Overall, hospital programs for respiratory management have been shown to benefit individuals more so than traditional hospital care. These programs reduce 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 had less complications than those who did not.
A newer case control study, of moderate size, found that patients admitted early to a specialized level-1 trauma center had over all fewer procedures and complications (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 individuals were discharged to the community and not long-term care. All of these patients treated with a specialized respiratory care protocol, however more research is needed to determine how this level of specialized care compares to other standards of care.
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 acute SCI patients.
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 acute SCI patients.
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 acute SCI patients.
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 acute SCI patients, 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 acute SCI patients.
|Richard-Denis et al.
|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
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
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).
|Romero-Ganuza et al.
|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
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
5. 20 patients had permanent
|Wong et al. (2012)
|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
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 individuals with C3 AIS A were
ventilator weaned in 24 to 62 days
(average 43.67 days). Eight
individuals with C4 AIS A were
ventilator weaned in 14 to 31 days
(average 22.13 days). Two
individuals with C4 AIS B were
weaned from the ventilator in 19 to
22 days (average 20.5 days). One
individual 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
|Cameron et al. (2009)
|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,
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. 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
3. Post-TRAMS patients had a
significantly shorter duration of
cannulation compared to pre-TRAMS
4. Post-TRAMS patients began using
one-way speaking valves significantly
earlier than pre-TRAMS patients
5. There were no tracheostomy-related
deaths in either group.
|Vitaz et al. (2001)
|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.