PULMONARY ISSUES IN
SPINAL CORD INJURIES
Andrew Zadoff MD, FCCP
Medical Director ICU and Respiratory
Therapy, Shepherd Center
Atlanta Pulmonary Associates
Health Impact of Pulmonary
Problems in SCI*
80% of deaths in cervical injuries are 20 to pulmonary
problems.
50% of these deaths are 20 to pneumonia.
As expected, pre-existing lung disease, smoking history,
level of SCI, and other nonpulmonary problems related to
trauma contribute to respiratory complications.
* J Spinal Cord Med.2007;30:309-18
Financial Importance
Respiratory complications are the most common cause
of morbidity and mortality: an incidence of 36- 83%.1
Respiratory complications increase length of stay and
cost.
Mechanical ventilation, pneumonia, need for surgery,
and the use of a tracheostomy explain nearly 60% of
hospital costs.2
1. 1. J Spinal Cord Med. 2007; 30: 309-18
2. Chest. 2002; 121: 1548-54
PREVIEW
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ACUTE RESPIRATORY ISSUES
PULMONARY PHYSIOLOGY
VENTILATION AND VENTILATORS
WEANING
SECRETION CONTROL
OTHER ICU ISSUES
Clinical Problem #1
A 17 yo man suffered a C6 fracture dislocation a with resultant C5-6
ASIA A spinal injury after diving into a swimming pool. No LOC and he
reports no sense of drowning – friends were at poolside.
2 days after injury mild LLL atelectasis is noted on AM CXR. He notes
some dyspnea. ABG 7.38/ 41/ 65 on 2L N/C. Respiratory RX started.
Day 3 routine AM CXR shows complete atelectasis on left side. ABG is
about the same.
What would you do about his respiratory status?
PHYSIOLOGY AND LOSS OF
FUNCTION
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Loss of function is predictable if extent of
injury is known.
Complications may be predictable and
potential harm to the patient can be
anticipated and prevented.
Recovery of lung function may be
predictable.
ACUTE RESPIRATORY ISSUES
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Acute neurogenic pulmonary edema
Hemodynamic instability, i.e., bradycardia,
hypotension, hypothermia – spinal shock
Unstable cervical spine/ risk of worsening
neurologic injury
Inspiratory difficulty, loss of respiratory
musculature, flail physiology
ACUTE RESPIRATORY ISSUES
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Aspiration risks
Direct injury to the airway
Secondary injury to the airway, i.e., ETT
and tracheostomy complications,
esophageal fistulae to the airway
ACUTE RESPIRATORY ISSUES
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Loss of cough ability secondary to the loss
of expiratory muscles
Inability to generate high expiratory
pressures secondary to ETT’s or trachs
Pain, pain meds, and sedation issues
Restrictive lung physiology
Brain injuries, ability to follow commands
PARASYMPATHETHIC TONE
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“Increased” tone with injuries above the
T1 level
Bronchoconstriction, narrowing of the
airways
Increased bronchial gland secretion
Increased mucus production
Increased viscosity of the mucus
ACUTE RESPIRATORY ISSUES
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For high injuries, ~40 – 60%* of patients will
develop atelectasis usually in the left lower lung.
Pneumonia is common in acute spinal injuries.
In the first 3 – 5 days, it will usually be typical
community organisms: strep pneumonia, staph
aureus, H. Influenza, Moraxella. After 5 days
hospital acquired organisms will be more
common.
Anaerobic infections will be < 15% of causes.
*J Spinal Cord Med 2007;30:309 - 18
LATE RESPIRATORY ISSUES
*
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Restrictive lung physiology may limit
cough and increase risk of pneumonia
Sleep apnea-prevalence 22-62%
Natural loss of lung function over time
Pre- existing lung disease
Blunted respiratory drive or reduced CO2
sensitivity
* Resp Physiology and Neurobiology 166(2009):129-41
PULMONARY PHYSIOLOGY
Chest 1994
PULMONARY NERVES AND
MUSCLES - INSPIRATORY
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Diaphragm- the major respiratory muscle,
80% of quiet breathing, a smaller % for
active breathing
Works by descending, increasing negative
inspiratory pressure, lateral expansion of
the rib cage
Controlled by cervical nerves C3, 4, and 5
(“ C3,4,5 keep the diaphragm alive”)
PULMONARY NERVES AND
MUSCLES - INSPIRATORY
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The intercostal muscles stabilize the chest
wall and cause lateral expansion of the
mid and upper rib cage.
The intercostal muscles include internal
(expiratory) and external (inspiratory)
muscles.
The thoracic spine innervates the
intercostal muscles, T1-T7
PULMONARY NERVES AND
MUSCLES - INSPIRATORY
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The spinal accessory nerves, cranial nerve
XI , innervates the accessory muscles of
respiration, the scalene,
sternocleidomastoid, and trapezius.
