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