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Respiratory Management during the Acute Phase of Spinal Cord Injury

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Acute Respiratory Management Executive Summary

Mullen E, Faltynek P, Mirkowski M, Benton B, McIntyre A, Vu V, Teasell RW. (2019). Respiratory Management during the Acute Phase of Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Research Evidence. Version 7.0: p 1-51.



1.0 Executive Summary

The majority of research in the area of early respiratory management is primarily centered on ventilation (including related topics: tracheostomy, intubation, and extubation) and the prevention and treatment of pulmonary complications. The emphasis in acute care is to maintain an open airway and diaphragm functioning while preventing respiratory failure, atelectasis, and pneumonia. This is a delicate balance for medical personnel as the presence of ventilation itself–despite assisting breathing–can directly lead to these pulmonary complications. This review has shown that less than ten percent of studies to date are in the form of randomized controlled trials (RCTs); the majority are retrospective studies  examining which factors on admission to acute care are associated with certain interventions and outcomes. This suggests a lack of interventional research in the area of acute respiratory care during acute SCI. Effective RCTs may be difficult to undertake in this research area as there are often standard protocols in place for airway management; further, it may be unethical to create a control group that receives less than the highest quality of pulmonary resuscitation (Casha & Christie, 2011). Lastly, a common theme emerging throughout this chapter is that individuals with complete, high level injuries tend to require more mechanical ventilation, intubation, and tracheostomies than individuals with incomplete or lower level injuries. These patients also experience more pulmonary complications and have more difficulty weaning from ventilation. This patient demographic would benefit most from prospective RCTs in respiratory management; this would allow for improved acute care and rehabilitation outcomes. With significant advances in technology, new interventions may be studied. Neuroplasticity is continuously playing a larger role in neurorehabilitation in all stages and spinal cord injury is no exception. As respiratory function is controlled nervously, it is a prime area for the exploration of neuroplasticity and it can be anticipated that it will start to emerge in the literature more frequently in the near future (Fuller & Mitchell, 2017; Fields & Mitchell, 2015).

Gaps in the Evidence
Although this is an important area of clinical care, high quality research is lacking, and consists largely of cohort and case-controlled studies. This creates problems in that more severe strokes are more likely to be associated with poorer outcomes and are more likely to have more aggressive treatments, such as a tracheostomy. RCTs are uncommon and of those many are of poor quality with low PEDro scores and/or very small sample sizes. The current literature does point to where high quality RCTs are necessary, preferably multi-sited studies with high PEDro scores. These are designed to answer the following questions which include:

  • What is the efficacy of intermittent positive pressure in acute SCI on pulmonary indices
    and pulmonary complications?
  • What is the impact of earlier tracheostomies on pulmonary complications and ventilation
    times?
  • What is the impact of percutaneous tracheostomies on pulmonary complications and
    ventilation/hospital times when compared to more traditional surgical tracheostomies?
  • Is diaphragmatic pacing better than mechanical ventilation for those SCI patients who
    need breathing assistance in reducing the incidence of pneumonia and number of
    ventilator days?
  • In acute SCI patients, does higher tidal volume ventilation speed up the mechanical
    ventilation weaning process when compared to lower tidal volume ventilation?
  • Does mechanical insufflation/exsufflation techniques clear secretions better than manual
    assisted coughing techniques?
  • Do combined inspiratory and expiratory muscle training improve pulmonary indices
    better than inspiratory or expiratory muscle training alone.
  • Do bronchodilators such as Salbutamol improve pulmonary indices when compared to
    placebo?