DRAFT RESPIRATORY CARE PROTOCOL FOR PATIENTS WITH ACUTE SPINAL CORD INJURY.
MANAGEMENT OF THE NON-INTUBATED SCI PATIENT
1. Initial Evaluation at Admission.
a) Obtain arterial blood gas / pulse oximetry for standard assessment of oxygenation and
ventilation.
b) Assess the adequacy of the airway, breathing pattern, presence of chest wall instability,
respiratory muscle discoordination / paradoxical breathing, and respiratory distress.
c) Obtain a baseline measurement of VC, MIP
i. Triplicate measurements should be made in the supine position.
ii. The best performance should be recorded and
iii.
Noticeable deterioration (over 3 attempts) in performance should be noted as a
comment.
d) Ensure patient's height is measured and entered into ICIP for monitoring VC in mL/Kg
e) Inquire from ICU team /Neuro Critical Care information on level and completeness of injury.
2. Daily Evaluation:
VC, MIP and ABG will be measured in all patients with cervical or thoracic SCI every day for the first 3
days following ICU admission. The need for further measurements should be re-evaluated after 72 hr.
a) If VC < 20 mL/kg: increase measurements of VC, MIP and ABG to every shift
b) Notify ICU immediately when VC reaches the following thresholds:
I.
< 15 mL/kg (invasive mechanical ventilation advised)
II.
< 10 mL/kg. (invasive mechanical ventilation considered mandatory)
3. Basic Respiratory Therapy in Nonintubated Patients.
a) Nasal O2 therapy 1-6 L/min as needed to keep SpO2 > 95%.
b) High flow nasal or mask O2 therapy when >6 L/min is needed.
c) All SCI patients will be started on incentive spirometry Q – 2 h (while awake).
d) E-Z PAP therapy at 10 cm H2O Q-4h (while awake)
e) All patients with a smoking history and or history of reactive airways disease will be started on
aerosolized albuterol 2.5 mg unit dose combined with aerosolized atrovent 0.5 mg unit dose Q –
4 hr (while awake) basis.
4. Escalation of Respiratory Therapy in Nonintubated Patients
1
Initiated: 9/2011; Reviewed: 6/2012
DRAFT RESPIRATORY CARE PROTOCOL FOR PATIENTS WITH ACUTE SPINAL CORD INJURY.
Indications:
i.
Presence of thick and/or purulent secretions
ii.
Poor cough
iii.
VC < 20 mL/kg
a) Aerosolized Albuterol (2.5 mg)/Atrovent (0.5 mg) Q – 4 hr (while awake). in all patients
regardless of smoking or reactive airways disease history.
b) Aerosolized Acetylcysteine (Mucomyst) either 6 mL of 10%, or 3 mL of 20%solution will be
started on Q – 4 hr (while awake) only for thick purulent secretions. This should be administered
after Albuterol / Atrovent therapy to lessen likelihood of bronchospasm.
c) Alternative: aerosolized Sodium Bicarbonate (4mL of 3.75%HCO3) at the discretion of the ICU
team when Mucomyst is too irritating, or there is a history of reactive airways disease.
d) Mechanical insufflation-exsufflation therapy initiated Q – 4 hr (while awake) in patients who are
producing thick sputum and a weak cough. Escalation of therapy beyond Q – 4h should be at
the discretion of clinicians based upon severity of sputum consistency and amount.
e) Nasotracheal suctioning at clinician discretion. Should be considered when mechanical cough
assist therapy appears ineffective. Particularly in the context of increasing FiO2 requirements
(e.g.: > 0.60).
2
Initiated: 9/2011; Reviewed: 6/2012