Respiratory Management (Acute Phase)

Hospital Programs for Respiratory Management in SCI

Respiratory management for patients with SCI is thought to be most effective when the care extends beyond the individual to incorporate specialized hospital programs (Parker et al. 2010). Studies have examined the effect of respiratory management programs on enhancing patient recovery and decreasing hospital stay compared to regular hospital treatment that may differ for each person.

Author Year
Country
Research Design

Score
Sample Size

 Methods Outcomes
Richard-Denis et al.
2018
Canada
Case Control
N=81		 Population: (Group 1): Mean age: 43.6 yr;
Gender: male=75.4%, female=24.6%; Injury
severity: Mean ISS= 35.3. (Group 2): Mean
age; 42.5yr; Gender: male=83.3%,
female=16.7%; Injury severity: Mean
ISS=42.7%.
Intervention: Patients in group 1 were
transferred early to a level-1 trauma center
for surgical management of SCI. Patients in
Group 2 were transferred late (postoperatively)
to the same SCI trauma center for care.
Outcome Measures: Tracheostomy
requirement, mechanical ventilation
requirement, ventilation support duration,
Chronicity: Patient population was defined as acute SCI.
  1. Group 2 had significantly higher rates of required tracheostomies (p=0.004).
  2. There were no significant differences between groups in terms of the number of patients who required mechanical ventilation support.
  3. There was a significant difference between groups for the number of days spent on ventilation, with Group 2 spending on average 50 more days on ventilation (p=0.006).
Cinotti et al. 2019

France

Pre-post

Level 4

N = 117

 Population: 117 patients with a traumatic cervical SCI admitted in the ICU in the first 48 hours; 81 males and 36 females; mean age 46.5 years; AIS A (n = 67), AIS B (n = 16), AIS C (n = 18), and AIS D (n = 16); and clinical motor level (ASIA score) C2 (n = 4), C3 (n = 2), C4 (n = 22), C5 (n = 36), C6 (n = 20), C7 (n = 15), and T1 (n = 3).

Intervention: Study was divided in two periods (where patients were analyzed receiving different intervention protocols):

  • Control phase (n = 57): Consisted of all consecutive patients who were admitted to ICUs receiving general care according with local protocol and French guidelines.
  • Intervention phase (n = 60): Involved all consecutive patients receiving an early rehabilitation strategy with an early tracheostomy (ET) in case of upper injury (> C6), bronchial drainage physiotherapy, assisted cough with mechanical insufflator/exsufflator in atelectasis and aerosol therapy based on beta-2 mimetics, among other techniques.

*Some of the interventions remained similar in the two intervention phases.

Outcome Measures: The Delta ASIA motor score (ASIA motor score variation between ICU admission and ICU discharge) in the subgroup of patients with AIS grade A; compliance with rehabilitation program; the number of respiratory complications; in-ICU LOS; hospital LOS; ASIA score at 1 year; and 1-year mortality.

Chronicity: Patients were admitted in the ICU in the first 48 hours.
  1. During the intervention period, overall bundle compliance* was achieved in 0 patients in the control group and 5 (8.3%) patients after the rehabilitation program implementation.
  2. Median ICU LOS was not statistically different between the two periods (26 [16–47] vs. 29 [11.00–46.75] days; p=0.9).
  3. During the control period, the Delta ASIA motor score between ICU discharge and admission was +6 [0–14], as compared to +16 [4–32] with the rehabilitation program (p < 0.05). In a multi-variate linear regression model, the intervention period was significantly associated with a higher Delta ASIA motor score (b coefficient, 11.4; CI95 [1.9–21.0]; p = 0.01). In the subgroup of patients with AIS Grade A patients, the Delta ASIA motor scale was +1 [0–10] in the control period, and +10 [3–24]; p = 0.02) in the intervention period.
  4. One year after SCI, the Delta ASIA motor score between 1-year follow-up and ICU admission remained higher in the intervention phase than in the control period (+34 [15–60] vs. +11 [0–33]; p < 0.05).

