Separation from mechanical ventilation and survival after spinal cord injury: a systematic review and meta-analysis

Abstract

Background Prolonged need for mechanical ventilation greatly impacts life expectancy of patients after spinal cord injury (SCI). Weaning outcomes have never been systematically assessed. In this systematic review and meta-analysis, we aimed to investigate the probability of weaning success, duration of mechanical ventilation, mortality, and their predictors in mechanically ventilated patients with SCI. Methods We searched six databases from inception until August 2021 for randomized-controlled trials and observational studies enrolling adult patients (≥ 16 years) with SCI from any cause requiring mechanical ventilation. Titles and abstracts were screened independently by two reviewers. Full texts of the identified articles were then assessed for eligibility. Data were extracted independently and in duplicate by pairs of authors, using a standardized data collection form. Synthetic results are reported as meta-analytic means and proportions, based on random effects models. Results Thirty-nine studies (14,637 patients, mean age 43) were selected. Cervical lesions were predominant (12,717 patients had cervical lesions only, 1843 in association with other levels’ lesions). Twenty-five studies were conducted in intensive care units (ICUs), 14 in rehabilitative settings. In ICU, the mean time from injury to hospitalization was 8 h [95% CI 7–9], mean duration of mechanical ventilation 27 days [20–34], probability of weaning success 63% [45–78] and mortality 8% [5–11]. Patients hospitalized in rehabilitation centres had a greater number of high-level lesions (C3 or above), were at 40 days [29–51] from injury and were ventilated for a mean of 97 days [65–128]; 82% [70–90] of them were successfully weaned, while mortality was 1% [0–19]. Conclusions Although our study highlights the lack of uniform definition of weaning success, of clear factors associated with weaning outcomes, and of high-level evidence to guide optimal weaning in patients with SCI, it shows that around two-thirds of mechanically ventilated patients can be weaned in ICU after SCI. A substantial gain in weaning success can be obtained during rehabilitation, with additional duration of stay but minimal increase in mortality. The study is registered with PROSPERO (CRD42020156788).

Functional state of the diaphragm in patients with cervical spinal cord injury at the stages of respiratory support

“…В зависимости от уровня повреждения спинного мозга развивается паралич или парез диафрагмы [1]. Резкое изменение механики дыхания определяет необходимость применения методов инвазивной искусственной вентиляции легких (ИВЛ) [1,2]. Потребность в ИВЛ у пациентов с травмой спинного мозга является одной из самых высоких среди общей когорты пациентов, находящихся в отделениях реанимации и интенсивной терапии [2,3].…”

“…По данным метаанализа [2], опубликованного в 2021 г. и включавшего в себя 39 исследований общей численностью 14 637 клинических наблюдений, в проведении ИВЛ, длительность которой в среднем составила 30,9 сут, при полном функциональном повреждении спинного мозга на уровне шейного отдела нуждались 90 % пациентов. Ранее мы получили вполне сопоставимые результаты: длительная ИВЛ требовалась 92 % пациентов при тяжести повреждения спинного мозга ASIA A [4].…”

“…Присоединение осложнений со стороны легких на этом фоне способствует нарастанию слабости диафрагмы и увеличе-нию продолжительности ИВЛ. У 15 % пациентов с травмой спинного мозга на шейном уровне сохранялась пожизненная зависимость от респираторной терапии [2].…”

Rehabilitation interventions for weaning from mechanical ventilation in patients with spinal cord injury: A systematic review

“…On the other hand, recent research is now focusing on a precise stratification based on patients' characteristics. In particular, the review by Schreiber et al [30] recently assessed the factors potentially related to successful weaning and weaning duration in patients with SCI. Interestingly, the authors underlined that It might be partly related to specific consequences on muscle recruitment and ventilation mechanics, which might be significantly influenced by patient's SCI level and SCI completeness [30].…”

“…Interestingly, the systematic review by Schreiber et al [30] assessed the patient's characteristics that might affect separation from MV in patients with SCI. How-58 ever, the authors did not focus on rehabilitation ap-59 proaches aiming at optimizing the weaning process.…”