November 03, 2023
3 min read
- Successful weaning occurred more often with low level injuries.
- Prior weaning attempts had failed for many patients.
- Weaning success was not linked to age, motor completeness or rehab injury reclassification.
HONOLULU — Patients with spinal cord injury often achieved ventilator weaning during rehabilitation, with greater success seen among those with low cervical spinal cord injuries, according to a poster presented at the CHEST Annual Meeting.
Patients with cervical spinal cord injuries often experience respiratory dysfunction, and this is a notable contributor to morbidity and mortality in the population, according to the abstract.
“A lot of these patients met these [weaning] milestones at day 45 in rehab [following a 2-week hospital stay],” Casey Fenger, MD, of the division of physical medicine and rehabilitation at University of Utah, told Healio. “Many patients did successfully wean off the ventilator and, for the most part, the ones who didn’t had high complete and high incomplete injuries. The biggest predictor was the level, so patients with lower cervical injuries are more likely to wean.”
Using records from the University of Utah rehabilitation department between 2015 and 2021, Brown and colleagues assessed 42 patients (mean age, 44 years; 79% men) with spinal cord injuries who needed mechanical ventilation via tracheostomy to analyze the odds for weaning off of ventilation.
A median 16 days (interquartile range [IQR], 13-25 days) passed between the injury and rehab admission for the total cohort, with a median length of stay of 64 days (IQR, 56-76 days). Intubation frequently occurred right after the patient’s injury (median, 0 days; IQR, 0-4 days), and the median amount of time that passed between intubation and tracheostomy was a week (IQR, 4-9 days).
Researchers grouped patients according to their injury levels: C4 spinal cord injury or higher plus complete motor impairment (n = 20), C4 injury or higher plus incomplete motor impairment (n = 5), C5 injury or below plus complete motor impairment (n = 14) and C5 injury or below plus incomplete motor impairment (n = 3).
Of the total cohort, decannulation occurred in 48% of patients.
When assessing discharges, researchers observed four different outcomes: discharged to a skilled nursing facility (45%), discharged home with home health (19%), discharged to a long-term acute facility (19%) and discharged home without home health (17%).
During the evaluation of odds ratios in ordinal logistic regression analysis, researchers found significant elevated odds (OR = 7.11; 95% CI, 1,79-28.25) for better weaning outcomes among those with low level injuries (C5 or below).
Notably, 15 patients from the total cohort had their injury reclassified when admitted into rehab, and this could be important considering that injury level predicts outcomes, Fenger told Healio.
“We saw quite a bit of reclassification of injury levels in both directions,” he said. “This is important for tailoring rehab, because if we're expecting someone to go home and wean, we're going to focus a lot of time on weaning. If not, then we might pull back on the vent weaning a little bit.”
In terms of discharge location, researchers observed decreased odds for home discharge as patients got older (OR per 10 years = 0.68; 95% CI, 0.5-0.94).
Notably, no link was found between weaning success and age, motor completeness and injury reclassification at rehab, according to researchers.
“One of the things we really want to do is use this to help us create our own weaning protocol going forward because, right now, we base everything off of how the patient's doing clinically to guide us rather than having a specific algorithm to follow,” Fenger told Healio. “Part of this is that we don’t know why some patients don’t meet these weaning milestones. If we have a protocol, we're hoping we can use that as a way to find where people are getting stuck in this process to overcome those barriers.”
The accident occurred as she was en route to her workplace when her scooty was struck by a car, pinning her beneath the vehicle and causing a spinal fracture along with the severing of her spinal cord.
The injuries were severe, including a collapsed left lung, necessitating a month-long stay in the ICU and reliance on a ventilator at a private hospital in Kochi. At that time, medical professionals offered a grim prognosis, suggesting she might be bedridden for life. Following a month in the ICU and on a ventilator, she was sent home with no improvement.
However, she remained resolute, stating, "In the deepest corner of my heart, I was not ready to give up."
Her journey towards recovery took a positive turn when she was referred to Dr KM Mathew, senior consultant in Physical Medicine & Rehabilitation at Aster Medcity, Kochi, who devised a comprehensive rehabilitation plan.
Tailored physiotherapy and occupational therapy sessions were specifically designed to address her unique challenges, encompassing chest physiotherapy, upper limb strengthening, activities of daily living (ADL) training, and effective bed positioning. The introduction of a bowel program, including stimulants, dietary adjustments, and manual evacuation, played a pivotal role in her holistic recovery.
Gradually, the patient began regaining sensation in her hands, enabling her to perform daily activities such as brushing and eating. She also achieved antigravity movements in her upper limbs, marking significant progress.
Dr Mathew said, "The patient's journey underscores the power of multidisciplinary care and patient-centric rehabilitation. Her recovery stands as a testament to our commitment to clinical excellence and our dedication to pushing the boundaries of what is achievable in spinal cord rehabilitation. This achievement is credited to the medical team, her supportive husband, and her family who unwaveringly stood by her side."