Progressive resistive exercise in weaning high quadriplegics from the ventilator

Acutely high level quadriplegics may experience neuromuscular respiratory insufficiency secondary to loss of use of intercostal and abdominal muscles as well as partial involvement of the phrenic nerve. Frequently, these patients will require mechanical ventilation in the initial stages of their treatment. These patients may present difficulty with weaning off the ventilator. In addition, poor respiratory reserve increases the risk of episodic decompensation. We have instituted a progressive resistive exercise protocol (PRE) analogous to PRE commonly used in training skeletal muscle, to wean patients off the ventilator. This involves determining the patient's endurance to the development of fatigue while off the ventilator. Patients are re-evaluated weekly until they are weaned from the ventilator. Three case studies are reported in which this protocol was used. In addition to our standard respiratory therapy and physical therapy protocols, values for vital capacity and maximum inspiratory force at admission and post-weaning were recorded. After completion of the programme, none of the patients required re-intubation or subsequent mechanical ventilation. This method of diaphragm training may be useful in weaning high level quadriplegics from the ventilator.