* Overall bundle compliance is defined by the association of ET as recommended in the 7 days after ICU admission, protective ventilation (6–8 mL/kg-1), PEEP >0 cmH2O, early enteral nutrition, early mobilization, and early active perineal care, within 48 h after ICU admission.
Romero-Ganuza et al.
2015
Spain
Pre-Post Test
N=68		 Population: Mean age: 53.8 yr; Gender:
male=49, female=19; Level of SCI: C1-
C4=44, C5-C8=11, thoracic=13.
Intervention: Patients were treated with a
specific respiratory care comprehensive
rehabilitation program.
Outcome Measures: Hospital mortality,
length of stay, discharged to community,
discharged home, discharge to extended
care facilities, discharge to acute care
hospital, weaned from ventilation, patients
with permanent respiratory support.
Chronicity: Patients were admitted within 3
months of injury.
  1. Five patients died in hospital.
  2. The average length of stay for survivors was 195.6 days.
  3. 63/68 of patients were discharged to the community, 47 patients were discharged home, 13 were discharged to extended-care facilities, and 3 were sent to an acute care hospital setting.
  4. 23 patients were weaned at the hospital.
  5. 20 patients had permanent respiratory support.
Wong et al. 2012
USA
Post Test
N=24		 Population: Mean age: 33 yr; Gender:
male=22, female=2; Level of injury: C1-C4;
Severity of injury: complete=79%,
incomplete=21%; AIS A-D.
Intervention: Retrospective analysis of
patients who received a hospital program at
an SCI specialty unit of high tidal volume
ventilation, high frequency percussive
ventilation, and mechanical insufflationexsufflation were compared before and after the program.
Outcome Measures: Occurrence of high
tidal ventilation, high frequency percussive
ventilation, mechanical insufflationexsufflation, initiating a speaking valve, ventilator weaning attempts, time from admission to ventilator wean
Chronicity: Average time from injury to transfer to the SCI unit was 33.8 days.
  1. In 14 patients who were weaned off the ventilator, the average day to be weaned from the time of admission was 27.6 days (SD 12.9 days).
  2. Three participants with C3 AIS A were ventilator weaned in 24 to 62 days (average 43.67 days). Eight participants with C4 AIS A were ventilator weaned in 14 to 31 days (average 22.13 days). Two participants with C4 AIS B were weaned from the ventilator in 19 to 22 days (average 20.5 days). One participant with C4 AIS C was weaned in 37 days.
  3. Six subjects were decannulated prior to discharge to home, and the average days to be decannulated after admission was 42.0 days (SD 16.6 days).
Cameron et al. 2009
Australia
Cohort
N=102		 Population: Age range: 24-52 yr; Gender:
male=78, female=24; Level of injury: C4-C8.
T1-T5, T6 and below; Severity of injury:
complete=44, incomplete=58; AIS A-D.
Intervention: Patients either received
tracheostomy review and management
services (post-TRAMS group, 2003-2006) or
did not receive tracheostomy review and
management services (pre-TRAMS group,
1991-2001).
Outcome Measures: Hours mechanically
ventilated, hours in intensive care unit (ICU),
length of hospital stay, duration of
cannulation, initiation of communication
through a one-way speaking valve, deaths.
Chronicity: Length of acute hospital stay
was a median of 60 days (pre-TRAMS
group) and 41.5 days (post-TRAMS group);
time since injury was not specified.
  1. 1. There were no significant differences with regards to hours mechanically ventilated (p=0.71) and hours in ICU (p=0.60) between pre-TRAMS patients and post-TRAMS patients.
  2. Post-TRAMS patients had a significantly shorter hospital stay compared to pre-TRAMS patients (p=0.03).
  3. Post-TRAMS patients had a significantly shorter duration of cannulation compared to pre-TRAMS patients (p=0.03).
  4. Post-TRAMS patients began using one-way speaking valves significantly earlier than pre-TRAMS patients (p<0.01).
  5. There were no tracheostomy-related deaths in either group.
Vitaz et al. 2001
USA
Cohort
N=58		 Population: Mean age: 33 yr; Gender: not
specified; Level of injury: C1-T5; Severity of
injury: not specified.
Intervention: Patients either received
treatment according to the clinical care
pathway (Group 1) or received regular
treatment (Group 2; control).
Outcome Measures: The following during
hospital stay: episodes of pneumonia,
length of hospital stay, length of intensive
care unit (ICU) stay, days on ventilator.
Chronicity: Average overall length of
hospital stay was 36 days and 24 days for
Group 1 and Group 2 patients, respectively;
time since injury was not specified.
  1. Patients in Group 1 experienced significantly fewer episodes of pneumonia compared to patients in the control group (p<0.05).
  2. Patients in Group 1 experienced a significantly shorter stay in the hospital (p<0.05) and ICU (p<0.05), and required significantly fewer days on the ventilator (p<0.05) compared to patients in the control group.

