PULMONARY ISSUES IN SPINAL CORD INJURIES

PULMONARY ISSUES IN PULMONARY ISSUES IN SPINAL CORD INJURIESSPINAL CORD INJURIES

Andrew Zadoff MD, FCCPAndrew Zadoff MD, FCCPMedical Director ICU and Medical Director ICU and

Respiratory Therapy, Shepherd Respiratory Therapy, Shepherd Center Atlanta Pulmonary Center Atlanta Pulmonary

Associates Associates

Health Impact of Pulmonary Problems in

SCI*80% of deaths in cervical injuries are 20 to pulmonary problems.

50% of these deaths are 20 to pneumonia.

As expected, pre-existing lung disease, smoking history, level of SCI, and other nonpulmonary problems related to trauma contribute to respiratory complications.

* J Spinal Cord Med.2007;30:309-18

Financial Importance

Respiratory complications are the most common cause of morbidity and mortality: an incidence of 36- 83%.1

Respiratory complications increase length of stay and cost.

Mechanical ventilation, pneumonia, need for surgery, and the use of a tracheostomy explain nearly 60% of hospital costs.2

1. 1. J Spinal Cord Med. 2007; 30: 309-18 2. Chest. 2002; 121: 1548-54

PREVIEWPREVIEW

ACUTE RESPIRATORY ISSUESACUTE RESPIRATORY ISSUES PULMONARY PHYSIOLOGYPULMONARY PHYSIOLOGY VENTILATION AND VENTILATORSVENTILATION AND VENTILATORS WEANINGWEANING SECRETION CONTROLSECRETION CONTROL OTHER ICU ISSUESOTHER ICU ISSUES

Clinical Problem #1Clinical Problem #1

A 17 yo man suffered a C6 fracture dislocation a with resultant C5-6 ASIA A spinal injury after diving into a swimming pool. No LOC and he reports no sense of drowning – friends were at poolside.

2 days after injury mild LLL atelectasis is noted on AM CXR. He notes some dyspnea. ABG 7.38/ 41/ 65 on 2L N/C. Respiratory RX started.

Day 3 routine AM CXR shows complete atelectasis on left side. ABG is about the same.

What would you do about his respiratory status?

PHYSIOLOGY AND LOSS OF PHYSIOLOGY AND LOSS OF FUNCTIONFUNCTION

Loss of function is predictable if Loss of function is predictable if extent of injury is known.extent of injury is known.

Complications may be predictable Complications may be predictable and potential harm to the patient can and potential harm to the patient can be anticipated and prevented.be anticipated and prevented.

Recovery of lung function may be Recovery of lung function may be predictable.predictable.

ACUTE RESPIRATORY ACUTE RESPIRATORY ISSUESISSUES

Acute neurogenic pulmonary edema Acute neurogenic pulmonary edema Hemodynamic instability, i.e., Hemodynamic instability, i.e.,

bradycardia, hypotension, hypothermia bradycardia, hypotension, hypothermia – spinal shock– spinal shock

Unstable cervical spine/ risk of Unstable cervical spine/ risk of worsening neurologic injuryworsening neurologic injury

Inspiratory difficulty, loss of respiratory Inspiratory difficulty, loss of respiratory musculature, flail physiology musculature, flail physiology


Aspiration risksAspiration risks Direct injury to the airwayDirect injury to the airway Secondary injury to the airway, i.e., Secondary injury to the airway, i.e.,

ETT and tracheostomy complications, ETT and tracheostomy complications, esophageal fistulae to the airwayesophageal fistulae to the airway


Loss of cough ability secondary to Loss of cough ability secondary to the loss of expiratory musclesthe loss of expiratory muscles

Inability to generate high expiratory Inability to generate high expiratory pressures secondary to ETT’s or pressures secondary to ETT’s or trachstrachs

