• Consortium for Spinal Cord Medicine. Respiratory management following spinal cord injury: a clinical practice guideline for health-care professionals. Washington (DC): Paralyzed Veterans of America; 2005 Jan. 49 p. [123 references]

This is the current release of the guideline.

Rating schemes for the levels of scientific evidence (I, II, III, IV, V), grade of recommendation (A, B, C) and the strength of panel opinion (Low, Moderate, Strong) are defined at the end of the "Major Recommendations" field.

Initial Assessment of Acute Spinal Cord Injury (SCI)

1. Guide the initial management of people presenting with suspected or possible spinal cord injury in the field and in the emergency department using the American Heart Association and the American College of Surgeons' principles of basic life support, advanced cardiac life support, and advanced trauma life support.

   (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

2. Perform an initial history and physical exam to include the following:
   • Relevant past medical history
   • Prior history of lung disease
   • Current medications
   • Substance abuse
   • Neurologic impairment
   • Coexisting injuries

   (Scientific evidence-- NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

3. The initial laboratory assessment should include:
   • Arterial blood gases
   • Routine laboratory studies (complete blood count, chemistry panel, coagulation profile, cardiac enzyme profile, urinalysis, toxicology screen)
   • Chest x-ray
   • Electrocardiograph (EKG)

   Conduct periodic assessments of respiratory function to include:

   • Respiratory complaints
   • Physical examination of the respiratory system
   • Chest imaging as indicated
   • Continuous pulse oximetry
   • Performance of the respiratory muscles: vital capacity (VC) and maximal negative inspiratory pressure
   • Forced expiratory volume in 1 second (FEV₁) or peak cough flow
   • Neurological level and extent of impairment

   (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

4. Monitor oxygen saturation and end tidal carbon dioxide (CO₂) to measure the quality of gas exchange during the first several days after injury in correlation with patient expression of respiratory distress.

   (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Prevention and Treatment of Atelectasis and Pneumonia

5. Monitor indicators for development of atelectasis or infection, including:
   • Rising temperature
   • Change in respiratory rate
   • Shortness of breath
   • Increasing pulse rate
   • Increasing anxiety
   • Increased volume of secretions, frequency of suctioning, and tenacity of secretions
   • Declining vital capacity
   • Declining peak expiratory flow rate, especially during cough

   Note: If atelectasis or pneumonia is present on the chest x-ray, institute additional treatment and follow serial chest radiographs. If temperature, respiratory rate, vital capacity, or peak expiratory flow rate is trending in an adverse direction, obtain a chest radiograph.

   (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

6. Intubate the patient for the following reasons:
   • Intractable respiratory failure, especially if continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) or noninvasive ventilation has failed
   • Demonstrable aspiration or high risk for aspiration plus respiratory compromise

   (Scientific evidence--III; Grade of recommendation--C; Strength of panel opinion--Strong)

7. If the vital capacity shows a measurable decline, investigate pulmonary mechanics and ventilation with more specific tests.

   (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

8. Implement the following steps to clear the airway of secretions:
   • Assisted coughing
   • Use of an in-exsufflator/exsufflator
   • Intermittent positive pressure breathing (IPPB) "stretch"
   • Glossopharyngeal breathing
   • Deep breathing and coughing
   • Incentive spirometry
   • Chest physiotherapy
   • Intrapulmonary percussive ventilation
   • CPAP and bi-level positive airway pressure BiPAP
   • Bronchoscopy
   • Positioning (Trendelenburg or supine)

   (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

9. Determine the status of the movement of the diaphragm (right and left side) by performing a diaphragm fluoroscopy.

   (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

10. Successful treatment of atelectasis or pneumonia requires reexpansion of the affected lung tissue. Various methods include:
    • Deep breathing and voluntary coughing
    • Assisted coughing techniques
    • Insufflation-exsufflation treatment
    • IPPB "stretch"
    • Glossopharyngeal breathing
    • Incentive spirometry
    • Chest physiotherapy
    • Intrapulmonary percussive ventilation (IPV)
    • CPAP and BiPAP
    • Bronchoscopy with bronchial lavage
    • Positioning the patient in the supine or Trendelenburg position
    • Abdominal binder
    • Medications

    (Scientific evidence--III/IV; Grade of recommendation--C; Strength of panel opinion--Strong)

    Please refer to the original guideline document for a discussion of medications used in a comprehensive medical management program.

