No abstract

BACKGROUND Respiratory failure after acute spinal cord injury (SCI) is well recognized, but data defining which patients need long-term ventilator support, and criteria for weaning and extubation are lacking. We hypothesized that many patients with SCI, even those with cervical SCI, can be successfully managed without long-term mechanical ventilation and its associated morbidity. METHODS Under the auspices of the Western Trauma Association Multi-Center Trials Group, a retrospective study of patients with SCI at 14 major trauma centers was conducted. Comprehensive injury, demographic, and outcome data on patients with acute SCI was compiled. The primary outcome variable was the need for mechanical ventilation at discharge. Secondary outcomes included the use of tracheostomy, and development of acute lung injury (ALI) and ventilator-associated pneumonia (VAP). RESULTS 360 patients had SCI requiring mechanical ventilation. Sixteen patients were excluded for death within the first 2 days of hospitalization. Of the 344 patients included, 222 (64.5%) had cervical SCI. Notably, 62.6% of patients with cervical SCI were ventilator-free by discharge. 149 patients (43.3%) underwent tracheostomy and 53.7% of them were successfully weaned from the ventilator, compared to an 85.6% success rate among those with no tracheostomy (p<0.05). Patients who underwent tracheostomy had significantly higher rates of VAP (61.1% vs 20.5%, p<0.05) and ALI (12.8% vs 3.6%, p<0.05), and fewer ventilator free days (1 vs. 24 p<0.05). When controlled for injury severity, thoracic injury, and respiratory comorbidities, tracheostomy after cervical SCI was an independent predictor of ventilator dependence with an associated 14-fold higher likelihood of prolonged mechanical ventilation (OR 14.1, CI 2.78–71.67, p<0.05). DISCUSSION While many patients with SCI require short-term mechanical ventilation, the majority can be successfully weaned prior to discharge. In patients with SCI tracheostomy is associated with major morbidity and its use, especially among patients with cervical SCI, deserves further study. LEVEL OF EVIDENCE Level III, care-management/prognostic