Intubation after cervical spinal cord injury: to be done selectively or routinely?

Patients with cervical spinal cord injuries (CSCIs) often develop acute respiratory failure and require intubation. It is unknown if intubation should be offered preemptively in all CSCI patients or selectively based on signs of acute respiratory failure. The purpose of this study was to evaluate the role of routine early intubation in CSCI patients. The medical records of 68 patients with CSCI were reviewed. Univariate and multivariate analyses were used to identify independent risk factors for the need of intubation. Statistical significance was considered at P < 0.05. Fifty patients (74%) required intubation and 27 (40%) developed pneumonia. Of patients with CSCI above C5, 87.5 per cent required intubation compared with 61 per cent of patients with CSCI at C5-C8 (P = 0.026). Similarly, of patients with complete quadriplegia, 90 per cent required intubation compared to 48.5 per cent of patients with incomplete quadriplegia or paraplegia (P < 0.001). Of 31 patients not presenting with overt signs of acute respiratory failure on admission, 13 (42%) decompensated later and were eventually intubated up to 53 hours after admission. Six of these 13 patients had emergent intubation due to acute desaturation and developed pulmonary complications associated with emergent intubation. There were 3 independent risk factors for the need of intubation: Injury Severity Score > 16, CSCI higher than C5, and complete quadriplegia. The combination of the 2 latter risk factors resulted in intubation in 21 of 22 patients (95%). The majority of patients with CSCI require intubation. In patients with CSCI above C5 and complete quadriplegia, intubation should be offered routinely and early because delays may cause preventable morbidity.