Can Paralyzed People Be Placed on a Ventilator?
Yes, paralyzed people can and often must be placed on mechanical ventilation, as paralysis—whether from spinal cord injury, neuromuscular disease, or pharmacologic agents—eliminates or severely impairs the ability to breathe spontaneously. Modern ventilators are specifically designed to deliver prescribed minute ventilation when patients are not breathing spontaneously 1.
Types of Paralysis Requiring Mechanical Ventilation
Spinal Cord Injury with Respiratory Muscle Paralysis
- High spinal cord injuries cause respiratory muscle paralysis that requires full ventilatory support 2
- Noninvasive ventilation (NIV) can provide continuous ventilatory support for inspiratory muscle paralysis in high SCI patients 2
- For patients with intact phrenic nerves, diaphragm pacing can provide full-time ventilatory support as an alternative to mechanical ventilation 3
Pharmacologic Paralysis (Neuromuscular Blockade)
- Paralysis via neuromuscular blockade in ICU patients absolutely requires mechanical ventilation 4
- In severe ARDS, a 48-hour administration of cisatracurium (pharmacologic paralysis) with controlled ventilation decreases mortality in the most hypoxemic patients 5
- Pharmacologically paralyzed patients can be successfully ventilated, though they require matching for minute ventilation requirements, airflow resistance, and compliance 1
Neurological Disease-Related Paralysis
- Patients with advanced neurological diseases causing respiratory insufficiency can be treated with ventilation therapy 1
- The decision to initiate invasive ventilation should be critically evaluated regarding medical prospects, potential for intensive long-term therapy, and patient wishes 1
Ventilator Requirements for Paralyzed Patients
Ventilators used for paralyzed patients must be able to accurately deliver a prescribed minute ventilation when patients are not breathing spontaneously 1. Key requirements include:
- Ability to oxygenate and ventilate patients with significant airflow obstruction or ARDS 1
- Function with low-flow oxygen and without high-pressure medical gas 1
- Sufficient alarms for apnea, circuit disconnect, low gas source, low battery, and high peak airway pressures 1
Ventilator Modes for Paralyzed Patients
- Timed or assist/control ventilation (ACV) mode is particularly important for paralyzed patients who may cease making spontaneous effort 1
- Patients with neuromuscular disease may require timed support as respiratory effort may be insufficient to trigger a breath 1
- Total ventilatory support techniques like pressure control may require neuromuscular blockade but may not provide eucapnic ventilation 4
Critical Considerations and Pitfalls
Severe Complications Requiring Ventilation
- Respiratory compromise may develop if botulinum toxin affects respiratory muscles, potentially requiring mechanical ventilation in severe cases 6
- Recovery from paralysis takes weeks to months and occurs after sprouting of new nerve terminals 6
One Ventilator Per Patient Rule
- Each paralyzed patient should have their own mechanical ventilator 1
- While research has shown pharmacologically paralyzed sheep with normal lungs can share a ventilator, this is not recommended for clinical practice 1
- Parameters like minute ventilation requirements, airflow resistance, and compliance vary during mechanical ventilation and may change over minutes 1
Long-Term Ventilation Considerations
- Home mechanical ventilation is an increasing treatment option for patients with chronic respiratory insufficiency 1
- Quality of life and happiness is significantly reduced in patients after one year of long-term ventilation survival 1
- Patients receiving home mechanical ventilation should receive routine outpatient palliative care 1
- The indication for continued long-term ventilation should be assessed individually and critically, considering prognosis and quality of life 1