C6 injury EXTUBATED!!

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curiousgeorge
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C6 injury EXTUBATED!!

Postby curiousgeorge » Sun Nov 13, 2016 2:19 pm

Our patient still has a c6 level. After about 2 weeks of ventilation on 21% O2 with cough assist and high PS I extubated her today. She did very well during the day on mouthpiece ventilation and required only occasional MIE. We will put her on mask ventilation for the night. I put her on PS 20 equivalent through the mouthpiece and AVAPS 18 bpm for the night. How would you recommend continuing to wean from ventilation? Decreasing pressure (the normal way) or allowing the patient to use the mouth piece less as she wishes?

She complained of a very dry mouth from the mouth piece, so I put a heater/humidifier into the circuit which seemed to help.

I have a couple of questions:

1) I found very little research on cough assist in the general ICU population. It seemed to help, but there seem to be almost no randomized trials or good outcome studies. Do you know why?

2) Most ventilation recommendations suggest the exact opposite of the cough assist approach. They recommend limiting peak pressure, using low TV and maintaining PEEP to try and maintain the FRC. The cough assist approach uses higher pressure, high TV and with the negative pressures can de-recruit the lung. Does this suggest to you that the cough assist approach should be limited only to patients who do not have inflammatory lung disease, or would you use cough assist widely?

3) If I can answer my own questions (!!) I would like to try using cough assist in all patients who are weaning, especially those whose cough seems ineffective. Would you suggest use in other acute populations?

(Asked by a physician)

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bachjr
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Re: C6 injury EXTUBATED!!

Postby bachjr » Sun Nov 13, 2016 2:22 pm

curiousgeorge wrote:Our patient still has a c6 level. After about 2 weeks of ventilation on 21% O2 with cough assist and high PS I extubated her today. She did very well during the day on mouthpiece ventilation and required only occasional MIE. We will put her on mask ventilation for the night. I put her on PS 20 equivalent through the mouthpiece and AVAPS 18 bpm for the night. How would you recommend continuing to wean from ventilation? Decreasing pressure (the normal way) or allowing the patient to use the mouth piece less as she wishes?

First, what is her vital capacity? You can get this by putting her on CPAP mode with zero pressure support when intubated, and now that she is extubated, with a portable spirometer. If over 250 ml, she is weanable to sleep noninvasive ventilatory support (NVS) and if over 700-1000 ml, she may be off all NVS soon. To wean, we simply discontinue the NVS until her O2 sat baseline decreases below 95% and/or she is dyspneic, then put her back on NVS for 30 minutes, then take her off again, etc., and let her use NVS for sleep. Remember, she must receive no supplemental O2.

With a c6 injury, the patient likely can simply use a modified device to assist with holding the mouthpiece. Daytime weaning should involve the patient taking breaths as needed via a mouthpiece on NVS. This should be combined with coughassist 3 times a day (15 breaths per session) to improve lung compliance or more frequently as needed to maintain oxygen saturation greater than 94% for airway secretions. Pressure support can be maintained as pressure assist/control of 18-20 cm H2O using an active ventilator circuit and non-vented (cover the holes) nasal or oral interface. Ultimately, need for nighttime ventilation depends on vital capacity and whether the patient is symptomatic in the morning (headaches, etc.) and on noctural CO2 and O2 saturation.

Recall that oxygen supplementation should avoided in patients without respiratory disease.


curiousgeorge wrote:She complained of a very dry mouth from the mouth piece, so I put a heater/humidifier into the circuit which seemed to help.

Correct!

curiousgeorge wrote:I have a couple of questions:

1) I found very little research on cough assist in the general ICU population. It seemed to help, but there seem to be almost no randomized trials or good outcome studies. Do you know why?

It is unethical to perform randomized trials on such patients. Airway secretions MUST be cleared and suctioning only clears the right mainstem bronchus. Still, there is one paper and I attached it.

curiousgeorge wrote:2) Most ventilation recommendations suggest the exact opposite of the cough assist approach. They recommend limiting peak pressure, using low TV and maintaining PEEP to try and maintain the FRC. The cough assist approach uses higher pressure, high TV and with the negative pressures can de-recruit the lung. Does this suggest to you that the cough assist approach should be limited only to patients who do not have inflammatory lung disease, or would you use cough assist widely?

Very good question! Actually, the pressures are 3 times less than those generated by normal coughing (200 vs. 60 cm H2O. Also, the pressures are not in the lungs. The goal is to rapidly expand the lungs and rapidly empty them, not to leave the machine connected for 30 seconds!!!

curiousgeorge wrote:3) If I can answer my own questions (!!) I would like to try using cough assist in all patients who are weaning, especially those whose cough seems ineffective. Would you suggest use in other acute populations?

I think that it is safe for all populations except, possibly, ARDS.

JB
John R. Bach MD
Medical Director, VentilaMed BreatheNVS
Medical Director, Center for Ventilator Management Alternatives
Professor of Physical Medicine and Rehabilitation, Professor of Neurology, Rutgers New Jersey Medical School

LassenLaw
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Re: C6 injury EXTUBATED!!

Postby LassenLaw » Thu Dec 15, 2016 8:59 pm

@bachjr thanks! That is a very good and complete explication .


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