Mechanical Ventilation

Intractable Atelectasis

11. If the patient needs mechanical ventilation, use a protocol that includes increasing ventilator tidal volumes to resolve or prevent atelectasis.

    (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

12. Set the ventilator so that the patient does not override the ventilator settings.

    (Scientific evidence--III/V; Grade of recommendation--C; Strength of panel opinion--Strong)

Surfactant, Positive-End Expiratory Pressure (PEEP), and Atelectasis

13. Recognize the role of surfactant in atelectasis, especially when the patient is on the ventilator.

    (Scientific evidence--None; Grade of Recommendation—NA; Strength of panel opinion--Strong)

Complications of Short-Term and Long-Term Ventilation

Atelectasis

14. Use a protocol for ventilation that guards against high ventilator peak inspiratory pressures. Consider the possibility of a "trapped" or deformed lung in individuals who have trouble weaning and have had a chest tube or chest surgery.

    (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

Pneumonia

15. Employ active efforts to prevent pneumonia, atelectasis, and aspiration.

    (Scientific evidence--IV/V; Grade of recommendation--C; Strength of panel opinion--Strong)

Pulmonary Embolism and Pleural Effusion

16. Monitor ventilated patients closely for pulmonary embolism and pleural effusion.

    (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

Long-Term Ventilation

17. Evaluate the need for long-term ventilation.
    • Order equipment as soon as possible.
    • If a ventilator is needed, recommend that patients also have a backup ventilator.

    (Scientific evidence--III/V; Grade of recommendation--C; Strength of panel opinion--Strong)

Weaning from the Ventilator

18. Consider using progressive ventilator-free breathing (PVFB) over synchronized intermittent mandatory ventilation (SIMV).

    (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

Electrophrenic Respiration

19. For apneic patients, consider evaluation for electrophrenic respiration.

    (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

20. Consider the advantages of acute and long-term use of noninvasive ventilation over initial intubation and long-term tracheostomy if the treatment staff has the expertise and experience in the use of such devices.

    (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

Sleep-Disordered Breathing

21. Perform a polysomnographic evaluation for those patients with excessive daytime sleepiness or other symptoms of sleep-disordered breathing.

    (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

22. Prescribe positive airway pressure therapy if sleep disordered breathing is diagnosed.

    (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

Dysphagia and Aspiration

23. Evaluate the patient for the following risk factors:
    • Supine position
    • Spinal shock
    • Slowing of gastrointestinal tract
    • Gastric reflux
    • Inability to turn the head to spit out regurgitated material
    • Medications that slow gastrointestinal activity or cause nausea and vomiting
    • Recent anterior cervical spine surgery
    • Presence of a tracheostomy
    • Advanced age

    (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

24. Prevent aspiration by involving all caregivers, including respiratory therapists, speech therapists, physical therapists, pharmacists, nurses, and physicians, in the care of the patient.
    • Institute an alert system for patients with a high risk for aspiration.
    • Position the patient properly.
    • Ensure easy access to a nurse call light and alarm system.
    • Have the patient sit when eating, if possible.
    • Screen patients without a tracheostomy who have risk factors or signs and symptoms of dysphagia.
    • If the patient is found to be aspirating and is on large ventilator tidal volumes, monitor the peak inspiratory pressure closely.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Moderate)

