Patients with acute SCI requiring ventilation are usually intubated, either in the field or upon admission to the hospital. Intubation can either be orotracheal or nasotracheal; both options are normally used for short periods of ventilation of less than 10 days (Shirawi & Arabi, 2006). Prolonged intubation is not recommended as it can lead to the development of pneumonia, subglottic or tracheal stenosis, and increased airway resistance. In addition, it limits patients’ mobility, prolongs ventilator weaning, and makes pulmonary and oral hygiene difficult (Shirawi & Arabi, 2006). In cases where ventilation is required for longer than 10 days, a tracheostomy is usually performed. Intubation is safest when it is performed electively under anaesthesia to reduce neurological damage experienced from neck manipulation (Durbin et al. 2014), so it often occurs before a patient is experiencing severe breathing difficulty. The risk of damage is elevated when intubation is performed urgently in the case of sudden respiratory distress. Patient outcomes vary as a result of intubation depending on their initial condition and other procedures received, and are reviewed below.
Among patients with cervical SCI, it has been reported that the majority require intubation upon hospital admission, with reports ranging 54% to 65% (Seidl et al. 2010; Velmahos et al. 2003). A subset of patients who do not immediately require intubation eventually do need this procedure due to declining respiratory status; Velmahos et al. (2003) reported that among 50 patients who required intubation, 26% were intubated 1 to 53 hours after hospital admission. Overall, most studies found that the need for intubation was higher in patients with complete injuries (Iwashita et al. 2006; Seidl et al. 2010; Velmahos et al. 2003) and higher levels of cervical injury (Iwashita et al. 2006; Velmahos et al. 2003), although Como et al. (2005) reported no difference with regard to injury level. To date, there are no RCTs (randomized controlled trial) that compare the efficacy and safety of different intubation techniques in SCI patients or evaluating the precise timing a patient should be removed from intubation.
There is level 2 evidence (from two case series and one cohort study; Seidl et al. 2010; Velmahos et al. 2003; Iwashita et al. 2006) that complete injuries predict the need for intubation in acute SCI patients.
There is level 2 evidence (from one cohort study and one case series; Iwashita et al. 2006; Velmahos et al. 2003) that higher level cervical injuries predict the need for intubation in acute SCI patients.
Complete or higher level cervical injuries (C4 and above) are risk factors for necessitating intubation during the acute phase post SCI.