Transcript Weaning in Spinal Cord Injury

ICS 12/2007
Weaning in Spinal Cord Injury
Age vs Incidence
30
25
20
% 15
10
5
0
0-10
11-20
21-30
31-40
41-50
51-60
>60
800-1000 new SCI/
Yr in UK
Level of Injury vs Incidence
60
50
40
% 30
20
10
0
Cervical
Thoracic
Thoracolumbar
Lumbosacral
Epidemiology, Demographics and Pathophysiology of Acute Spinal Cord Injury. Lali H.S. et al SPINE 26;245; s2-s12
Acute respiratory management
68 patients
>C5 88% needed intubating
C5-C8 60% needed intubating
Velmahos gc et al American surgeon 2003
156 Patients
Injuries C2-C8
107 required tracheostomies
Harop et al Journal of neurosurgery spine 2004
84
10
5
12
6
14
7
16
8
18
9
21
0
23
1
25
2
27
3
63
42
21
1
Litres
FVC
2
1.5
1
0.5
0
day
Acute VC
1 Year VC
100-70%
100-70%
60-70%
Lumbar
Unable to cough
Low thoracic
 chest wall compliance
 Vital capacity
High thoracic
 chest wall compliance
 Vital capacity
poor expansion. Basal collapse
30-50%
C5/C6
Diaphragms, Scalenes, Accessory
20%
C3/C4/C5
Sternomastoid and partial diaphragm
Above C3
Sternomastoid only
5-10%
40-50%
Weanable?
• C5-C8 wean in 14 days
• C4 and above in around 60 days
» Jacson AB Groomes TE Arch Phys Med Rehab 1994:75:270-275
• 73 pts with diaphragm function weaned 3-93 days
» Ooh t, Watt J Spinal Cord 1999;37:117=122
30
17
26
14
22
18
15
12
Survival
Weaning
Time9 RNOH 6
11
5
9
3
50
16
14
12
10
8
6
4
2
0
Yrs
40
30
C1-C4
20
10
0
0-5
6-10
C5-C8
10 15 20 25 30 35 40 45 50 55 60 65 70 75
11-15 16-20 21-25 26-30 31-35 36-40 >60 never
Age at Injury
Days to Wean
Vent dependant
When; How; Why
When; How; Why
All other pathology improved
Lung parenchyma optimal
Secretions manageable
Awake and cooperative
Spasticity evident
Some useful spontaneous respiratory activity
When; How; Why
Bronchodilators
?High TV Ventilation (>20 ml/Kg)?1
?Anabolic steroids?2
Supine
1.
2.
The effect of tidal volumes on the time to wean persons with high tetraplegia from ventilators
Peterson W. et al spinal cord 1999 37(4):284-288
Spungen et Al Mount Sinai Journal of Medicine may 1999
When; How; Why
Progressive ventilator free breathing
Measure Vital Capacity
VC
Time off Vent
<250 mls
-500 mls
-750 mls
-1000 mls
5 Mins
15 Mins
30 Mins
60 Mins
Measure VC Post weaning >70% pre weaning
Southport Spinal Injury Centre
Cuff down: Speaking valve
Inspiratory muscle training
When; How; Why
Slow Weaners & Non-weaners?
Cuff down ventilation
Refer onwards
When; How; Why
Hospitalised 1 year mortality 15%
Survival
50
Yrs
40
C5-C8
30
C1-C4
20
Vent dependant
10
0
10 15 20 25 30 35 40 45 50 55 60 65 70 75
Age at Injury
National Spinal Cord Injury Statistical Centre, University of Alabama
Costs
Summary
Progressive Ventilator Free Breathing
Transfer to spinal injury centre
Respiratory Information for Spinal Cord Injury
www.risci.org.uk