25. Consider a tracheostomy for patients who are aspirating. If the patient has a tracheostomy and is aspirating, the tracheostomy cuff should only be deflated when the speech therapist--and possibly a nurse or respiratory therapist as well--is present. (All involved personnel should be expert in suctioning.) Monitor SPO₂ as an early indicator of an aspiration impact.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Psychosocial Assessment and Treatment

Adjustment to Ventilator-Dependent Tetraplegia

26. Consider the manner in which the individual is accommodating to the spinal cord injury, including the individual's post-injury psychological state.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Enhancement of Coping Skills and Wellness

27. Assist the patient and family in the development, enhancement, and use of coping skills and health promotion behaviors.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Affective Status

28. Monitor the patient's post-injury feeling states, specifically for the emergence of depression and anxiety.

    (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

Substance Abuse

29. Assess the patient for the presence of comorbid substance abuse beginning in the acute rehabilitation setting.

    (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

Pain

30. Assess the patient's level of pain, if any, and establish the type of pain to determine the most appropriate physical and psychological treatment modalities.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Secondary Mild Brain Injury

31. Assess for possible comorbid brain trauma as indicated by the clinical situation.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Decision-Making Capacity

32. Determine the individual's capacity to make decisions and give informed consent on medical-related issues by examining the following:
    • Organicity
    • Medications
    • Psychological reactions
    • Pre-morbid substance abuse
    • Pain

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Advance Directives

33. Discuss advance directives, specifically the living will and durable power for medical health care, with the competent patient or the patient's proxy to determine the validity of the documents post trauma.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Family Caregiving

34. As appropriate, assess and support family functioning.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Intimacy and Sexuality

35. Explore issues of intimacy and sexuality with the patient and other appropriate parties.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Establishment of an Effective Communication System

36. Assess the patient's ability to communicate, and ensure that all staff can effectively interact with the patient to determine his or her needs and concerns.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Education Program Development

37. Plan, design, implement, and evaluate an educational program to help individuals with SCI and their families and caregivers gain the knowledge and skills that will enable the individual to maintain respiratory health, prevent pulmonary complications, return home, and resume life in the community as fully as possible.

    (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

Discharge Planning

38. Working with the multidisciplinary rehabilitation team, the patient and his or her family develop a discharge plan to assist the individual with ventilator-dependent spinal cord injury in transitioning from the health-care facility to a less restrictive environment, preferably a home setting.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Home Modifications

39. Evaluate and then modify the home environment to accommodate the demands of wheelchair access and respiratory equipment.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Caregivers

40. Home health-care workers, family members, privately hired assistants, and others trained in personal care and respiratory management of the individual with spinal cord injury should provide care or be available to assist the patient 24 hours a day. Efficient care of the patient depends on careful charting by home caregivers and proper management of the home medical supply inventory.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Durable Medical Equipment

41. Prescribe the appropriate durable medical equipment for home use based on the evaluations of therapy staff and the patient. Consider emergency provisions (e.g., backup generator and alarms) and assistive technology as part of a safe and effective environment.

    (Scientific evidence--V; Grade of recommendation--C; Strength of panel opinion--Strong)

Transportation

42. Use a van equipped with a lift and tie downs or accessible public transportation to transport the person with ventilator-dependent spinal cord injury. The patient should be accompanied by an attendant trained in personal and respiratory care.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Finances

43. Evaluate thoroughly the patient's personal and financial resources and provide expert guidance in applying for benefits and coordinating assets to maximize all available resources.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Leisure

44. Explore and provide information on diversionary pursuits, leisure interests, local community resources, and adaptive recreational equipment.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Vocational Pursuits

45. Arrange a vocational evaluation to determine special aptitudes, interests, and physical abilities; factor in the need for transportation and attendant services.

