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Comparative or Combination Interventions

There are limited studies examining combinations of interventions for the improvement of respiratory function post SCI. However, of those that meet the SCIRE inclusion criteria, the primary focus is on the type of ventilation received by patients: multiple, singular, or none.

Table 4. Comparative or Combination Interventional Studies for Respiratory Function during Acute SCI

Author Year

Country

Research Design

Sample Size

MethodsOutcomes
Gregoretti et al. (2005)

Italy

Prospective Controlled Trial

N=10

Population: Mean age: 34 yr; Gender: male=10, female=0; Level of injury: C4-C6; Severity of injury: not specified.

Intervention: Patients first received endotracheal invasive ventilation (EIV) for 1-15 days and then later received transtracheal open ventilation (TOV) for 1 day.

Outcome Measures: The following during EIV treatment, at 1-hr post TOV treatment, and 24 hrs post TOV treatment: ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2), arterial blood gas analysis in the form of partial pressure of inspired oxygen in arterial blood (PaO2), partial pressure of carbon dioxide in arterial blood (PaCO2), Respiratory rate, pressure within the distal trachea, pressure-time product of esophageal pressure.

Chronicity: Time since injury not specified.  

1.     There were no significant differences between the EIV treatment and the TOV treatment with regards to PaO2/FiO2, PaO2, respiratory rate, and pressure within the distal trachea (p>0.05).

2.     Patients had a significantly lower PaCO2 while receiving EIV compared to 1 hr post TOV and 24 hr post TOV (p<0.0001).

3.     Patients had a significantly lower pressure-time product of esophageal pressure after 24 hr of receiving TOV compared to 1 hr post TOV and during EIV (p<0.05).

 

Watt et al. (2011)

United Kingdom

Case Control

N=189

Population: Mean age: 32 yr; Gender: male=163, female=26; Level of injury: C1-S5; Severity of injury: complete=136, incomplete=53; AIS A-D.

Intervention: Patients were either weaned from ventilation at discharge or remained on ventilation at discharge. Among those who required mechanical ventilation, some patients also used diaphragm pacing. Patients were further stratified by age 0-30 yr, 31-45 yr, and 46+ yr.

Outcome Measures: Mean survival time.

Chronicity: Time since injury not specified. The date of ventilation was within a few days of injury.

1.     Patients aged 31-35 who were weaned from the ventilator at discharge had a significantly higher mean survival time than patients who still required ventilation at discharge (p=0.047). There were no significant differences in survival times in the other age groups.

2.     Among those who required mechanical ventilation at discharge, patients who used diaphragm pacing had a significantly better survival than the group who only used mechanical ventilation (p<0.05).

Romero-Ganuza et al. (2011b)

Spain

Case Control

N=323

Population: Mean age: 42 yr; Gender: male=255, female=68; Level of injury: cervical to thoracic; Severity of injury: complete=229, incomplete=94.

Intervention: Patients either received a tracheostomy or did not. Of those who did, they either received a surgical tracheostomy or a percutaneous tracheostomy. They also either received an early tracheostomy (≤7 days post intubation) or a late tracheostomy (>7 days post intubation).

Outcome Measures: The following during hospital stay: incidence of tracheostomy, incidence of complications.

Chronicity: Mean interval from injury to admission=11.4 days.

1.     There were 69 cases of perioperative complications following tracheostomy. Patients who received an early tracheostomy had significantly fewer cases of tracheal stenosis than patients who received a late tracheostomy (p=0.003). There were no significant differences in pneumonia (p=0.81), stomal cellulitis (p=0.45), bleeding (p=0.96), or mortality rate (p=0.22) between the two groups.

2.     Patients who received a percutaneous tracheostomy experienced fewer cases of pneumonia (p=0.011) compared to patients who received a surgical tracheostomy.

Discussion

A case control study by Watt et al. (2011) determined that patients who used diaphragm pacing with mechanical ventilation compared to those who only had mechanical ventilation had significantly higher survival rates. Of those patients between the ages of 31-35 years, those who were weaned from a ventilator before discharge experienced higher rates of survival compared to those that were not weaned from a ventilator before discharge (Watt et al., 2011). With respect to other respiratory parameters, when comparing endotracheal invasive ventilation with transtracheal open ventilation, there were no significant differences in partial pressure of oxygen between the two treatment types, although patients did have significantly lower partial pressure of carbon dioxide with endotracheal invasive ventilation (Gregoretti et al., 2005). The last study by Romero-Ganuza et al. (2011b) examined timing, type, and presence of tracheostomies in acute SCI patients. Of those who received an early tracheostomy there were fewer cases of tracheal stenosis compared to late tracheostomy. The type of tracheostomy that patients received also resulted in significant differences, where patients who had a percutaneous tracheostomy experienced fewer cases of pneumonia compared to surgical tracheostomy.

Conclusion

There is level 2 evidence (from one prospective controlled trial; Gregoretti et al., 2005) that endotracheal invasive ventilation may lower partial pressure of carbon dioxide compared to transtracheal open ventilation in acute SCI individuals.

There is level 3 evidence (from one case control study; Watt et al., 2011) that diaphragm pacing in combination with mechanical ventilation may result in higher survival than mechanical ventilation alone in acute SCI populations.

There is level 3 evidence (from one case control study; Romero-Ganuza et al., 2011b) that percutaneous tracheostomies may result in fewer cases of pneumonia compared to surgical tracheostomies in acute SCI individuals.

  • Diaphragm pacing in combination with mechanical ventilation can increase survival rates post SCI.

    Endotracheal invasive ventilation can lower partial pressure of carbon dioxide in acute SCI individuals.

    Percutaneous tracheostomies may reduce rates of pneumonia when compared to surgical tracheostomies in acute SCI individuals.