Objectives:

This report describes evidence on the respiratory management of persons with acute or chronic cervical level spinal cord injury (SCI), including mechanical ventilation and other interventions aimed at preventing or treating respiratory diseases.

Search Strategy:

Databases searched were MEDLINE (1966-Feb 2000), HealthSTAR (1975-Feb 2000), Cumulative Index to Nursing & Allied Health Literature (CINAHL) (1983-Feb 2000), and EMBASE (1980-Feb 2000). The search strategies included the MeSH terms spinal cord injuries, paraplegia, and quadriplegia [exploded] and text words for tetraplegia, quadriplegia, and paraplegia with a pulmonary disease concept. The search was limited to articles pertaining to humans and published in the English language.

Selection Criteria:

The population of interest is adults with traumatic cervical SCI. Interventions considered include intubation and airway management, mechanical ventilation initiation, and weaning as well as medications (bronchodilators, mucolytics) and respiratory therapy (noninvasive positive pressure ventilation [NPPV], assisted cough, postural drainage, humidification, spirometry, vital capacity assessment). Evidence was considered from controlled or uncontrolled studies.

Data Collection and Analysis:

At least two reviewers independently screened titles and abstracts; references included by either rater were retained. Full reports were reevaluated according to the selection criteria and data describing study population, study design, interventions, and outcome data were recorded. Quality was assessed based on criteria related to external validity (characterization of the study population) and internal validity (strength of study design).

Main Results:

Patients with C4-level SCI have greater weaning success using progressive ventilatory-free breathing than synchronized intermittent mandatory ventilation techniques. In addition, high ventilator volume (more than 20 cc/kg) is associated with less atelectasis and faster weaning. Aggressive multimodal respiratory therapy interventions (including frequent turning, suctioning [and bronchial lavage], chest percussion and assisted coughing, inhaled bronchodilator treatments, deep breathing, and incentive spirometry) and rotating beds have been associated with reduced mortality, atelectasis, need for mechanical ventilation, or tracheostomy. Other secretion clearance modalities show evidence of improved cough (manual assisted cough, mechanical insufflator-exsufflator, glossopharyngeal breathing) but include no data on health outcomes. There is little evidence of an effect for other interventions, including active respiratory muscle exercise with incentive spirometry, inspiratory resistance training, and abdominal weight training.

Several alternatives to tracheostomy positive pressure ventilation (PPV) for long-term ventilatory support have been demonstrated, including electrophrenic respiration, noninvasive positive pressure ventilation, intermittent positive pressure breathing, pneumobelt, and glossopharyngeal breathing. Noninvasive ventilation may reduce the risk of pneumonia compared with tracheostomy PPV for patients requiring chronic ventilatory support.

Conclusions:

Treatments aimed at improving ventilation, cough, and secretion clearance reduce atelectasis, pneumonia and the need for mechanical ventilation. Clinical research studies on pulmonary disease following cervical SCI cover only a small number of many important management decisions. Few studies use control groups (randomized or otherwise) or other designs to reduce bias.