Patofizjologia niewydolności oddechowej po urazach rdzenia kręgowego

*Aleksander Zeliaś

Summary
Patients who sustain spinal cord injury (SCI) with neurologic deficit may require a definitive airway with or without prolonged mechanical ventilation. The risk of pneumonia, and risk of death is significantly greater for patients with high injuries. In cases of cervical SCI, mortality reaches 20% and respiratory morbidity – 100%. Among the most common complications are atelectasis, pneumonia and pulmonary embolism.
Paralysis of respiratory muscles leads to hypoventilation, sputum retention and atelectasis resulting in respiratory insufficiency. Since the SCI is frequently associated with craniocerebral trauma, unconscious and uncooperative patients cannot actively cooperate and are especially prone to pulmonary complications.
High cervical SCI (C₁-C₃) is followed by complete paralysis of respiratory muscles and lifetime ventilator dependence. Diaphragmatic nerve stimulators may sometimes restore diaphragmatic function but the availability of this method is limited. In tetraplegic patients with diaphragm paralysis, respiratory movements are caused by contraction of the sternocleidomastoid and interscalene muscles which can raise the upper part of the chest wall only. Spastic paresis of the chest wall and abdominal muscles prevents retraction of the chest wall during inspiration
Medium cervical SCI (C₃-C₅) is followed by transient respiratory insufficiency; some patients being weaned from the ventilator after spinal cord oedema regression and restoration of respiratory muscle function. In cases of lower cervical SCI (C₆-C₈), diaphragmatic and inspiratory neck muscle function is preserved. Intercostal and abdominal muscles are paralyzed, making active expiration impossible. Respiratory complications after thoracic SCI are caused more by the associated chest trauma than by the paralysis of the respiratory muscles. Coughing is usually preserved in such cases.
Other respiratory complications include aspiration, bronchial hyperactivity and cardiogenic pulmonary oedema. In some tetraplegic patients, sleep apnoea may occur.
The majority of patients with SCI require intubation. In patients with CSCI above C₅ and complete quadriplegia, intubation should be offered routinely and early because delays may cause preventable morbidity.

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