Pain, pain meds, and sedation issuesPain, pain meds, and sedation issues Restrictive lung physiologyRestrictive lung physiology Brain injuries, ability to follow Brain injuries, ability to follow

commandscommands

PARASYMPATHETHIC TONEPARASYMPATHETHIC TONE

““Increased” tone with injuries above Increased” tone with injuries above the T1 levelthe T1 level

Bronchoconstriction, narrowing of the Bronchoconstriction, narrowing of the airwaysairways

Increased bronchial gland secretionIncreased bronchial gland secretion Increased mucus productionIncreased mucus production Increased viscosity of the mucusIncreased viscosity of the mucus


For high injuries, ~40 – 60%* of patients will For high injuries, ~40 – 60%* of patients will develop atelectasis usually in the left lower develop atelectasis usually in the left lower lung.lung.

Pneumonia is common in acute spinal injuries. Pneumonia is common in acute spinal injuries. In the first 3 – 5 days, it will usually be typical In the first 3 – 5 days, it will usually be typical community organisms: strep pneumonia, staph community organisms: strep pneumonia, staph aureus, H. Influenza, Moraxella. After 5 days aureus, H. Influenza, Moraxella. After 5 days hospital acquired organisms will be more hospital acquired organisms will be more common.common.

Anaerobic infections will be < 15% of causes.Anaerobic infections will be < 15% of causes.*J Spinal Cord Med 2007;30:309 - 18

LATE RESPIRATORY ISSUESLATE RESPIRATORY ISSUES**

Restrictive lung physiology may limit Restrictive lung physiology may limit cough and increase risk of pneumoniacough and increase risk of pneumonia

Sleep apnea-prevalence 22-62%Sleep apnea-prevalence 22-62% Natural loss of lung function over timeNatural loss of lung function over time Pre- existing lung diseasePre- existing lung disease Blunted respiratory drive or reduced Blunted respiratory drive or reduced

CO2 sensitivityCO2 sensitivity* Resp Physiology and Neurobiology 166(2009):129-41

PULMONARY PHYSIOLOGY

Chest 1994

PULMONARY NERVES AND PULMONARY NERVES AND MUSCLES - INSPIRATORYMUSCLES - INSPIRATORY

Diaphragm- the major respiratory Diaphragm- the major respiratory muscle, 80% of quiet breathing, a muscle, 80% of quiet breathing, a smaller % for active breathingsmaller % for active breathing

Works by descending, increasing Works by descending, increasing negative inspiratory pressure, lateral negative inspiratory pressure, lateral expansion of the rib cageexpansion of the rib cage

Controlled by cervical nerves C3, 4, and Controlled by cervical nerves C3, 4, and 5 (“ C3,4,5 keep the diaphragm 5 (“ C3,4,5 keep the diaphragm alive”)alive”)


The intercostal muscles stabilize the The intercostal muscles stabilize the chest wall and cause lateral expansion chest wall and cause lateral expansion of the mid and upper rib cage.of the mid and upper rib cage.

The intercostal muscles include The intercostal muscles include internal (expiratory) and external internal (expiratory) and external (inspiratory) muscles.(inspiratory) muscles.

The thoracic spine innervates the The thoracic spine innervates the intercostal muscles, T1-T7intercostal muscles, T1-T7


The spinal accessory nerves, cranial The spinal accessory nerves, cranial nerve XI , innervates the accessory nerve XI , innervates the accessory muscles of respiration, the scalene, muscles of respiration, the scalene, sternocleidomastoid, and trapezius.sternocleidomastoid, and trapezius.

These muscles pull up the upper These muscles pull up the upper chest “opposes” the diaphragm.chest “opposes” the diaphragm.

Chest 1994

PULMONARY - NERVES AND PULMONARY - NERVES AND MUSCLES - EXPIRATORYMUSCLES - EXPIRATORY

The major cough muscles are the The major cough muscles are the abdominal muscles (the rectus and abdominal muscles (the rectus and transverse abdominis and transverse abdominis and external/internal obliques), the internal external/internal obliques), the internal (expiratory) intercostals, and the (expiratory) intercostals, and the clavicular portion of the pectoralis major clavicular portion of the pectoralis major (C5-7).(C5-7).

