Summary: Respiratory complications are the most common cause of morbidity and mortality in acute spinal cord injury (SCI), with an incidence of 36% to 83%. Eighty percent of deaths in patients hospitalized with cervical SCI are secondary to pulmonary dysfunction, with pneumonia the cause in 50% of the cases. The number of respiratory complications during the acute hospital stay contributes significantly to the length of hospital stay and cost. Four factors (use of mechanical ventilation, pneumonia, the need for surgery, and use of tracheostomy) explain nearly 60% of hospital costs and may be as important a predictor of hospital cost as level of injury. Atelectasis (36.4%), pneumonia (31.4%), and ventilatory failure (22.6%) are the most common complications during the first 5 days after injury. Ventilatory failure occurs on average 4.5 days after injury. Transfer to an SCI center specializing in acute management of tetraplegia has been shown to significantly reduce the number of respiratory complications. This review concentrates on the first 5 days after injury, focusing on complications, predictive factors, prevention, and management of those complications.

Background:In individuals with cervical spinal cord injury (SCI), respiratory complications arise within hours to days of injury. Paralysis of the respiratory muscles predisposes the patient toward respiratory failure. Respiratory complications after cervical SCI include hypoventilation, hypercapnea, reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Ultimately, the patient must use increased work to breathe, which results in respiratory fatigue and may eventually require intubation for mechanical ventilation. Without specialized respiratory management for individuals with tetraplegia, recurrent pneumonias, bronchoscopies, and difficulty in maintaining a stable respiratory status will persist. Objective: This retrospective analysis examined the effectiveness of specialized respiratory management utilized in a regional SCI center. Methods: Individuals with C1-C4 SCI (N = 24) were the focus of this study as these neurological levels present with the most complicated respiratory status. Results: All of the study patients' respiratory status improved with the specialized respiratory management administered in the SCI specialty unit. For a majority of these patients, respiratory improvements were noted within 1 week of admission to our SCI unit. Conclusion: Utilization of high tidal volume ventilation, high frequency percussive ventilation, and mechanical insufflationexsufflation have demonstrated efficacy in stabilizing the respiratory status of these individuals. Optimizing respiratory status enables the patients to participate in rehabilitation therapies, allows for the opportunity to vocalize, and results in fewer days on mechanical ventilation for patients who are weanable.

Dysphagia is present in approximately 38% of individuals with acute tetraplegia. Because only one of the 21 subjects was diagnosed differently based on VFSS, we believe that BSE is an appropriate screening tool for dysphagia for individuals with cervical SCI. However, VFSS provided additional information on diet and liquid recommendations, so there appears to be an important clinical role for the VFSS.

No abstract

Background: Dysphagia is a relatively common secondary complication that occurs after acute cervical spinal cord injury (SCI). The detrimental consequences of dysphagia in SCI include transient hypoxemia, chemical pneumonitis, atelectasis, bronchospasm, and pneumonia. The expedient diagnosis of dysphagia is imperative to reduce the risk of the development of life-threatening complications. Objective: The objective of this study was to identify risk factors for dysphagia after SCI and associated respiratory considerations in acute cervical SCI. Methods: Bedside swallow evaluation (BSE) was conducted in 68 individuals with acute cervical SCI who were admitted to an SCI specialty unit. Videofluroscopy swallow study was conducted within 72 hours of BSE when possible. Results: This prospective study found dysphagia in 30.9% (21 out of 68) of individuals with acute cervical SCI. Tracheostomy (P = .028), ventilator use (P = .012), and nasogastric tube (P = .049) were found to be significant associated factors for dysphagia. Furthermore, individuals with dysphagia had statistically higher occurrences of pneumonia when compared with persons without dysphagia (P < .001). There was also a trend for individuals with dysphagia to have longer length of stay (P = .087). Conclusion: The role of respiratory care practitioners in the care of individuals with SCI who have dysphagia needs to be recognized. Aggressive respiratory care enables individuals with potential dysphagia to be evaluated by a speech pathologist in a timely manner. Early evaluation and intervention for dysphagia could decrease morbidity and improve overall clinical outcomes.

Background/objective: Dysphagia following cervical spinal cord injury (SCI) can increase risk for pulmonary complications that may delay the rehabilitative process. The objective of this study was to identify risk factors for dysphagia after cervical SCI. Design: Prospective cohort study. Methods: Individuals with cervical SCI within 31 days of injury underwent a bedside swallow evaluation (BSE) followed by a videofluoroscopy swallow study (VFSS) within 72 hours of the BSE. Subjects were diagnosed as having dysphagia if they had positive findings in either BSE or VFSS. Results: Twenty-nine patients (7 female and 22 male) were enrolled. Of these, 21 (72%) had high cervical tetraplegia (C4 or higher) and 8 (38%) had lower cervical tetraplegia. A tracheostomy was present in 18 (62%) patients; 15 (52%) subjects were on ventilators. Dysphagia was diagnosed in 12 (41%) subjects. Dysphagia was noted in 62% of the subjects with tracheostomy and 53% of the subjects on the ventilator, but only tracheostomy resulted in a statistically significant association with dysphagia (P = 0.047). All three subjects who had nasogastric tubes were diagnosed with dysphagia (P = 0.029). The relationships between dysphagia and gender, high versus low tetraplegia, presence of halo or collar, head injury, and ventilator use were not statistically significant, but age was a significant risk factor (P = 0.028). Conclusions: Dysphagia is present in about 41% of individuals with acute tetraplegia. Only age, tracheostomy, and nasogastric tubes were identified as significant risk factors for dysphagia for individuals with tetraplegia. No relationship between dysphagia and level of SCI, spine surgery, collar, and ventilator use was found to exist.

Study design: Retrospective analysis. Objectives: In patients with spinal cord injury, limitations in upper extremity (UE) motor function are cited as a reason for the lack of adherence to clean intermittent catheterization (CIC). By examining the UE function in spinal cord injury (SCI) patients, we aim to provide insight into why CIC 'dropout' occurs and determine a more appropriate target percentage for CIC in this patient population. Setting: United States centers participating in National Spinal Cord Injury Database (NSCID). Methods: We assessed discharge data from the 2006 to 2012 NSCID. Neurologic motor scores for C5 to C8 (involved in UE movement) were transformed into a binary variable consisting of the ability ('strong') or the inability ('weak') to achieve active motion against resistance. We generated an algorithm based on expert opinion and published literature to categorize a person's ability to perform CIC by the UE function alone. Results: Of the 4481 patients evaluated, 77.3% were unable to volitionally void. Of this subset, 58.8% were categorized as able to catheterize, 12.9% as possibly able, 4.3% as only able with surgical assistance and 23.3% as unable. Among patients discharged with an indwelling catheter, 33.4% had adequate UE function for CIC. Among patients performing CIC at discharge, 14.1% had inadequate UE function for self-catheterization. Conclusions: CIC dropout may occur at least, in part, because of inadequate UE motor function. In a 'best-case' scenario,~76% of patients with SCI who cannot volitionally void could potentially perform CIC given appropriate assistance.

No abstract