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Transition Resources

46. Identify medical and other transition resources in the home community, including:
    • Local specialists
    • Respiratory services
    • Home supply and durable medical equipment
    • Vendors
    • Pharmacies
    • Home health-care services
    • Advocacy groups

    (Scientific evidence--NA; Grade of recommendation--NA; Strength of panel opinion--Strong)

Definitions:

Hierarchy of the Levels of Scientific Evidence

1. Large randomized trials with clear-cut results (and low risk of error)
2. Small randomized trials with uncertain results (and moderate to high risk of error)
3. Nonrandomized trials with concurrent or contemporaneous controls
4. Nonrandomized trials with historical controls
5. Case series with no controls

Categories of the Strength of Evidence Associated with the Recommendation (Grade of Recommendation)

1. The recommendation is supported by one or more level I studies.
2. The recommendation is supported by one or more level II studies.
3. The recommendation is supported by expert opinion one or more level III, IV, or V studies.

Levels of Panel Agreement with the Recommendations (Strength of Panel Opinion)

Low - Mean agreement score 1.0 to less than 2.33

Moderate - Mean agreement score 2.33 to less than 3.67

Strong - Mean agreement score 3.67 to 5.0

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

A list of references is provided in the original guideline document, which includes all sources used by the guideline development panel to support their recommendations. It provides the level of scientific evidence (I-V or NA) for each graded article.

• Consortium for Spinal Cord Medicine. Respiratory management following spinal cord injury: a clinical practice guideline for health-care professionals. Washington (DC): Paralyzed Veterans of America; 2005 Jan. 49 p. [123 references]

Not applicable: The guideline was not adapted from another source.

2005 Jan

Consortium for Spinal Cord Medicine - Private Nonprofit Organization

Consortium Member Organizations include: American Academy of Orthopedic Surgeons, American Academy of Physical Medicine and Rehabilitation, American Association of Neurological Surgeons, American Association of Spinal Cord Injury Nurses, American Association of Spinal Cord Injury Psychologists and Social Workers, American College of Emergency Physicians, American Congress of Rehabilitation Medicine, American Occupational Therapy Association, American Paraplegia Society, American Physical Therapy Association, American Psychological Association, American Spinal Injury Association, Association of Academic Physiatrists, Association of Rehabilitation Nurses, Christopher Reeve Paralysis Foundation, Congress of Neurological Surgeons, Insurance Rehabilitation Study Group, International Spinal Cord Society, Paralyzed Veterans of America, U.S. Department of Veterans Affairs, United Spinal Association

Paralyzed Veterans of America

Guideline Development Panel

Panel Members: Kenneth C. Parsons, MD (Panel Chair) (Physical Medicine and Rehabilitation) Institute for Rehabilitation Research, Houston, TX; Richard Buhrer, MN, RN, CRRN-A (SCI Nursing) VA Puget Sound Health Care System, Seattle, WA; Stephen P. Burns, MD (Physical Medicine and Rehabilitation) VA Puget Sound Health Care System, Seattle, WA; Lester Butt, PhD, ABPP (Psychology) Craig Hospital, Englewood, CO; Fina Jimenez, RN, Med (SCI Nursing) Vancouver Hospital and Health Sciences Center, Vancouver, BC, Canada; Steven Kirshblum, MD (Physical Medicine and Rehabilitation) Kessler Institute for Rehabilitation, West Orange, NJ; Douglas McCrory, MD (Evidence-based Methodology) Duke Evidence-based Practice Center, Duke University Medical Center, Durham, NC; W. Peter Peterson, MD (Ret.) (Pulmonary Disease and Internal Medicine) Denver, CO; Louis R. Saporito, BA, RRT (Respiratory Therapy) Wayne, NJ; Patricia Tracy, LCSW (Social Work) Craig Hospital, Englewood, CO

Not stated

This is the current release of the guideline.

A number of care protocols are available in the appendices to the original guideline document.

None available

This NGC summary was completed by ECRI on August 8, 2005. The information was verified by the guideline developer on August 18, 2005.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. This summary was copied and abstracted with permission from the Paralyzed Veterans of America (PVA).