Management and Complications
Discussion
There is a significant paucity of information and consensus regarding the management of respiratory insufficiency in the pediatric SCI population. Gilgoff (1988) described attempts to gain ventilator-free time in a group of eight children with high-level tetraplegia (C1-2) and no spontaneous breathing by using a neck accessory muscle strengthening program; Seven of the eight children gained 20 min-12 hours of ventilator-free time using this technique and were able to maintain adequate respiratory parameters. While the neurologic level was mentioned in the study report, the severity of and time from injury were not, thus making it hard to predict weaning success extrapolating the data presented. Padman (2003) looked at a cohort of 47 children (split into 2 groups C1-2 and C3-T1) that underwent weaning off the ventilator 10-60 days post-injury. While the severity of the injury and the exact number of participants in each neurologic level grouping was not specified in the paper, a detailed pathway of care and ventilator weaning for children with tracheostomies was presented. Sixty-three percent of patients were successfully weaned from mechanical ventilation. Taller children with injuries C3-4 or lower and tidal volumes of 18 to 20 cm2/kg were more successfully weaned from mechanical ventilation (assumed to be related to better lung volumes and more motor function). Atelectasis development was a poor predictor factor for weaning and a significant number of children (34%) developed suprastomal granulation tissue that required bronchoscopic removal prior to decannulation.
Vogel (2002b) administered a survey aiming to quantify the prevalence of medical complications to 216 individuals who sustained SCI at age 18 or younger and were at least 24 years of age at the interview. 68 of 216 participants experienced pneumonia at least once, and 17 required temporary or chronic ventilation since their injury; of the 68 subjects, 39 experienced one episode, 10 had two episodes, and 19 had more than three episodes. The individuals who experienced respiratory complications were older at follow-up, had a longer duration of and more severe SCI, with lower motor and Functional Independence Measure scores. In addition, the most common reason for hospitalization within three years from injury was respiratory disorders (N=13).
Lastly, the role of anxiety awareness and management in the context of SCI-related respiratory dysfunction was discussed in a case report of an 8-year-old ventilator-dependent child (Warzak et al. 1991), as well as in a case series involving eight children with SCI (Gilgoff et al. 1988).
