Ventilator Weaning with Spinal Cord Injury & Tracheostomy

18 patients in critical care beds awaiting transfer 5> 6 months RISCI snapshot survey 2009 South of England Review of Standards in Spinal Cord injury  National Spinal Cord Injury Strategy Board Weaning guidelines for Spinal Cord Injured patients in Critical Care Units 

Ventilated spinal injured patients 15-20% Initially ventilated 98% Weanable 1% Nocturnal ventilation 1% Fully ventilator dependant = 8-12 patients/yr ~ 120 patients in UK

LumbarUnable to cough100-70% Low thoracic  chest wall compliance  Vital capacity High thoracic  chest wall compliance30-50%  Vital capacity poor expansion. Basal collapse C5/C6Diaphragms, Scalenes 20% C3/C4/C5Sternomastoid and partial diaphragm Above C3Sternomastoid only5-10% Acute VC1 Year VC % 40-50% 60-70% Respiratory effects

Weaning Based on little evidence but vast experience Prerequisites Good pulmonary compliance Low FiO2 requirement Awake and cooperative Some respiratory activity Committed team

Any respiratory activity? Testing Volume measurement Beware sensitive ITU Vents Modified brainstem death test

Progressive ventilator free breathing Measure Vital Capacity VCTime off Vent <250 mls5 Mins -500 mls15 Mins -750 mls30 Mins mls60 Mins Measure VC Post weaning >70% pre weaning Southport Spinal Injury Centre Weaning Increase duration and/ or frequency

Weaning Wait for spasticity Bronchodilators ?High TV Ventilation (>20 ml/Kg)? 1 Supine 1.The effect of tidal volumes on the time to wean persons with high tetraplegia from ventilators Peterson W. et al spinal cord (4):

FVC and Posture

Weaning Off vent requires PEEP/CPAP to reduce atalectasis Best option cuff  with speaking valve. Ditch the ITU vent Don’t reduce pressure support too far Try to stick to plan Aim for off all day, support at night

Speech essential Eating optional

How to wean BIPAP/ PS laryngeal function vs resp function Cuff down on vent VFB speaking valve VFB Cuff up VFB Cuff down speaking valve Downsized uncuffed tube Decannulate Fast weaners Slow weaners

How successful ? Southport spinal injuries unit 246 patients over 20 years 63% weaned 33% Ventilator dependant 4% Died

Post weaning Maintenance ‘ Maintain Range of Movements’ Manual hyperinflation IPPB Cough Assist/ Clearway Improve muscle strength Inspiratory muscle training

Tracheostomy Surgical may be better than percutaneous –Safer if unstable spine –Anatomically accurate –Easier changes long term –Worse scar –Logistically difficult

Trachy Tubes Use what you are used to but… Avoid fenestrations

Trachy Tubes Definitely avoid

Trachy Tubes Definitely consider supraglottic suction tubes

Trachy Tubes If they need a tube long term

Trachy Tubes

Don’t dismiss

Speaking valves Are not all the same

When to decanulate No respiratory support required Secretion clearance guaranteed