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Respiratory Management (Acute Phase)

Pharmacological Interventions

Author Year
Country
Research Design
PEDro
Sample Size
Methods Outcomes
Barratt et al. (2012)
Australia
RCT
PEDro=9
N=12
Population: Age range: 25-37 yr;
Gender: male=9, female=3; Level of
injury: C5-C7; Severity of injury:
complete=10, incomplete=2; AIS A-B.
Intervention: Patients were randomized
to receive either bronchodilator therapy
(inhaler, 100 µg salbutamol) or placebo
(propellant only).
Outcome Measures: The following at 10
minutes and 30 minutes after inhalation:
forced vital capacity (FVC), forced
expiratory volume in one second (FEV1),
and peak expiratory flow (PEF) rate.
Chronicity: The median time since injury
was 24 (18-35) days.
1. After 10 minutes, patients who
received the bronchodilator therapy
experienced a significant
improvement in FVC (p<0.05), FEV1
(p<0.05), and PEF (p<0.05)
compared to patients who received
the placebo.
2. After 30 minutes, patients who
received the bronchodilator therapy
experienced a significant
improvement in FVC (p<0.05) and
FEV1 (p<0.05) compared to patients who received the placebo. There were no significant differences between groups with regard to PEF (p>0.05).
Li et al. (2012)
China
RCT
PEDro=6
N=61
Population: Age range: 39-67 yr;
Gender: male=40, female=21; Level of
injury: cervical; Severity of injury:
complete=27, incomplete=34 AIS A-B.
Intervention: Patients were randomized
to receive either high-dose ambroxol
(990 mg/day for 5 days) or placebo (5%
glucose in 500 mL saline for 5 days) after
spinal fixation surgery.
Outcome Measures: The following
during hospital stay: post-operative
pulmonary complications in the form of
pulmonary infection, atelectasis, and
hypoxemia.
The following after 3 and 5 days in the
intensive care unit (ICU): 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), and
ratio of arterial oxygen partial pressure to
fractional inspired oxygen.
Chronicity: Time since injury not
specified.
1. Patients who received high dose
ambroxol experienced significantly
fewer episodes of pneumonia
(p=0.027) and hypoxemia (p=0.047)
than patients who received placebo.
There were no significant differences
with regards to atelectasis between
groups (p=0.430).
2. After 3 days in ICU, patients who
received high dose ambroxol had a
significantly higher oxygenation index
than patients who received placebo
(p=0.049). There were no significant
differences in PaO2 (p=0.683) and
PaCO2 (p=0.847) between groups.
3. After 5 days in ICU, patients who
received high dose ambroxol had a
significantly higher oxygenation index
than patients who received placebo
(p=0.032). There were no significant
differences in PaO2 (p=0.193) and
PaCO2 (p=0.928) between groups.

Pharmacological treatments for pulmonary function in SCI patients aims to improve breathing and coughing, thereby gaining more independence from mechanical ventilation, and to decrease the likelihood of infection. This area of research has been explored largely in patients with chronic SCI, where bronchodilators and anabolic steroids have shown varying degrees of success (see the rehabilitation chapter on Respiratory Management in SCIRE version 6.0).

Discussion

Although several types of bronchodilators and secretolytic agents exist, only two have been tested within the acute SCI population which also met the SCIRE inclusion criteria. Based on one study alone, bronchodilator therapy with salbutamol provided effective short-term improvements in lung function. Barratt et al. (2012) showed that these drugs increased forced vital capacity and forced expiratory volume; these improvements were maintained for half an hour. Peak cough expiratory flow also improved, but this effect deteriorated after ten minutes. The second RCT by Li et al. (2012) studied ambroxol and demonstrated more long-term improvements in pulmonary functioning. Oxygenation indexes remained elevated after five days, and patients had fewer episodes of pneumonia and hypoxemia overall. These two studies showed that pharmacological interventions may be helpful in improving breathing and reducing infection, but long-term treatments (>1 month) and the efficacy of alternative drugs remain unknown.

Conclusion

There is level 1b evidence (from one RCT: Barratt et al. 2012) that bronchodilator therapy with salbutamol may improve pulmonary function compared to placebo in acute SCI patients.

There is level 1b evidence (from one RCT: Li et al. 2012) that high-dose ambroxol may reduce postoperative respiratory complications and increase blood oxygenation following surgery compared to placebo in acute cervical SCI patients.

There is level 4 evidence (from one case series: Xiong et al. 2015) that spinal anesthesia may be more effective at preventing incidence of AD during cystolitholapaxy compared to local or general anesthesia.

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