Radha Korupolu, MD, MS, Agryrios Stampas, MD, and their research team have published a paper that challenges conventional wisdom about the safety and efficacy of using higher tidal volumes in patients with spinal cord injury on mechanical ventilation via tracheostomy. Dr. Korupolu, the lead author, is an assistant professor in the department of Physical Medicine and Rehabilitation at McGovern Medical School at UTHealth and an attending physician at TIRR Memorial Hermann. Dr. Stampas, also an assistant professor in the department, is clinical research director of TIRR Memorial Hermann’s Spinal Cord Injury Medical Program.
The article, “Comparing Outcomes of Mechanical Ventilation with High vs. Moderate Tidal Volumes in Tracheostomized Patients in the Acute Inpatient Rehabilitation Setting: A Retrospective Cohort Study,” was published in Spinal Cord,1 the official journal of the International Spinal Cord Society.
“When I came to TIRR for my fellowship, I noted that we were using high tidal volume for our patients with spinal cord injury, in contrast to what I observed while doing research at Johns Hopkins University,” Dr. Korupolu says. “For people with acute respiratory distress syndrome, lower tidal volumes protect the lungs and are recommended based on clinical trials. The argument for using higher tidal volumes in people with SCI who do not have acute respiratory distress syndrome (ARDS) is that their lungs are healthy, and higher tidal volumes expand the lower lungs.”
Physicians from all over the world have expressed interest in participating in a future clinical trial to promote the use of evidence-based practice and develop standardized guidelines. That's our next objective.
After reviewing the literature, Dr. Korupolu observed that even in people who don’t have ARDS, lower tidal volume ventilation showed better outcomes with lower rates of pneumonia and acute lung injury compared to those who received higher volumes.
Given the lack of robust evidence in people with SCI, Dr. Korupolu and Dr. Stampas re-examined the current protocol for determining optimal tidal volume in that population. After designing a study protocol and gaining institutional approval, they conducted a cohort study, examining data from 84 adults with SCI admitted to TIRR Memorial Hermann on mechanical ventilation. In 50 patients, they used moderate tidal volume; the remaining 34 received high tidal volume. They concluded that high tidal volume is associated with increased risk of pneumonia and higher odds of adverse pulmonary events in tracheostomized patients with SCI.
“This has changed the way we do things at TIRR,” Dr. Korupolu says. “We have decreased the tidal volume on patients with SCI who are hospitalized on ventilators. We examined our 2019 data a lower incidence of pneumonia during this time period accompanying the change in practice.” Dr. Korupolu presented the research team’s findings at the Academy of Spinal Cord Injury Professionals (ASCIP) virtual meeting in September 2020.
To study practice variation in the management of mechanical ventilation in people with SCI, she and Dr. Stampas, in collaboration with their colleagues and the respiratory therapy team at TIRR Memorial Hermann, conducted an international survey of health care providers who care for people with acute SCI on ventilation. Results from this survey suggest the need for evidence-based clinical guidelines for optimal ventilator settings for people with acute SCI who require mechanical ventilation. Dr. Korupolu is currently designing a randomized controlled trial in collaboration with Dr. Stampas and other staff at TIRR Memorial Hermann, including attending physicians Isaac Hernandez Jimenez, MD, and Matthew Davis, MD, and Darby Cruz, BSRT, RRT, respiratory therapy manager at the hospital, to further refine optimal ventilator settings to improve outcomes for people with spinal cord injury.
“Physicians from all over the world have expressed interest in participating in a future clinical trial to promote the use of evidence-based practice and develop standardized guidelines,” she says. “That’s our next objective.”
1Korupolu R, Stampas A, Uhlig-Reche H, Ciammaichella E, Mollett PJ, Achilike EC, Pedroza C. Comparing outcomes of mechanical ventilation with high vs. moderate tidal volumes in tracheostomized patients with spinal cord injury in acute inpatient rehabilitation setting: a retrospective cohort study. Spinal Cord. 2020. 9 July. https://doi.org/10.1038/s41393-020-0517-4.