Appendix A. In these situations, it is also desirable to transfer the patient to a specialized center with expertise in caring for tetraplegic patients (Applebaum, 1979; Bellamy et al., 1973).

Respiratory Management Following Spinal Cord Injury

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