These muscles pull up the upper chest
“opposes” the diaphragm.
Chest 1994
PULMONARY - NERVES AND
MUSCLES - EXPIRATORY
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The major cough muscles are the
abdominal muscles (the rectus and
transverse abdominis and external/internal
obliques), the internal (expiratory)
intercostals, and the clavicular portion of
the pectoralis major (C5-7).
Innervation of the abdominal m. is by the
lower thoracic spine.
Clinical Problem #2
A 27yo woman C4 complete injury (MVA) comes to your ICU
intubated. CXR shows mild atelectasis at the bases. Past medical history
discloses no medical or surgical history.
What are your ventilator settings?
Clinical Problem #3
A 27yo woman C4 complete injury (MVA) comes to your ICU
intubated. CXR shows mild atelectasis at the bases. Past medical history
discloses no medical or surgical history.
2 days later atelectasis is mildly more pronounced. ABG shows
7.43/38/65 on assist control rate 10, tidal volume 650, PEEP 5, Fi02 50.
What are your ventilator orders now?
VENTILATORS & VENTILATION
Ventilation and the Airway
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Early tracheostomy if appropriate
Monitor cuff pressures, ideally less than
20cm pressure
Cuff leaks, assisted devices to allow
speech
VENTILATION
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High volume ventilation to prevent
atelectasis but….
Keep peak airway pressure < 35cm H2O
Anticipation of recovery: realism, defining
target parameters such as vital capacity,
minute ventilation, secretion control
Time of Admission
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Initial evaluation and physical exam
Vital capacity (Vc) and negative inspiratory
force (NIF)
ABG
Routine cultures, if indicated
EKG
Time of Admission
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High volume ventilation, low PEEP
Unplugging the airways: aggressive lavage
usually with sodium bicarbonate,
suctioning. Avoid in-line suction.
If appropriate: quad or assist cough;
inexsufflation; vibratory devices- vests,
CPT; bronchoscopy; etc
WEANING
Weaning Parameters
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P1 Max - maximal inspiratory pressure
Spontaneous breathing trials
Respiratory protocols - therapist driven
protocols
WEANING PARAMETERS
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Tidal volume, vital capacity, minute
ventilation, respiratory rate, negative
inspiratory force, maximal inspiratory
pressure
CROP Index = (Cdyn X P I max X PaO2/ PAO2)
/ rate
Rapid Shallow Breathing Index =
frequency/ tidal volume in breaths/min/L
WEANING PARAMETERS
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Tidal volume > 5cc/ kg
Vital capacity > 10cc/ kg
Minute ventilation < 10L / min
or < 2X normal
Respiratory rate < 30/ min
CROP index > 13
Rapid shallow breathing index < 100
WEANING
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At Shepherd Center, weaning is begun
when vital capacity is approximately
8ml/kg and secretions are under control.
Tracheostomy is usually safer and
maintains airway control
CPAP/PS trials are used rather than SIMV
weaning
Time is on our side
SECRETION CONTROL
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High tidal volume ventilation
Sodium bicarbonate, inhaled bronchodilators
Turning modalities, tilt and turn beds
Inexsufflation
CPT vest
Quad cough / assisted cough
IPPB
Intermittent percussive ventilation/ IPV
INFECTIONS
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Minimize (optimize) antibiotic use
Reduce antibiotic use to specific organism
Hand washing, alcohol cleansers, isolation
gowns, gloves, oral care
The payoff- low incidence of C. difficile
and ventilator associated pneumonias
(VAP)
LONG TERM ISSUES
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Identifying care providers prior to
discharge, home and physician care
For trach and home ventilator patients,
family training, the “what if”s of problem
solving, the “AMBU is your friend” speech
Sleep study evaluation (polysomnography)
if there is any question
Appropriate vaccinations
SHEPHERD DATA
WEANING STATISTICS
2007, 2008
Weaning at Shepherd
Compiled by Wendy Fritz, RRT
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Total vents
Home with vent
2007
83
95
15(18%) 22(22%)
Weaned/total
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C-1, C-2
C-3
C-4
2008
3/7
4/6
22/25
weaned/total
3/12
2/6
22/27
2007/2008
Avg # days
-/27
8/21
23/24
Weaning at Shepherd
2007
Weaned/Total
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C-5 thru 7
T-1 thru 12
Rancho 1 thru 5
22/25
6/6
10/13
2008
Weaned/Total
2007/2008
Avg # days
24/26 16/13
15/18 18/20
5/6
7/12
Age of non-weans 2007: 77, 34, 61, 46,
31, 35, 31, 19, 59, 58, 52
OTHER MEDICAL ISSUES
11/2/09
11/2/09
Hospital-acquired and Ventilatorassociated Pneumonia
1, 2
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VAP makes up 1/3 of total nosocomial
infections in the ICU- the most common
10- 20% of pts ventilated >48hrs
Mortality rate 10- 50%, a doubling of
mortality rate, depending on population
and organism
Length of stay increases a mean of 6.1 d
1. Chest 2006; 130:597- 604
2. Am J Respir Crit Care Med 2005; 171:388- 416
Hospital-acquired and Ventilatorassociated Pneumonia
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Extra costs up to $40,000 per patient
Early onset HAP/VAP less than 4 days
usually represents community organisms,
i.e., antibiotic sensitive
Late onset HAP/VAP greater than 5 days
usually composed of MDR organisms
Health care related pneumoniaconsidered MDR unless otherwise proven
Hospital-acquired and Ventilatorassociated Pneumonia
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The usual organisms to be considered for
empiric antibiotic: MRSA, Pseudomonas,
Acinetobactor, other MDR organisms
common to your facility.
