Resources
Preface and applicability
Currently within our unit there is no agreed/standardised respiratory care for patients with high thoracic and cervical cord injuries. The demographic has changed over recent years with many of these patients now being in their late 60’s, 70’s and even 80’s. The patients coming to our unit often also have high levels of co-morbidity especially obesity, diabetes and smoking related lung disease. Many of these patients will end up being ventilated for prolonged periods and a proportion of these will be ventilator dependent via tracheostomy, this causes substantial difficulty in finding cate for them often resulting in the more elderly patients being unable to return to their own homes.
From initial verbal discussions all parties are agreed that we should be striving to keep these patients from being intubated and ventilated if at all possible. When this fails we should be aiming to prevent respiratory muscle de-training and move to early warning and tracheostomy. We are also all agreed that a weaning protocol would be desirable. The remainder of this document will be split into three sections: 1. Intubation prevention 2. Prevention of respiratory muscle de-training 3. Weaning.
Section 1 – Intubation Prevention
Patients with high cord injuries are intubated most commonly for two reasons, either neuromuscular failure as a result of a cord injury +/- progressive oedema or retained secretions +/- chest infection. If the injury is high and there is loss of diaphragmatic function then it would seem impossible to prevent intubation although if bulbar function and consciousness is intact then it may be possible to manage via non-invasive ventilation (NIV).
Most commonly we see our patients struggling to clear their secretions and this coupled to atelectasis will often precipitate intubation. The effects of cord injury include direct loss of respiratory muscle innervation (intercostals and diaphragm) and also sympathectomy resulting in bronchoconstriction and an increase in the tenacity of mucus.
The areas where we can intervene therefore include:
- Use of carbocisteine as a mucolytic
- Use of long acting inhaled bronchodilators
- Regular use of cough assist machine to clear secretions
- Postural drainage to clear secretions
- Regular physiotherapy
- Regular use of non-invasive ventilation to re-recruit alveoli
It would seem sensible to commence the above from the moment the patient is admitted to the unit (there may also be a case for advising the referring unit on respiratory management but this is a later piece of work). The aim being to prevent loss of lung function before the only option becomes invasive ventilation.