Ventilator Weaning with Spinal Cord Injury
&Tracheostomy
18 patients in critical care beds awaiting transfer5> 6 months
RISCI snapshot survey 2009
South of England Review of Standards in Spinal Cord injury
National Spinal Cord Injury Strategy Board
Weaning guidelines for Spinal Cord Injured patients in Critical Care Units
Ventilated spinal injured patients
• 15-20% Initially ventilated• 98% Weanable• 1% Nocturnal ventilation• 1% Fully ventilator dependant
• = 8-12 patients/yr• ~ 120 patients in UK
Lumbar Unable to cough 100-70%
Low thoracic chest wall compliance Vital capacity
High thoracic chest wall compliance 30-50% Vital capacitypoor expansion. Basal collapse
C5/C6 Diaphragms, Scalenes 20%
C3/C4/C5 Sternomastoid and partial diaphragm
Above C3 Sternomastoid only 5-10%
Acute VC 1 Year VC
100-70%
40-50%
60-70%
Respiratory effects
Weaning
Based on little evidence but vast experience
PrerequisitesGood pulmonary complianceLow FiO2 requirementAwake and cooperativeSome respiratory activityCommitted team
Any respiratory activity?
TestingVolume measurement
Beware sensitive ITU Vents
Modified brainstem death test
Progressive ventilator free breathing
Measure Vital Capacity
VC Time off Vent
<250 mls 5 Mins-500 mls 15 Mins-750 mls 30 Mins-1000 mls 60 Mins
Measure VC Post weaning >70% pre weaning
Southport Spinal Injury Centre
Weaning
Increase duration and/ or frequency
Weaning
Wait for spasticity
Bronchodilators
?High TV Ventilation (>20 ml/Kg)?1
Supine
1. The effect of tidal volumes on the time to wean persons with high tetraplegia from ventilators Peterson W. et al spinal cord 1999 37(4):284-288
FVC and Posture
Supine
Sitting no binder
Sitting Binder
0
0.5
1
1.5
2
2.5
3
3.5
4
FVC
Weaning
Off vent requires PEEP/CPAP to reduce atalectasisBest option cuff with speaking valve.Ditch the ITU vent
Don’t reduce pressure support too farTry to stick to planAim for off all day, support at night
Speech essentialEating optional
How to wean
BIPAP/ PS
laryngeal function vs resp function
Cuff down on vent
VFB speaking valve
VFB Cuff up
VFB Cuff down speaking valve
Downsized uncuffed tube
Decannulate
Fast weanersSlow weaners
How successful ?
Southport spinal injuries unit
• 246 patients over 20 years
• 63% weaned• 33% Ventilator dependant• 4% Died
Post weaning Maintenance
‘ Maintain Range of Movements’Manual hyperinflationIPPBCough Assist/ Clearway
Improve muscle strengthInspiratory muscle training
Tracheostomy
• Surgical may be better than percutaneous– Safer if unstable spine– Anatomically accurate– Easier changes long term– Worse scar– Logistically difficult
Trachy Tubes
Use what you are used to but…
Avoid fenestrations
Trachy Tubes
Definitely avoid
Trachy Tubes
Definitely consider supraglottic suction tubes
Trachy Tubes
If they need a tube long term
Trachy Tubes
Trachy Tubes
Don’t dismiss
Speaking valves Are not all the same
When to decanulate
No respiratory support required
Secretion clearance guaranteed