Pediatric-Onset Rehabilitation

Management and Complications

Author, Year

Country

Study Design

Sample Size

Population

Intervention

Outcome Measure

Results

(Vogel et al., 2002b)

USA

Observational

N=216

Population: Age at injury: 14.1±4.0 yr; Age at interview: 28.6±3.4 yr; Gender: males=150, females=66; Time since injury: 14.2±4.6 yr; Level of injury: tetraplegia=123, paraplegia=93. Severity of injury: C1-4 ABC=41, C5-8 ABC=67, T1-S5 ABC=82, tetra/para D=26.

Intervention: None. Survey.

Outcome Measures: Prevalence of respiratory complications.

1.         In total, 68 subjects experienced pneumonia at least once, and 17 had required temporary or chronic ventilation since their injury.

2.        Of the 68 subjects who had pneumonia, 39 experienced 1 episode, 10 had 2 episodes, and 19 had 3+ episodes.

3.        Of 71 individuals who experienced pneumonia or respiratory failure were older at follow-up (p=0.028) and had longer duration of SCI (p=0.002).

4.        Those with pulmonary complications had significantly more severe neurologic impairments with lower ASIA Motor scores (p<0.001).

5.        Individuals with tetraplegia were more likely than those with paraplegia to have respiratory complications (p=0.003).

6.        In addition, respiratory complications most commonly affected those in the more severe injury groups (C1-8) compared with those with less severe injuries (Tl-S5, tetra/para D) (p=0.005).

7.        Those with respiratory complications had lower total (p=0.003) and motor (p=0.003) FIM scores.

8.        A total of 59 subjects required hospitalizations within 3 yr of their interview and the most common reasons were respiratory disorders (N=13).

Author, Year

Country

Study Design

Population, Intervention, Outcome Measures

(Warzak et al., 1991)

USA

Case Report

N=1

Population: 8 yr, male, C4 tetraplegia SCI, ventilator-dependent.

Intervention: Information-only procedure involving anxiety-reduction activities including relaxation and cognitive distraction.

Outcome Measures: Heart rate, mouth noises, and verbalizations during tracheostomy care, ventilation checks, and conversation.

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).

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