Acute respiratory management

Following a spinal cord injury (SCI) with a neurological level of injury (NLI) above T12 will result in some degree of respiratory function change. Early assessment will determine predictive factors for respiratory function changes and complications. Frequent monitoring will determine the adequacy of ventilation and sputum clearance, as well as any deterioration in breathing patterns and increase in the work of breathing.

Outcomes will ultimately determine ongoing ventilation and respiratory health needs, depending on the extent of chronic respiratory dysfunction and persistent respiratory risk factors.

During the acute management phase, the following key interventions should be implemented to optimise respiratory management:

• ventilation support
• lung volume augmentation
• secretion management.

Respiratory management actions

The following actions are recommended in the acute phase following SCI to support respiratory function and manage the risk of complications.

• Obtain and prepare emergency airway management supplies, including wall suction and oxygen.
• Establish spinal precautions in all handling and positioning.
• Position the person in supine to reduce the work of breathing, but also assess the risk for aspiration.
• Provide emergency care in the event of vomiting while supine, particularly when spinal stability is uncertain.

• Conduct comprehensive and early multidisciplinary assessment of respiratory function and monitoring for deterioration, including:
  • continuous pulse oximetry for at least 48-72 hours and beyond, until signs of spinal shock resolve and respiratory function stabilises
  • regular arterial blood gas and capnography monitoring, as pulse oximetry will not be sufficient to detect early signs of respiratory deterioration
  • spirometry
  • a neurological assessment using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI)
  • other respiratory muscle assessments, including breathing patterns and cough effectiveness
  • work of breathing review
  • sputum and saliva clearance check
  • swallowing and voice assessment, especially following cervical spine surgery (e.g. anterior cervical discectomy and fusion) or extubation/decannulation
  • relevant medical investigations.
• Identify predictive factors from assessed respiratory changes and consider the risk for complications, including pulmonary embolism, pulmonary oedema, atelectasis, aspiration, pneumonia, respiratory failure, an ascending lesion and sleep-disordered breathing.
• Develop and implement multidisciplinary respiratory management plans, including pre- and post-surgical care, including:
  • bronchodilator treatment such as ipratropium or salbutamol
  • neurogenic shock management, but avoid excessive fluid resuscitation
  • venous thromboembolism/pulmonary embolism prophylaxis
  • pain management
  • ventilation support
  • lung volume augmentation
  • secretion management.
• Adequate multidisciplinary collaboration and management planning, including:
  • medical– from respiratory physicians, intensivists, radiologists, orthopaedic surgeons to pain and SCI specialists, to optimise and coordinate respiratory management while other medical issues are being addressed
  • nursing– to provide close monitoring of ventilation status and airway patency, facilitating medication administration and feeding routines, optimising skin care management for supine positioning, as well as bowel management for optimal diaphragm function
  • physiotherapy– to assist respiratory assessment and implementation of ventilation support and positioning, lung volume augmentation and secretion management
  • speech therapy– to guide dysphagia management including eventual introduction of feeding, along with implementation of communication strategies and speech as appropriate
  • pharmacy– to optimise medications for pain management, diaphragm contractility, airway reactivity, sputum viscosity, gut motility
  • dietician– to implement nutritional and hydration plans, including for dysphagia and gut motility management
  • occupational therapy– to optimise mattress pressure relief and comfort, maximising capacity for supine positioning, along with implementation of nurse call/communication technology as appropriate
  • social work– to provide psychosocial and emotional supports, along with supporting communication, advocacy and future discharge planning
  • psychology– to provide counselling and support for anxiety and adjustment, while exploring health literacy and beliefs to promote compliance with management recommendations.

Ongoing respiratory monitoring

Respiratory deterioration

Ongoing monitoring by the multi-disciplinary team is very important and facilitates early detection of any signs of deterioration in respiratory function.