Respiratory Management of Pediatric Patients with Spinal Cord Injuries: Retrospective Review of the duPont Experience

Abstract

Pulmonary complications contribute to morbidity and mortality in spinal cord injuries (SCIs). A retrospective review of 20 years of experience with tracheostomy- and ventilator-dependent SCI children is presented. The authors developed and analyzed a database of 47 children (average age = 11.4 years). Of the patients, 27% had concomitant brain injuries, 6% had prior histories of reactive airway disease, and 2% had thoracic fractures. Injuries were caused by motor vehicle accidents (53%); gunshot wounds (19%); sports-related accidents (19%); and vascular injuries, transverse myelitis, or spinal tumors (8%). Of the injuries, 52% were high level (C1 to C2) and 48% were mid- or low level (C3 to C5). Two groups were analyzed for demographic information. Complications included tracheitis, atelectasis, and pneumonia. Mean tidal volume was 14 cm2/kg (maximum = 22 cm2/kg). Bedside lung function parameters were attempted to assess readiness and the rapidity of weans. T-piece sprints were used to successfully wean 63% of patients. Successfully weaned patients were compared with those not weaned. No deaths or readmissions for late-onset respiratory failure postwean occurred. The authors' clinical impression favors higher tidal volumes and aggressive bronchial hygiene to minimize pulmonary complications and enhance weaning. Successfully weaned patients had fewer complications. A critical pathway for respiratory management of SCI children is presented.

Modulation of Lipopolysaccharide-Induced Gene Transcription and Promotion of Lung Injury by Mechanical Ventilation

“…MV is typically initiated with moderate tidal volumes of 8 -12 ml/kg. Although this magnitude of tidal volume exceeds that typically observed at rest during spontaneous respiration, it is consistent with tidal volumes during exercise, is used routinely for prolonged periods in spinal cord injury patients (1), and has been considered safe in the absence of lung injury. Recently, however, tidal volumes of this magnitude have been associated with increased mortality as compared with smaller tidal volumes in patients with severe ALI (the acute respiratory distress syndrome (ARDS)) (2).…”

Mechanical ventilation induces inflammation, lung injury, and extra-pulmonary organ dysfunction in experimental pneumonia

“…22,23 This process generally does not occur in healthy individuals with normal lungs. 24,25 However, in the setting of previous injury or infection, MV may lead to inflammation and injury of the alveolar epithelial membrane and the development of ALI. 10,26 Several studies have reported increased levels of proinflammatory cytokines in BALF and serum in patients with ARDS.…”

Update on critical care for acute spinal cord injury in the setting of polytrauma

“…21 The 19 High VT is reportedly associated with earlier weaning off of mechanical ventilation and more rapid resolution of atelectasis in patients with SCI. 10,62,75 In patients without SCI who are at risk for acute respiratory distress syndrome, studies have focused on the safety of high VT ventilation and the risk for barotrauma. Recently, the safety and efficacy regarding high VT in patients with SCI has been debated, particularly because of the prevalence of acute respiratory distress syndrome in these patients.…”