Innervation of the abdominal m. is by Innervation of the abdominal m. is by the lower thoracic spine. the lower thoracic spine.


A 27yo woman C4 complete injury (MVA) comes to your ICU intubated. CXR shows mild atelectasis at the bases. Past medical history discloses no medical or surgical history.

What are your ventilator settings?


A 27yo woman C4 complete injury (MVA) comes to your ICU intubated. CXR shows mild atelectasis at the bases. Past medical history discloses no medical or surgical history.

2 days later atelectasis is mildly more pronounced. ABG shows 7.43/38/65 on assist control rate 10, tidal volume 650, PEEP 5, Fi02 50.

What are your ventilator orders now?

VENTILATORS & VENTILATORS & VENTILATIONVENTILATION

Ventilation and the AirwayVentilation and the Airway

Early tracheostomy if appropriateEarly tracheostomy if appropriate Monitor cuff pressures, ideally less Monitor cuff pressures, ideally less

than 20cm pressurethan 20cm pressure Cuff leaks, assisted devices to allow Cuff leaks, assisted devices to allow

speechspeech

VENTILATIONVENTILATION

High volume ventilation to prevent High volume ventilation to prevent atelectasis but….atelectasis but….

Keep peak airway pressure < 35cm Keep peak airway pressure < 35cm HH22O O

Anticipation of recovery: realism, Anticipation of recovery: realism, defining target parameters such as defining target parameters such as vital capacity, minute ventilation, vital capacity, minute ventilation, secretion controlsecretion control

Time of Admission Time of Admission

Initial evaluation and physical examInitial evaluation and physical exam Vital capacity (Vc) and negative Vital capacity (Vc) and negative

inspiratory force (NIF)inspiratory force (NIF) ABGABG Routine cultures, if indicatedRoutine cultures, if indicated EKG EKG

Time of Admission Time of Admission

High volume ventilation, low PEEPHigh volume ventilation, low PEEP Unplugging the airways: aggressive Unplugging the airways: aggressive

lavage usually with sodium lavage usually with sodium bicarbonate, suctioning. Avoid in-line bicarbonate, suctioning. Avoid in-line suction.suction.

If appropriate: quad or assist cough; If appropriate: quad or assist cough; inexsufflation; vibratory devices- inexsufflation; vibratory devices- vests, CPT; bronchoscopy; etcvests, CPT; bronchoscopy; etc

WEANINGWEANING

Weaning ParametersWeaning Parameters P1 Max - maximal inspiratory P1 Max - maximal inspiratory

pressure pressure Spontaneous breathing trialsSpontaneous breathing trials Respiratory protocols - therapist Respiratory protocols - therapist

driven protocolsdriven protocols

WEANING PARAMETERSWEANING PARAMETERS Tidal volume, vital capacity, minute Tidal volume, vital capacity, minute

ventilation, respiratory rate, negative ventilation, respiratory rate, negative inspiratory force, maximal inspiratory inspiratory force, maximal inspiratory pressurepressure

CROP Index = (CCROP Index = (Cdyn dyn X PX P I I maxmax X P X PaaO2/ O2/

PPAAO2) / rate O2) / rate Rapid Shallow Breathing Index = Rapid Shallow Breathing Index =

frequency/ tidal volume in frequency/ tidal volume in breaths/min/L breaths/min/L

WEANING PARAMETERSWEANING PARAMETERS Tidal volume > 5cc/ kgTidal volume > 5cc/ kg Vital capacity > 10cc/ kgVital capacity > 10cc/ kg Minute ventilation < 10L / min Minute ventilation < 10L / min

or < 2X normal or < 2X normal Respiratory rate < 30/ minRespiratory rate < 30/ min CROP index > 13CROP index > 13 Rapid shallow breathing index < 100Rapid shallow breathing index < 100

WEANINGWEANING

At Shepherd Center, weaning is begun At Shepherd Center, weaning is begun when vital capacity is approximately when vital capacity is approximately 8ml/kg 8ml/kg andand secretions are under secretions are under control.control.

