A 50 year old man is brought into the Emergency Department after acute flexion injury to the neck while surjing.  He is unable to move both arms or kgs and has a sensory level at C4·5.   He ls a heavy smoker with a history of chronic bronchitis.

(d) Five days later he is orally intubated and has a forced vital capacity of  200 mls.  His unstable cervical injury has been managed by tongs and traction. 
What will you do to facilitate weaning?
 

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College Answer

(d) A VC of 200ml if correctly measured suggests weaning such a patient will be a major problem. The question does not explain whether the cervical injury is  complete or incomplete and stable or unstable. This is central to this management. If the lesion is complete at C4.5 in this mature man with some degree of chronic lung disease, he is going to be very difficult to wean from tracheostomy and will require some degree of mechanical support.

If the lesion is incomplete then with time some recovery may be expected and the aim in the short term would be to maintain spontaneous respiration, prevent nosocomial infection etc.

As in (c). considering surgical stabilisation and tracheostomy are essential. Percutaneous forceps technique of ·tracheostomy with the neck stabilised in the neutral position is not contraindicated.

General weaning principles should also have been applied {eg. optimise nutrition, treat sepsis, optimise breathing circuit and ventilator, treat abdo distension and lung pathology).

Discussion

Strategy for weaning

  • Minimise sedation
  • Maximise postural assistance to respiration: sit in a chair if possible
  • Adequate sleep and nutrition
  • Respiratory physiotherapy
  • Optimise cardiac function; aim for dry fluid balance
  • Optimise respiratory function; manage pulmonary infections aggressively
  • Prevent VAP with post-jejunal feeding, oral hygiene and possibly selective digestive tract decontamination. Cease the regular PPIs.
  • Consider tracheostomy
  • Consider NAVA

Plan B

  • Consider the neccesity for long term ventilation at home
  • discuss this possibility with the family