2002 OPEN FORUM Abstracts
Ventilator-Dependent Spinal Cord Injured Patients - A Pilot Study
Charles J. Gutierrez, MS, RRT, Jeffrey Harrow, MD, PhD, Fred Haines, RRT, and Joy Jurena Williams, RN, RRT, MHS James A. Haley Veterans Hospital, Respiratory Care & Diagnostic Services, SCI / 7N Sub-Acute Care Program, and Spinal Cord Injury / Dysfunction Service, Tampa, FL 33612
Introduction: Evidence-based techniques were used to develop and implement a clinical protocol for improving respiratory muscle strength of ventilator-dependent spinal cord injured patients preparing for weaning from mechanical ventilation. Results from the first 4 patients are presented.
Methods and Materials: A thorough literature search was performed to obtain scientific articles about outcomes in ventilator weaning. Articles were rated in terms of their quality and applicability. While many studies examined the value of resistance training or endurance training, no protocol combined both of these. Based on evidence of effective methods, a protocol was developed that encompassed nutritional parameters, resistance training, and endurance training. Inclusion criteria: ventilator-dependent spinal cord injured patients, medically stable. Exclusion criteria: age > 70, unable to cooperate. Protocol: Prior to initiating respiratory rehabilitation exercises, nutritional parameters were examined. Patients with abnormal pre-albumin underwent intensive nutritional support ranging from tube feeding supplements to patient-initiated eating. After normalization of pre albumin, patients with abnormal albumin underwent liver function and prostate specific antigen assays before being placed on Oxandrolone, an anabolic steroid. Inspiratory resistance strength training was performed in a progressive manner using a commercially available device. Endurance training consisted of on-vent breathing with pressure support (PSV 5) and continuous positive airway pressure (CPAP 5), progressing to off-vent weaning trials as tolerated. Patients were maintained within protocol parameters. In the event of intolerance patients were returned to Assist / Control mode for at least 24 hours.
Results: Patients (n=4) with incomplete cervical spinal cord injury (C2C7) underwent respiratory rehabilitation for 3 to 12 months. Indices of respiratory muscle strength including maximal inspiratory pressure (PiMAX) and vital capacity (VC) were recorded before and after participating in the rehabilitation program. Pre albumin (Pre alb) was monitored as an index of muscle repletion and readiness. 75% of patients progressed to off-vent weaning trials and 50% remained off vent for 5 or more hours per day.
|PiMAX (cm H2O)||-3.0||1.4||-16.5||5.7||< 0.01|
|VC (cc)||245.0||110.9||572.5||303.5||< 0.05|
|Pre alb (mg / dl)||16.5||3.1||30.0||8.1||< 0.04|
Conclusion: A review of the literature using evidence-based techniques lead to development and implementation of protocol-guided rehabilitation for vent-dependent SCI patients. Nutritional normalization, resistance and endurance training constituted key elements of the protocol. Evidence-based protocol guided rehabilitation of vent-dependent spinal cord injured patients resulted in significantly improved respiratory muscle strength.