High-Level Spinal Cord Injury and the Failure of US Acute Rehabilitation: An Analysis and Commentary

Acute and long-term morbidity and mortality rates have not changed in the United States for people with high-level spinal cord injury in 40 yrs, neither has the conventional invasive respiratory management for these patients. This is despite a 2006 challenge to institutions for a paradigm shift to avoid or decannulate patients of tracheostomy tubes. Centers in Portugal, Japan, Mexico, and South Korea decannulate high-level patients to up to continuous noninvasive ventilatory support and use mechanical insufflation exsufflation, as we have done and reported since 1990, but there has been no such paradigm shift in US rehabilitation institutions. The quality of life and financial consequences of this are discussed. An example of decannulation of a relatively easy case, after failure to do so during 3 mos of acute rehabilitation, is presented to encourage institutions to begin to learn and apply noninvasive management before decannulating more severe patients with little to no ventilator free breathing ability.