Tracheostomy is usually safer and Tracheostomy is usually safer and maintains airway controlmaintains airway control

CPAP/PS trials are used rather than CPAP/PS trials are used rather than SIMV weaningSIMV weaning

Time is on our sideTime is on our side

SECRETION CONTROLSECRETION CONTROL

High tidal volume ventilationHigh tidal volume ventilation Sodium bicarbonate, inhaled Sodium bicarbonate, inhaled

bronchodilatorsbronchodilators Turning modalities, tilt and turn beds Turning modalities, tilt and turn beds InexsufflationInexsufflation CPT vestCPT vest Quad cough / assisted coughQuad cough / assisted cough IPPBIPPB Intermittent percussive ventilation/ IPVIntermittent percussive ventilation/ IPV

INFECTIONSINFECTIONS

Minimize (optimize) antibiotic use Minimize (optimize) antibiotic use Reduce antibiotic use to specific Reduce antibiotic use to specific

organism organism Hand washing, alcohol cleansers, Hand washing, alcohol cleansers,

isolation gowns, gloves, oral careisolation gowns, gloves, oral care The payoff- low incidence of C. difficile The payoff- low incidence of C. difficile

and ventilator associated pneumonias and ventilator associated pneumonias (VAP)(VAP)

LONG TERM ISSUESLONG TERM ISSUES

Identifying care providers prior to Identifying care providers prior to discharge, home and physician caredischarge, home and physician care

For trach and home ventilator patients, For trach and home ventilator patients, family training, the “what if”s of problem family training, the “what if”s of problem solving, the “AMBU is your friend” speechsolving, the “AMBU is your friend” speech

Sleep study evaluation Sleep study evaluation (polysomnography) if there is any (polysomnography) if there is any questionquestion

Appropriate vaccinationsAppropriate vaccinations

SHEPHERD DATASHEPHERD DATA

WEANING STATISTICSWEANING STATISTICS

2007, 2008 2007, 2008

Weaning at ShepherdWeaning at Shepherd

Total vents 83 95 Total vents 83 95 Home Home with vent 15(18%) 22(22%)with vent 15(18%) 22(22%)

C-1, C-2 3/7 3/12 -/27C-1, C-2 3/7 3/12 -/27 C-3 4/6 2/6 8/21C-3 4/6 2/6 8/21 C-4 22/25 22/27 C-4 22/25 22/27

23/2423/24

2007 2008 Compiled by Wendy Fritz, RRT

Weaned/total weaned/total 2007/2008 Avg #

days

Weaning at ShepherdWeaning at Shepherd 2007 20082007 2008

C-5 thru 7 22/25 24/26 16/13C-5 thru 7 22/25 24/26 16/13 T-1 thru 12 6/6 15/18 18/20T-1 thru 12 6/6 15/18 18/20 Rancho 1 thru 5 10/13 5/6 7/12Rancho 1 thru 5 10/13 5/6 7/12

Age of non-weans 2007: 77, 34, 61, 46, Age of non-weans 2007: 77, 34, 61, 46,

31, 35, 31, 19, 59, 58, 5231, 35, 31, 19, 59, 58, 52

Weaned/Total Weaned/Total Avg # days

2007/2008

OTHER MEDICAL ISSUESOTHER MEDICAL ISSUES

11/2/09

Hospital-acquired and Hospital-acquired and Ventilator-associated Ventilator-associated

Pneumonia Pneumonia 1, 21, 2

VAP makes up 1/3 of total nosocomial VAP makes up 1/3 of total nosocomial infections in the ICU- the most common infections in the ICU- the most common

