1. Respiratory Weaning in Spinal injury patients
Dr Matthew Sames
Clinical lead intensive Mandeville Hospital
Buckinghamshire Hospitals NHS Trust May 2018

2. 11 National spinal injury centres
Belfast
Glasgow
Sheffield
Pinderfields Hospital Wakefield, Yorkshire
Southport
Middlesborough
Salisbury
Oswestry, Shropshire
Stanmore (RNOH)
Cardiff (Rookwood)
Stoke Mandeville Hospital NSIC
Southport have done a lot of work in home ventilation in SI patients.

3. Ventilated patients in the Spinal injury unit
The Key to all the spinal injury centres is the facility and surroundings for Rehabilitation.
At Stoke Mandeville we currently have a 12 bedded ICU usually >90% capacity (OPEL 3+) but the facility for 6-8 ventilated spinal injury patients on the NSIC wards.
No invasive monitoring, not 1:1or 1:2 ratio.
Building up ICU/NSIC staff interaction.
Currently 32 home ventilated patients & 7 in- patients. Respiratory scoring system for the ward.
Units have variable ability to ventilate – Salisbury ICU
RISCI guidelines
RISCI – Respiratory information
My understanding is that SMH NSIC is the largest respiratory weaning centre in the country.
There is much less networking than there should be.
Dr. Andrew Beechy in Sheffield. Dr. Fox at RNOH.
Currently we have a 4 bedded bay with 4 ventilated patients, fully ventilated at night, various times/duration breathing spontaneously during the day. This is staffed with 1 Nurse and 1 HCA.
2 ventilated patients in a side room (1 fully) with 2 non-ventilated patients, staffed with 1 nurse and 1 HCA.
1 ventilated patient in a 6 bedded bay with 5 non-ventilated patients …1 +1.
Salisbury do not have capacity for weaning outside of the ICU, therefore around 3 ventilated/weaning SI patients on their ICU.
I am not up to date with capacities of the other units…highly variable.
This year the trust has been continually at OPEL 3 meaning that one of the NSIC wards is permanently taking over by medicine.

4. Weaning in ICU - Protective Ventilation
Target 6mls/Kg predicted Body weight
Limit Vt range to maximal 8mls/Kg
Limit Plateau pressure to <30cm H20
Well known limitation of shearing forces to limit Baro-trauma.
Well known use of High PEEP to achieve & keep recruitment, rather than over- ventilation with increased Tidal Volumes....
However Acute Lung Injury .v. Denervated respiratory muscles in spinal injuries.

5. Issues with ventilated spinal injuries (1)
Often Polytrauma
High Spinal injury –associated acute lung injury
Loss of sympathetic function – High secretion load
Loss of sympathetic input – Spinal dysreflexia
Profound and continual Bradycardia unusual – rarely paced.
Acute injury associated with spinal cord oedema, resulting in ascending neurological level – MRI as well as CT. (1-3 levels).
Spinal dysreflexia – associated with autonomic dysfunction from stimulae of bladder or bowel causing excessive hypertension and associated bradycardia; headache and sweating being the common symptoms…only a problem usually with >T4 injury increases with higher lesions.
Oedema usually starts resolving within 1 month providing stable homeostasis. It might have longer duration, normal distribution 2SD, (recent C2 in ICU with 8 weeks medulla affect prior to secondary oedema and insult subsiding)

6. Issues with ventilated spinal injuries (2)
# Stabilization - need early input of spinal surgeon
level of injury >C5 loss of accessory muscles
Degree of diaphragmatic dysfunction. C1 –C4
Diaphragmatic wasting due to non use…the earliest use of spontaneous breathing time.
Diaphragmatic denervation – raised hemidiaphragm on CXR – U/S screening.
Loss of FRC
Basal atelectasis – estimation of preventative chronic PEEP requirements.
Additional OSA etc.
With denervation, there is clearly a cross over with other neuro-muscular conditions such as the muscular dystrophies.

7. NSIC (RISCI) criteria for Weaning high level SI patients
Review of CXR (stability) consideration of CT
Stable blood gases
EWS <4
No active Infection ↑Inflammatory markers/pyrexia
Manageable secretions
Stable ventilatory parameters
Cuffless ventilation
Entrainment <5l/min 02
PS<20cmH20 to achieve Vt 7-15mls/Kg.
This is deliberately non specific – individualised.
No set ICU Vt to determine outcome ?<250mls

8. Stable baseline ventilator weaning - PvfB
Progressive ventilator free breathing.
5,10,15,30,45 minutes every 48 hours as target.
Serial VC and EtCO2 weekly or 48 hours if <70% loss of functionality.
Cuff down ventilation – large leak, big Vt, difficult to measure Vt.
Over chronic timeframes, individual patients can develop amazing VC. C2 ASIA C with 1.6litres.
Success – as per other aspects of SC injury…
Glossopharyngeal swallowing – ‘Frog breathing’- rescue breaths – 5 minutes off a ventilator – to half hour off ventilator – to night time ventilation.

9. Thank you Ian Benson – senior physio NSIC
Paul Subong – Advanced nurse practitioner
Prof. Chinnay Rajan –NSIC associate specialist
Hannah Proctor – NSIC outreach lead.