The study conducted is the retrospective study and the main objective is to evaluate the benefits and safety of early versus late tracheostomy in traumatic spinal cord injury (SCI) patients requiring mechanical ventilation. Tracheostomy offers many advantages in critical patients who require prolonged mechanical ventilation. Despite the large amount of patients treated, there is still an open debate about advantages of early versus late tracheostomy. Early tracheostomy following the short orotracheal intubation is probably beneficial in appropriately selected patients. It is a retrospective clinical study and we evaluated clinical records of 152 consecutive trauma patients who required mechanical ventilation and who received tracheostomy. The results show that the early placement (before day 7 of mechanical ventilation) offers clear advantages for shortening of mechanical ventilation, reducing ICU stay and lowering rates of severe orotracheal intubation complication, such as tracheal granulomas and concentric tracheal stenosis. On the other hand, we could not demonstrate that early tracheostomy avoids neither risk of ventilator-associated pneumonia nor the mortality rate. In SCI patients, the early tracheostomy was associated with shorter duration of mechanical ventilation, shorter length of ICU stay and decreased laryngotracheal complications. We conclude by suggesting early tracheostomy in traumatic SCI patients who are likely to require prolonged mechanical ventilation.

Objective: To assess the effect of timing and techniques of tracheostomy on morbidity, mortality, and the burden of resources in patients with acute traumatic spinal cord injuries (SCIs) undergoing mechanical ventilation. Design: Review of a prospectively collected database. Setting: Intensive and intermediate care units of a monographic hospital for the treatment of SCI. Participants: Consecutive patients admitted to the intensive care unit (ICU) during their first inpatient rehabilitation for cervical and thoracic traumatic SCI. A total of 323 patients were included: 297 required mechanical ventilation and 215 underwent tracheostomy. Outcome measures: Demographic data, data relevant to the patients' neurological injuries (level and grade of spinal cord damage), tracheostomy technique and timing, duration of mechanical ventilation, length of stay at ICU, incidence of pneumonia, incidence of perioperative and early postoperative complications, and mortality. Results: Early tracheostomy (<7 days after orotracheal intubation) tracheostomy was performed in 101 patients (47%) and late (≥7 days) in 114 (53%). Surgical tracheostomy was employed in 119 cases (55%) and percutaneous tracheostomy in 96 (45%). There were 61 complications in 53 patients related to all tracheostomy procedures. Two were qualified as serious (tracheoesophageal fistula and mediastinal abscess). Other complications were mild. Bleeding was moderate in one case (late, percutaneous tracheostomy). Postoperative infection rate was low. Mortality of all causes was also low. Conclusion: Early tracheostomy may have favorable effects in patients with acute traumatic SC. Both techniques, percutaneous and surgical tracheostomy, can be performed safely in the ICU.

Objectives: Phrenic nerve pacing (PNP) is a method of respiratory support that can replace mechanical ventilation (MV) in high-level cervical spinal cord injury (SCI) patients with diaphragmatic paralysis. Our objective was to evaluate survival and long-term quality of life in patients with external respiratory support by PNP vs volumetric respirator in patients with severe respiratory insufficiency due to a high-level spinal cord injury. Design: This is a retrospective review study of a prospectively collected database for evaluate the survival and a questionnaire for quality of life has been collected face-to-face or by telephone at present. Patients: Cervical SCI patients with permanent respiratory support (PNP or MV). Methods: Long-term evaluation of a cohort of PNP-supported patients. We performed a comparison between these patients and volumetric respirator-supported patients. For survival analysis, we used the Kaplan-Meier method and Cox proportional hazards model. The health-related quality of life (HRQL) was assessed with SF-36 questionnaire, a general HRQL evaluation. Results: One hundred twenty six patients on permanent respiratory support were evaluated during the study period. Of these, 38 were on PNP and 88 were mechanically ventilated. Paced patients were younger and had a longer survival, but in a multivariate analysis adjusted for age using a multiple logistic correlation we found that length of survival was greater for PNP patients. In terms of HRQL, the PNP-supported patients showed better results in terms of social functioning. Conclusions: PNP is a stable and effective method of long-term respiratory support in this type of patients (SCI patients dependent on external respiratory support). In these patients it improves the length of survival and some social issues by quality of life when compared with patients under MV.

We present our series of patients with chronic ventilatory failure treated with electrophrenic respiration: 13 males and nine females with a mean age of 12+11.5 years. The etiology was, 13 tetraplegia, ®ve sequelae of surgical treatment of intracranial lesions, and four central alveolar hypoventilation. The mean duration of the conditioning period were 3 ± 4 months. Eighteen patients (81.8%) achieved permanent, diaphragmatically-paced breathing with bilateral stimulation and in four (18.2%) patients, pacing was only during sleep. Five patients died (22.7%): two during the hospital stay and three at home; two deaths had unknown cause and three were due respectively to, lack of at-home care, recurrence of an epidermoid tumor, and sequelae of accidental disconnection of the mechanical ventilation before beginning the conditioning period. Two cases were considered failures: One patient had transitory neurapraxia lasting 80 days, and the other had an ischemic spinal cord syndrome with progressive deterioration of the left-side response to stimulation. One patient had right phrenic nerve entrapment by scar tissue and four suered infections. The follow-up periods since pacemaker implantation are currently: 1, 11 years; 4, 10 years, and 17, less than 5 years. The results of our experience demonstrate that complete stable ventilation can be achieved using diaphragmatic pacing and that it improves the prognosis and life quality of patients with severe chronic respiratory failure.

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