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Ventilation and weaning

When the spinal cord is damaged at the level of the neck (cervical vertebrae C0 to C7), then the muscles which support the upper body (including the arms, chest and abdomen) are usually affected.

To be able to breathe normally, the chest muscles (intercostal muscles) and the diaphragm need to contract and relax effectively and there is increasing difficulty often experienced in breathing the higher up the neck the spinal cord is damaged.

If the cord is injured completely at C4 or above, then most likely the person will require permanent assistance with their breathing. This means surgically inserting an opening in the neck to allow a tracheostomy tube to be put in place, which is then connected to a mechanical ventilator which then undertakes breathing for the person.

We are the largest admitting centre in the UK for those with long-term ventilator dependence following spinal cord injury – at any time up to 10 beds are available for those who require support with ventilation.

Over the past 20 years, we have developed an expertise in treating people with high-level tetraplegia who require continued ventilation, and developing support services to such a degree that it is the norm rather than the exception for most patients to return home rather than require institutional care.

Is it possible to manage respiration without mechanical ventilation?

For some patients where the C3-5 vertebrae remain undamaged, the phrenic nucleus is preserved and will remain excitable and surgical implantation to induce breathing by means of diaphragm pacing is possible.

The pacer consists of electrodes implanted onto the phrenic nerve, a radio receiver implanted in a subcutaneous pocket (usually in the chest) and an external transmitter which sends energy and stimulus information to the implant.

Such developments have enabled those who were previously ventilator-dependent to spend variable lengths of time free from ventilator support.

The centre has developed internationally-recognised expertise in such surgery for those with spinal cord injury and supports the largest number of such cases in Europe.

Pacing systems therefore provide ventilator free breathing for varying times throughout the day and/or night.

However, it must always be remembered that these systems are an alternative for breathing; they do not reverse the underlying neurological damage to the spinal cord.

For further information on phrenic nerve implantation, please contact 01704 704333.

Can people become independent from the ventilator?

When people first injure their spinal cord. they may experience other injuries.

In a car accident, for example, people may suffer abdominal or chest wall injuries and a decision may be reached to ventilate simply to allow the body time to recover with less stress. Weaning off the ventilator would therefore be expected once the person’s injuries have resolved.

There is also another group of people who may require ventilation temporarily following injury to the spinal cord.

It was noted above that those with C4 and above injuries would likely in many cases require permanent ventilation. However, those with lower cervical injuries (C5-C7), and high thoracic injuries (T1-T4) may also require ventilation due to the processes which the spinal cord undergoes after injury.

To reduce the effort people need to make to breathe, the treating clinician may feel it necessary to intervene with ventilatory support, in the first instance passing a tube into the windpipe under either general anaesthesia or local anaesthesia.

Depending upon the patient’s state of health the subsequent tracheostomy would be agreed with them or their next of kin, and as the underlying physical complications resolve, a process of gradually increasing time breathing independently again begins (weaning).

Rehabilitation and ventilator dependence

At any one time, there are between 7-10 people requiring ventilation, and the centre aims to return people home after their rehabilitation is complete.

The goals of the programme include medical stabilisation, weaning from the ventilator when possible, and training the patient and family in home-care techniques and health management.

It is not our intention that families should become full-time carers, rather that families know what to do in the event of any problems or should they choose to spend time alone without professional support.

Patient at home

Services in the ventilator programme include medical management; nursing care and teaching; respiratory care; physical, psychological, occupational, and speech therapy, patient and family counselling, case management, discharge planning and follow-up services.

At the time of discharge a doctor, case manager, nurse and/or respiratory therapist accompanies the patient and family to the home to ensure a smooth transition to community care.

The centre maintains a 24-hour telephone support service for patients, families and care staff to advise on any aspect of spinal injuries management as required.

For more information about the centre’s ventilation programme, please contact 01704 704348.