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Ventilator Weaning with Spinal Cord Injury - PowerPoint PPT Presentation


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Ventilator Weaning with Spinal Cord Injury. & Tracheostomy. RISCI snapshot survey 2009. 18 patients in critical care beds awaiting transfer 5> 6 months. South of England Review of Standards in Spinal Cord injury. . National Spinal Cord Injury Strategy Board. .

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Presentation Transcript
slide4

RISCI snapshot survey 2009

18 patients in critical care beds awaiting transfer

5> 6 months

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
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
slide6

Respiratory effects

Acute VC

1 Year VC

Lumbar Unable to cough 100-70%

100-70%

Low thoracic é chest wall compliance

ê Vital capacity

High thoracic éé chest wall compliance 30-50%

êê Vital capacity

poor expansion. Basal collapse

60-70%

C5/C6 Diaphragms, Scalenes 20%

40-50%

C3/C4/C5 Sternomastoid and partial diaphragm

Above C3 Sternomastoid only 5-10%

slide7

Weaning

Based on little evidence but vast experience

Prerequisites

Good pulmonary compliance

Low FiO2 requirement

Awake and cooperative

Some respiratory activity

Committed team

slide8

Any respiratory activity?

Testing

Volume measurement

Beware sensitive ITU Vents

Modified brainstem death test

slide9

Weaning

Progressive ventilator free breathing

Measure Vital Capacity

VC Time off Vent

<250 mls 5 Mins

-500 mls 15 Mins

-750 mls 30 Mins

-1000 mls 60 Mins

Measure VC Post weaning >70% pre weaning

Southport Spinal Injury Centre

Increase duration and/ or frequency

slide10

Weaning

Wait for spasticity

Bronchodilators

?High TV Ventilation (>20 ml/Kg)?1

Supine

  • The effect of tidal volumes on the time to wean persons with high tetraplegia from ventilators
  • Peterson W. et al spinal cord 1999 37(4):284-288
slide12

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

slide13

Speech essential

Eating optional

slide14

How to wean

BIPAP/ PS

Slow weaners

Fast weaners

laryngeal function vs resp function

VFB Cuff up

Cuff down on vent

VFB Cuff down speaking valve

VFB speaking valve

Downsized uncuffed tube

Decannulate

how successful
How successful ?

Southport spinal injuries unit

  • 246 patients over 20 years
  • 63% weaned
  • 33% Ventilator dependant
  • 4% Died
slide16

Post weaning Maintenance

‘ Maintain Range of Movements’

Manual hyperinflation

IPPB

Cough Assist/ Clearway

Improve muscle strength

Inspiratory muscle training

tracheostomy
Tracheostomy
  • Surgical may be better than percutaneous
    • Safer if unstable spine
    • Anatomically accurate
    • Easier changes long term
    • Worse scar
    • Logistically difficult
trachy tubes
Trachy Tubes

Use what you are used to but…

Avoid

fenestrations

trachy tubes1
Trachy Tubes

Definitely avoid

trachy tubes2
Trachy Tubes

Definitely consider supraglottic suction tubes

trachy tubes3
Trachy Tubes

If they need a tube long term

trachy tubes5
Trachy Tubes

Don’t dismiss

speaking valves
Speaking valves

Are not all the same

slide25

When to decanulate

No respiratory support required

Secretion clearance guaranteed