10- 20% of pts ventilated >48hrs 10- 20% of pts ventilated >48hrs Mortality rate 10- 50%, a doubling of Mortality rate 10- 50%, a doubling of

mortality rate, depending on population mortality rate, depending on population and organismand organism

Length of stay increases a mean of 6.1 dLength of stay increases a mean of 6.1 d

1. Chest 2006; 130:597- 604

2. Am J Respir Crit Care Med 2005; 171:388- 416


Pneumonia Pneumonia Extra costs up to $40,000 per patientExtra costs up to $40,000 per patient Early onset HAP/VAP less than 4 days Early onset HAP/VAP less than 4 days

usually represents community usually represents community organisms, i.e., antibiotic sensitiveorganisms, i.e., antibiotic sensitive

Late onset HAP/VAP greater than 5 days Late onset HAP/VAP greater than 5 days usually composed of MDR organismsusually composed of MDR organisms

Health care related pneumonia- Health care related pneumonia- considered MDR unless otherwise considered MDR unless otherwise provenproven


Pneumonia Pneumonia The usual organisms to be considered The usual organisms to be considered

for empiric antibiotic: MRSA, for empiric antibiotic: MRSA, Pseudomonas, Acinetobactor, other Pseudomonas, Acinetobactor, other MDR organisms common to your MDR organisms common to your facility.facility.

Decide if criteria are met for Decide if criteria are met for pneumonia: blood cultures, tracheal pneumonia: blood cultures, tracheal aspirate culture, abnormal CXR, aspirate culture, abnormal CXR, worsening oxygenation, fever, elevated worsening oxygenation, fever, elevated WBC’s.WBC’s.


Pneumonia Pneumonia Tracheal cultures can include Tracheal cultures can include

endotracheal aspirate (10endotracheal aspirate (106 6 cfu’scfu’s), ), BAL sample (10BAL sample (1044-10-1055), blind mini-), blind mini-BAL(10BAL(1033), and protected brush(10), and protected brush(1033). ). This can include quantitative or semi-This can include quantitative or semi-quantitative colony counts.quantitative colony counts.

Surveillance cultures may not be Surveillance cultures may not be helpful for antibiotic choice.helpful for antibiotic choice.1,21,21. Am J Respir Crit Care Med 2002;165:41-46 35% correct

2. Chest 2005;127:589 83% correct

MODIFIABLE RISK FACTORS for MODIFIABLE RISK FACTORS for VAP VAP

Re-intubation; cuff pressure > 20cm; Re-intubation; cuff pressure > 20cm; possibly oral vs nasotracheal; possibly oral vs nasotracheal; subglottic suctioning; watching for subglottic suctioning; watching for condensate in vent circuits; oral carecondensate in vent circuits; oral care

Semirecumbent positioning 35-40Semirecumbent positioning 35-4000

Enteral feeding is probably better than Enteral feeding is probably better than parenteral nutrition.parenteral nutrition.

MODIFIABLE RISK FACTORS for MODIFIABLE RISK FACTORS for VAP VAP

Ulcer prophylaxis- The better the ulcer Ulcer prophylaxis- The better the ulcer prophylaxis (higher pH), the higher the risk prophylaxis (higher pH), the higher the risk of VAP. The best agent for both protection of VAP. The best agent for both protection is ____?is ____?

Blood transfusion may increase risk.Blood transfusion may increase risk. Tight glucose control may reduce risk.Tight glucose control may reduce risk. Sedation vacations and avoidance of Sedation vacations and avoidance of

paralytics may help.paralytics may help.


Pneumonia - Antibiotics Pneumonia - Antibiotics Know the common bacteria and best Know the common bacteria and best

pick pick empiric antibiotic choice. antibiotic choice. Simplify antibiotics when cultures Simplify antibiotics when cultures

return. Don’t continue gorillacillin if return. Don’t continue gorillacillin if you don’t need it.you don’t need it.

