Respiratory management of pediatric patients with spinal cord injuries: retrospective review of the duPont experience.

Pulmonary complications contribute to morbidity and mortality in spinal cord injuries (SCIs). A retrospective review of 20 years of experience with tracheostomy- and ventilator-dependent SCI children is presented. The authors developed and analyzed a database of 47 children (average age = 11.4 years). Of the patients, 27% had concomitant brain injuries, 6% had prior histories of reactive airway disease, and 2% had thoracic fractures. Injuries were caused by motor vehicle accidents (53%); gunshot wounds (19%); sports-related accidents (19%); and vascular injuries, transverse myelitis, or spinal tumors (8%). Of the injuries, 52% were high level (C1 to C2) and 48% were mid- or low level (C3 to C5). Two groups were analyzed for demographic information. Complications included tracheitis, atelectasis, and pneumonia. Mean tidal volume was 14 cm2/kg (maximum = 22 cm2/kg). Bedside lung function parameters were attempted to assess readiness and the rapidity of weans. T-piece sprints were used to successfully wean 63% of patients. Successfully weaned patients were compared with those not weaned. No deaths or readmissions for late-onset respiratory failure postwean occurred. The authors' clinical impression favors higher tidal volumes and aggressive bronchial hygiene to minimize pulmonary complications and enhance weaning. Successfully weaned patients had fewer complications. A critical pathway for respiratory management of SCI children is presented.

Recognition and management of respiratory dysfunction in children with tetraplegia.

Children less than 15 years of age comprise approximately 3% to 5% of all new spinal injuries each year. Approximately one third of these children sustain injuries to the cervical spine. Respiratory complications of spinal cord injuries at the level of C5 and above may include diaphragm dysfunction, retained airway secretions, recurrent aspiration, nocturnal hypoventilation, and respiratory failure. Although most newly injured children with cervical injuries above the level of C5 will require mechanical ventilation acutely, many eventually will be able to be weaned from technology. Despite their ability to breathe without mechanical support, these children often develop ongoing issues associated with respiratory compromise, which interfere with daily activities and can negatively affect quality of life. Poor endurance, failure to thrive, recurrent pneumonia, and sleep-disordered breathing all may be indications of significant respiratory dysfunction. This article describes assessment tools and management strategies aimed at supporting optimal health and preventing recurrent complications associated with unrecognized or untreated respiratory dysfunction.

Recognition and management of autonomic dysreflexia in pediatric spinal cord injury.

BACKGROUND: Autonomic dysreflexia (AD) is a well-documented complication of spinal cord injury (SCI) at or above the T6 level. However, research into AD has focused primarily on the adult. Because research that involves children with SCI is scarce, current guidelines may not be appropriate for children. Therefore, many episodes of AD may be unrecognized or inappropriately treated. To address this issue, Shriners Hospitals for Children undertook the development of a protocol specific to children and adolescents. METHOD: A task force was developed to look at current literature on AD and blood pressure in children. Utilizing this literature and consensus among the task force members, the tools necessary to treat children with SCI at risk for AD were developed. RESULTS: The task force developed several products intended to assist in the recognition and management of AD. These include an event flow sheet for recording incidents of AD, a letter for the child's school or primary care physician that provides a brief summary of AD and the child's baseline blood pressure, and a policy/protocol with 2 age-specific algorithms to standardize interventions across the 3 Shriners Hospitals in the United States with SCI programs (California, Illinois, and Pennsylvania). CONCLUSION: The Shriners Hospitals for Children Task Force on Autonomic Dysreflexia in Children with Spinal Cord Injury has developed several tools specific to children. However, many questions remain to be answered concerning blood pressure norms and the clinical presentation of AD in children.