The feasibility of using mouthpiece ventilation in the intensive care unit for post-extubation breathing support after acute tetraplegia.

STUDY DESIGN: A prospective cohort of patients with acute tetraplegia. OBJECTIVES: This study aimed to determine the feasibility of using mouthpiece ventilation (MPV) in the intensive care unit (ICU) for patients who are extubated after suffering an acute cervical spinal cord injury (CSCI). SETTING: ICU, Princess Alexandra Hospital, Brisbane Australia. METHODS: New admissions to ICU in the 14 months between April 2017 and June 2018 with a CSCI who underwent intubation were assessed for inclusion. MPV was provided to consenting participants (who were deemed likely to be able to maintain ventilation on their own) at the time of extubation and was utilised in addition to standard care while participants were awake. MPV settings, usage, and support hours to educate and facilitate MPV were collected. Feedback from participants and clinical staff was gathered throughout the study. Pre- and post-extubation measures of forced vital capacity (FVC), the frequency of endotracheal suction of sputum, and gas exchange using ventilation-perfusion ratios were recorded along with the incidence of reintubation. RESULTS: Fourteen participated in utilising MPV with 16 episodes of extubation. The average time per participant to have MPV titrated and bedside data collected was 178 minutes. Data from 16 episodes of extubation have been included. Three of the 14 participants failed initial extubation. Feedback from participants and clinicians has been positive and constructive, enabling MPV settings to be adapted to the person with acute CSCI during this pilot study. CONCLUSION: MPV is feasible to use post-extubation for people with CSCI in ICU. Pressure control mode MPV was deemed the most suitable for newly extubated acute CSCI patients. Intensive clinical support is required initially to provide education prior to MPV, and at the time of extubation for both patient and treating clinicians. Both report it to be a useful adjunct to ICU treatment.

Acute cervical spinal cord injury and extubation failure: A systematic review and meta-analysis.

PURPOSE: Respiratory complications are the most significant cause of morbidity and mortality in acute cervical spinal cord injury (CSCI). The prevalence of extubation failure (EF) and factors associated with it are unclear. This research aimed to systematically synthesise and pool literature describing EF and associated risk factors in acute CSCI. METHODS: A systematic review was performed using medical literature analysis and retrieval system online, cummulative index of nursing and allied health literature, excerpta medica dataBASE, and Cochrane library. Articles were screened using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. A proportion meta-analysis was conducted to pool rates of EF. Odds ratios and weighted mean differences were calculated to evaluate risk factors. The R statistical software package was used. RESULTS: Of the 347 articles that were identified, six articles satisfied the inclusion criteria (387 participants). The pooled EF rate was 20.25% (10.13-36.38%). Type of CSCI was the only statistically significant risk factor. The odds of EF occurring were 2.76 [95% confidence interval (CI): 1.14; 6.70] times greater for complete CSCI than for incomplete CSCI. CONCLUSIONS: One in five patients with acute cervical SCI fails extubation. The odds of EF occurring are almost three times greater in complete CSCI. Future research should aim to improve standard data sets and prospective evaluation of adjuvant therapy in the peri-extubation period.

Respiratory problems and management in people with spinal cord injury.

Spinal cord injury (SCI) is characterised by profound respiratory compromise secondary to the level of loss of motor, sensory and autonomic control associated with the injury. This review aims to detail these anatomical and physiological changes after SCI, and outline their impact on respiratory function. Injury-related impairments in strength substantially alter pulmonary mechanics, which in turn affect respiratory management and care. Options for treatments must therefore be considered in light of these limitations. KEY POINTS: Respiratory impairment following spinal cord injury (SCI) is more severe in high cervical injuries, and is characterised by low lung volumes and a weak cough secondary to respiratory muscle weakness.Autonomic dysfunction and early-onset sleep disordered breathing compound this respiratory compromise.The mainstays of management following acute high cervical SCI are tracheostomy and ventilation, with noninvasive ventilation and assisted coughing techniques being important in lower cervical and thoracic level injuries.Prompt investigation to ascertain the extent of the SCI and associated injuries, and appropriate subsequent management are important to improve outcomes. EDUCATIONAL AIMS: To describe the anatomical and physiological changes after SCI and their impact on respiratory function.To describe the changes in respiratory mechanics seen in cervical SCI and how these changes affect treatments.To discuss the relationship between injury level and respiratory compromise following SCI, and describe those at increased risk of respiratory complications.To present the current treatment options available and their supporting evidence.

Impact of an abdominal binder on speech outcomes in people with tetraplegic spinal cord injury: perceptual and acoustic measures.

