Noninvasive respiratory management of high level spinal cord injury

Abstract

This article describes noninvasive acute and long-term management of the respiratory muscle paralysis of high spinal cord injury (SCI). This includes full-setting, continuous ventilatory support by noninvasive intermittent positive pressure ventilation (NIV) to support inspiratory muscles and mechanically assisted coughing (MAC) to support inspiratory and expiratory muscles. The NIV and MAC can also be used to extubate or decannulate 'unweanable' patients with SCI, to prevent intercurrent respiratory tract infections from developing into pneumonia and acute respiratory failure (ARF), and to eliminate tracheostomy and resort to costly electrophrenic/diaphragm pacing (EPP/DP) for most ventilator users, while permitting glossopharyngeal breathing (GPB) for security in the event of ventilator failure.

Figure 1

Soldier with SCI transferred from the Greek military to New Jersey for electrophrenic pacemaker (EPP) despite having 750 ml of VC and daytime periods of ventilator-free breathing. After the pacemaker was placed he was transferred to us and decannulated. He then permanently discontinued EPP and used mouth piece NIV during the day and nasal NIV at night with a chin strap (seen here) to reduce insufflation leak.

Figure 2

Chin control motorized wheelchair with 15-mm angled mouth piece adjacent to the mouth for easy access for patient dependent on continuous noninvasive ventilation (NIV) for 38 years, apparently the longest duration of NIV dependence for any patient with SCI.

Figure 3

Patient who was continuously dependent on tracheostomy ventilation for 2 years, decannulated, then managed for 15 years by daytime intermittent abdominal pressure ventilation (IAPV) and nocturnal lip seal ventilation, seen here with the hose of the portable ventilator entering his IAPV under his clothing. This patient died when he could not access mouth piece ventilation during an epileptic seizure.

Figure 4

A 15-year-old patient with C3 complete motor SCI as a result of a diving accident, whose VC fell to 750 ml and PaCO₂ rose to 50 mmHg 24 hours after hospital admission. Initially he used a chest shell ventilator and within 24 hours his VC decreased further to 480 ml and he had no ventilator-free breathing ability. To accommodate Halo traction, he was switched to noninvasive ventilation (NIV). After trying nasal, oral, and lip seal NIV he chose to use mouth piece NIV (seen here) when awake and lip seal NIV for sleep. After 11 days of continuous NIV dependence, he weaned entirely over the next few days. Since he was not intubated, he never developed any airway secretion difficulties.

Figure 5

A 72-year-old woman with VC of 180 ml and no ventilator-free breathing ability, extubated to daytime mouth piece and nocturnal lip seal ventilation (Lipseal™, Phillips-Respironics International Inc., Murrysville, PA, USA).

Figure 6

As for the majority of patients who can master GPB for ventilator-free breathing once they are decannulated, this patient, with no measurable VC, has 60–90 ml per gulp, 6–8 gulps per breath, 12 breaths per minute for 48 ml/gulp or 4760 ml/min of alveolar ventilation and normal PaCO₂ throughout daytime hours by GPB and a maximum glossopharyngeal single-breath capacity of 3500 ml.