Decide if criteria are met for pneumonia:
blood cultures, tracheal aspirate culture,
abnormal CXR, worsening oxygenation,
fever, elevated WBC’s.
Hospital-acquired and Ventilatorassociated Pneumonia
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Tracheal cultures can include endotracheal
aspirate (106 cfu’s), BAL sample (104-105),
blind mini-BAL(103), and protected
brush(103). This can include quantitative
or semi-quantitative colony counts.
Surveillance cultures may not be helpful
for antibiotic choice.1,2
1. Am J Respir Crit Care Med 2002;165:41-46
2. Chest 2005;127:589
83% correct
35% correct
MODIFIABLE RISK FACTORS for
VAP
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Re-intubation; cuff pressure > 20cm;
possibly oral vs nasotracheal; subglottic
suctioning; watching for condensate in
vent circuits; oral care
Semirecumbent positioning 35-400
Enteral feeding is probably better than
parenteral nutrition.
MODIFIABLE RISK FACTORS for
VAP
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Ulcer prophylaxis- The better the ulcer
prophylaxis (higher pH), the higher the risk of
VAP. The best agent for both protection is ____?
Blood transfusion may increase risk.
Tight glucose control may reduce risk.
Sedation vacations and avoidance of paralytics
may help.
Hospital-acquired and Ventilatorassociated Pneumonia - Antibiotics
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Know the common bacteria and best pick
empiric antibiotic choice.
Simplify antibiotics when cultures return.
Don’t continue gorillacillin if you don’t
need it.
Most pneumonias will respond clinically in
5- 6 days; fever, WBC’s, etc, but X-ray
resolution is much slower. Don’t use X-ray
resolution as a criteria for stopping Ab’s
Hospital-acquired and Ventilatorassociated Pneumonia - Antibiotics
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Duration of antibiotics- Place stop dates
when starting drugs. It can be changed
later if need be.
Antibiotics for 7-8 days with clinical
response except Pseudomonas or
Acinetobacter (~14d), or possibly MDR
organism
Prolonged antibiotics are not associated
with better outcomes but are associated
with complication.
Clostridium DifficileAssociated Diarrhea (CDAD)
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CDAD – 6% incremental increase risk of
death among critically ill patients 1
Probably does not increase mortality rate
in pts with prolonged ventilation >96h
Increased length ~ 6 days 2
Total costs increased ~ $10,000 2
1 Chest 2007; 132: 418-24
2 Chest 2009; 136: 752- 8
11/2/09
DEEP VENOUS THROMBOSIS
PROPHYLAXIS
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High risk group with 40 – 100% risk of
occurrence
Pulmonary embolism is the 3rd leading
cause of death in acute SCI
Increased risk with age, lower extremity
fracture, complete injury, obesity, etc
DEEP VENOUS THROMBOSIS
PROPHYLAXIS*
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Low molecular wt heparin or low dose
heparin plus pneumatic compression
device
Use intermittent pneumatic compression
and/or graduated compression stocking if
risk of bleeding is high
Do not use heparin alone
*Antithrombotic and Thrombolytic Therapy. Chest 133(2008)#6
DEEP VENOUS THROMBOSIS
PROPHYLAXIS
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Do not automatically use a vena cava filter
Continue LMWH or use coumadin, INR 2-3
during in-patient rehabilitation or three
months
DECUBITUS ULCER
(Forgive me, I’m a pulmonologist)
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Significant morbidity- bed rest, DVT’s,
depression, potential for surgery and
surgical complications, infections including
osteomyelitis
Nutritional- protein loss
Expensive- estimated cost $50,000 –
70,000 per event*
*J Rehab Research and Development 40;2003: 433-42
Thank you for your attention