Discussion

Overall, specialized respiratory management programs provided in the hospital for respiratory management have been shown to benefit individuals more than traditional hospital care. These programs reduce the length of hospital stay and ventilator days (Cameron et al. 2009; Vitaz et al. 2001; Richard-Denis et al. 2018), help individuals gain independence by initiating speaking valves sooner (Wong et al. 2012) and reduce the incidence of pulmonary complications (Vitaz et al. 2001). Although Wong et al. (2012) did not perform statistical analyses to compare the efficacy of their program, the patients who received all three respiratory management therapies (high tidal volume ventilation, high frequency percussive ventilation, and mechanical insufflation-exsufflation) had fewer complications than those who did not.

Cinotti et al. (2019) prospectively studied 117 patients with traumatic cervical SCI admitted to the ICU in the first 48 hours and compared outcomes between a control phase (where treatment was administered following standard hospital protocols) and an intervention phase (based on a multiple-disciplinary rehabilitation program protocol which included, among other techniques, ET) observing that a higher Delta ASIA motor score was associated with the intervention phase compared to the control phase between ICU discharge and admission and between ICU admission and 1 year follow up.

Another moderate sized case control study found that patients admitted early to a specialized level-1 trauma center overall had fewer procedures and complications compared to who? (Richard-Denis et al. 2018). Early admission to this center significantly decreased the rates of tracheostomies, as well as the total number of days in hospital. Early admitted patients spent on average 50 fewer days on ventilation (Richard-Denis et al. 2018). Another study examining specialized care by Romero-Ganuza et al. (2015) found that a third of patients were able to be weaned at the hospital, and 63/68 participants were discharged to the community and not to long-term care. More research is needed to determine how this level of specialized care compares to other standards of care.

Conclusion

There is level 4 evidence (from one post-test: Wong et al. 2012) that the implementation of specialized respiratory management results in stabilization and improvement of respiratory status in patients with acute SCI.

There is level 2 evidence (from one cohort study: Cameron et al. 2009) that the tracheostomy review and management service reduces length of hospital stay and duration of cannulation while increasing speech valve usage compared to those who do not receive tracheostomy review and management in patients with acute SCI.

There is level 2 evidence (from one cohort study: Vitaz et al. 2001) that the use of a clinical care pathway reduces length of hospital stay and results in fewer complications compared to those who received regular care in patients with acute SCI.

There is level 3 evidence (from one case control study: Richard-Denis et al. 2018) that early admission to a level-1 trauma center results in lower rates of tracheostomies, as well as fewer ventilator days for patients with acute SCI, compared to late admission.

There is level 4 evidence (from one pre-post test: Romero-Ganuza et al. 2015) that specialized respiratory care results in a high number of community discharges in patients with acute SCI.

There is level 4 evidence (from one pre-post study: Cinotti et al. 2019) that a multiple-disciplinary rehabilitation protocol which included, among other techniques, ET, provides a higher Delta ASIA motor score between ICU discharge and admission and between ICU admission and 1 year follow up in patients with traumatic cervical SCI who were admitted in the ICU in the first 48 hours.

Specialized respiratory management programs provided in the hospital may lead to reduced procedures, ventilator days, hospital length of stay, and improved respiratory and patient discharge status, in the acute phase post SCI.

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