BACKGROUND: An abdominal binder (AB) is routinely used for patients who have suffered a spinal cord injury (SCI) resulting in tetraplegia. It is thought to restore abdominal pressure and consequently improve breathing capacity and reduce postural hypotension in patients who do not have functioning abdominal muscles. OBJECTIVE: To examine the early effects of an AB on respiratory and speech outcomes. METHODS: Thirteen individuals who sustained an acute motor complete SCI between C3 and T1 were assessed after a 6-week trial of using an elasticized AB from the time of first mobilizing in an upright wheelchair. Assessments were made using spirometry and perceptual and acoustics speech measures based on sustained phonation, sentence recitation, and passage reading. RESULTS: Significant improvements were found in the AB-on condition for 3 of 5 respiratory parameters (vital capacity, forced vital capacity, and forced expiratory volume in 1 second). Predominantly mild voice and speech dysfunction were noted in participants. No significant difference was found for any of the acoustic and perceptual speech parameters (maximum phonation time, vocal intensity for sentence recitation, perceptual speech characteristics, or vocal quality) between the AB conditions. CONCLUSIONS: Despite the finding that an AB results in significant improvements in respiratory function for individuals with tetraplegic SCI, the current study did not provide evidence that an AB improves speech production.

Auto-titrating continuous positive airway pressure treatment for obstructive sleep apnoea after acute quadriplegia (COSAQ): study protocol for a randomized controlled trial.

BACKGROUND: Quadriplegia is a severe, catastrophic injury that predominantly affects people early in life, resulting in lifelong physical disability. Obstructive sleep apnoea is a direct consequence of quadriplegia and is associated with neurocognitive deficits, sleepiness and reduced quality of life. The usual treatment for sleep apnoea is nasal continuous positive airway pressure (CPAP); however, this is poorly tolerated in quadriplegia. To encourage patients to use this therapy, we have to demonstrate that the benefits outweigh the inconvenience. We therefore propose a prospective, multinational randomized controlled trial of three months of CPAP for obstructive sleep apnoea after acute quadriplegia. METHODS/DESIGN: Specialist spinal cord injury centres across Australia, New Zealand, the UK and Canada will recruit medically stable individuals who have sustained a (new) traumatic quadriplegia (complete or incomplete second cervical to first thoracic level lesions). Participants will be screened for obstructive sleep apnoea using full, portable sleep studies. Those with an apnoea hypopnoea index greater than 10 per hour will proceed to an initial three-night trial of CPAP. Those who can tolerate CPAP for at least 4 hours on at least one night of the initial trial will be randomized to either usual care or a 3-month period of auto-titrating CPAP. The primary hypothesis is that nocturnal CPAP will improve neuropsychological functioning more than usual care alone. The secondary hypothesis is that the magnitude of improvement of neuropsychological function will be predicted by the severity of baseline sleepiness measures, sleep fragmentation and sleep apnoea. Neuropsychological tests and full polysomnography will be performed at baseline and 3 months with interim measures of sleepiness and symptoms of autonomic dysfunction measured weekly. Spirometry will be performed monthly. Neuropsychological tests will be administered by blinded assessors. Recruitment commenced in July 2009. DISCUSSION: The results of this trial will demonstrate the effect of nocturnal CPAP treatment of obstructive sleep apnoea in acute quadriplegia. If CPAP can improve neurocognitive function after injury, it is likely that rehabilitation and subsequent community participation will be substantially improved for this group of predominantly young and severely physically disabled people. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12605000799651.

Abdominal binder improves lung volumes and voice in people with tetraplegic spinal cord injury.

OBJECTIVE: To investigate the effect of an elasticated abdominal binder on respiratory, voice, and blood pressure outcomes for people with a motor complete acute tetraplegia during the first year after injury. DESIGN: Randomized crossover study. SETTING: Large university-affiliated referral hospital. PARTICIPANTS: Consenting participants (N=14, 13 men and 1 woman) with recent, motor complete, C3-T1 spinal cord injury. INTERVENTIONS: Abdominal binder on/off with participant seated in upright wheelchair, with 3 repeated measures at 6 weeks, 3 months, and 6 months after commencing daily use of an upright wheelchair. MAIN OUTCOME MEASURES: Forced vital capacity, forced expiratory volume in 1 second, peak expiratory flow, maximal inspiratory pressure, and maximal expiratory pressure were measured. Mean arterial pressure, maximum sustained vowel time, and sound pressure level were also measured. RESULTS: Overall, an abdominal binder resulted in a statistically significant improvement in forced vital capacity (weighted mean difference .34 L [95% confidence interval (CI) .10-.58], P=.005), forced expiratory volume in 1 second (.25 L [95% CI -.01 to .51], P=.05), peak expiratory flow (.81 L/s [95% CI .13-1.48], P=.02), maximal inspiratory pressure (7.40 cm H(2)O [95% CI 1.64-13.14], P=.01), and maximum sustained vowel time (3.75 s [95% CI .90-6.60], P=.01). There was no statistically significant improvement in maximal expiratory pressure (5.37 cm H(2)O [95% CI -1.15 to 11.90], P=.11), mean arterial pressure (4.41 mmHg [95% CI -6.15 to 14.97], P=.41), or sound pressure level (1.14 dB [95% CI -1.31 to 3.58], P=.36). CONCLUSIONS: An individually fitted abdominal binder significantly improved forced vital capacity, forced expiratory volume in 1 second, peak expiratory flow, maximal inspiratory pressure, and maximum sustained vowel time in people with newly acquired tetraplegia. Further study is needed into the effect of the long-term use of the abdominal binder on breathing mechanics, functional residual capacity, total lung capacity, and respiratory health.