Most pneumonias will respond Most pneumonias will respond clinically in 5- 6 days; fever, WBC’s, clinically in 5- 6 days; fever, WBC’s, etc, but X-ray resolution is much etc, but X-ray resolution is much slower. Don’t use X-ray resolution as slower. Don’t use X-ray resolution as a criteria for stopping Ab’s a criteria for stopping Ab’s


Pneumonia - Antibiotics Pneumonia - Antibiotics Duration of antibiotics- Place stop Duration of antibiotics- Place stop

dates when starting drugs. It can be dates when starting drugs. It can be changed later if need be.changed later if need be.

Antibiotics for 7-8 days with clinical Antibiotics for 7-8 days with clinical response except Pseudomonas or response except Pseudomonas or Acinetobacter (~14d), or possibly Acinetobacter (~14d), or possibly MDR organismMDR organism

Prolonged antibiotics are Prolonged antibiotics are notnot associated with better outcomes but associated with better outcomes but are associated with complication.are associated with complication.

Clostridium Difficile-Clostridium Difficile-Associated Diarrhea (CDAD)Associated Diarrhea (CDAD)

CDAD – 6% incremental increase risk CDAD – 6% incremental increase risk of death among critically ill patients of death among critically ill patients 1

Probably does not increase mortality Probably does not increase mortality rate in pts with prolonged ventilation rate in pts with prolonged ventilation >96h>96h

Increased length ~ 6 days Increased length ~ 6 days 22

Total costs increased ~ $10,000 Total costs increased ~ $10,000 22

1 Chest 2007; 132: 418-24

2 Chest 2009; 136: 752- 8

11/2/09

DEEP VENOUS THROMBOSIS DEEP VENOUS THROMBOSIS PROPHYLAXIS PROPHYLAXIS

High risk group with 40 – 100% risk High risk group with 40 – 100% risk of occurrence of occurrence

Pulmonary embolism is the 3Pulmonary embolism is the 3rdrd leading cause of death in acute SCIleading cause of death in acute SCI

Increased risk with age, lower Increased risk with age, lower extremity fracture, complete injury, extremity fracture, complete injury, obesity, etcobesity, etc

DEEP VENOUS THROMBOSIS DEEP VENOUS THROMBOSIS PROPHYLAXIS* PROPHYLAXIS*

Low molecular wt heparin Low molecular wt heparin or or low low dose heparin dose heparin plusplus pneumatic pneumatic compression devicecompression device

Use intermittent pneumatic Use intermittent pneumatic compression and/or graduated compression and/or graduated compression stocking if risk of compression stocking if risk of bleeding is highbleeding is high

Do not use heparin aloneDo not use heparin alone*Antithrombotic and Thrombolytic Therapy. Chest 133(2008)#6

DEEP VENOUS THROMBOSIS DEEP VENOUS THROMBOSIS PROPHYLAXIS PROPHYLAXIS

Do not automatically use a vena Do not automatically use a vena cava filtercava filter

Continue LMWH or use coumadin, Continue LMWH or use coumadin, INR 2-3 during in-patient INR 2-3 during in-patient rehabilitation or three monthsrehabilitation or three months

DECUBITUS ULCERDECUBITUS ULCER(Forgive me, I’m a (Forgive me, I’m a

pulmonologist)pulmonologist) Significant morbidity- bed rest, Significant morbidity- bed rest,

DVT’s, depression, potential for DVT’s, depression, potential for surgery and surgical complications, surgery and surgical complications, infections including osteomyelitisinfections including osteomyelitis

Nutritional- protein lossNutritional- protein loss Expensive- estimated cost $50,000 – Expensive- estimated cost $50,000 –

70,000 per event*70,000 per event**J Rehab Research and Development 40;2003: 433-42

Thank you for your Thank you for your attentionattention

PULMONARY ISSUES IN SPINAL CORD INJURIES

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