Article

Following repeated weaning failures in acute care services, spinal cord
injury (SCI) patients who require prolonged mechanical ventilation and
tracheostomy are discharged to their homes or skilled nursing facilities, with a
portable mechanical ventilator (MV) and/or tracheostomy tube (TT) with excess
risk of complications, high cost and low quality of life. We hypothesized that
many difficult-to-wean patients with cervical SCI can be successfully managed in
a rehabilitation clinic. The aim of our study was to develop a respiratory
rehabilitation, MV weaning and TT decannulation protocol and to evaluate the
effectiveness of this protocol in tetraplegic patients. METHODS: A
multidisciplinary and multifaceted protocol, including respiratory assessment and
management themes, was developed and performed based on the findings from other
studies in the literature. Tetraplegic patients with the diagnosis of
difficult-to-wean, who were admitted to the rehabilitation clinic after having
been discharged from the intensive care unit to their home with home-type MV
and/or TT, were included in this prospective observational study. RESULTS: The
respiratory rehabilitation protocol was applied to 35 tetraplegic patients (10
home-type MV and tracheostomy-dependent, and 25 tracheostomized patients) with
C1-C7 ASIA impairment scale grade A, B, and C injuries. Seven out of 10 patients
successfully weaned from MV and 30 of 35 patients were decannulated. Four
patients were referred for diaphragm pace stimulation and tracheal stenosis
surgery. The mean durations of MV weaning and decannulation were 37 and 31 days,
respectively. CONCLUSIONS: A multifaceted, multidisciplinary respiratory
management program can change the process of care used for difficult-to-wean
patients with SCI. Implications for rehabilitation Findings from this study
indicate the significance of a multidimensional evaluation of any reversible
factors for prolonged MV- and/or TT-dependent SCI patients. Thus, rehabilitation
specialists should take this into consideration and should provide the
appropriate amount of time to these patients. The proposed protocol of
respiratory rehabilitation for MV- and/or TT-dependent SCI patients shows
promising results in terms of changing the care used for these patients.
Successful implementation of a respiratory rehabilitation and weaning protocol is
dependent on careful planning and detailed communication between the
rehabilitation specialist and intensivist during the respiratory rehabilitation
process. Because many of the so-called difficult- or impossible-to-wean patients
were successfully weaned from MV and TT in the PMR clinic, the need for such an
outlet for countries without specialized centers is supported.

Langue : ANGLAIS