PULMONARY PROBLEMS: TREATMENT AND PREVENTION:
- Abdominal binder (or corset) positioned over the
lower ribs to the iliac crests bilaterally. This improves
venous return, lung volumes, and vital and inspiratory capacities
by providing additional support to the abdomen, thereby raising
the diaphragm to a more functional resting position. The effects
of abdominal straps in patients with cervical injuries may
be too small to improve the efficacy of cough (Estenne,
et al 1998).
- Inspiration (simple breathing) exercises
expand the chest wall, exercise the inspiratory muscles, and
prevent atelectasis. The effectiveness of inspiration exercises
is improved with both incentive spirometry, which provides
useful feedback to patients which helps them visualize exercise
goals, and with graded resistance, which improves strength
and endurance. Resistance weights in the epigastric area provide
resistance to diaphragmatic excursion and exercises to increase
thoracic expansion and strengthen the intercostal musculature,
which maintain chest wall mobility. Strength training improves
the inspiratory function of the accessory muscles of respiration
and should be continued indefinitely in quadriplegics (Slack
& Shucart, 1994). Resistive inspiratory muscle
training can improve ventilatory function, respiratory endurance,
and the perceived difficulty of breathing in patients with
complete cervical SCI within one-half year of trauma (Liaw,
et al 2000). Respiratory muscle training tended to improve expiratory muscle strength, vital capacity and residual volume. Insufficient data were available to make conclusions concerning the effects on inspiratory muscle strength, respiratory muscle endurance, quality of life, exercise performance and respiratory complications (Van Houtte, et al 2006).
- Proper positioning in a wheelchair and elsewhere
(in quadriplegics, inspiratory capacity and tidal volume are
improved in the supine, rather than the upright position);
regular changes in position (Slack
& Shucart, 1994); and rest, when muscle mass is
marginal for daily breathing.
- Glossopharyngeal (frog) breathing,
in which air is taken into the mouth, trapped in the pharynx,
and then forced into the lungs, can improve vital capacity
and chest expansion, help clear secretions, and assist with
cough. It is an important adjunct for patients requiring full-time
ventilatory assistance, and can enable some patients to be
ventilator independent for minutes or hours (Viroslav,
et al 1996).
- Assisted cough can increase the force of the cough
and improve clearance of secretions which can cause atelectasis
and pneumonia. There are several methods for this technique:
hands are placed in the epigastric area and pressure is
applied in an upward fashion, or, hands are placed
laterally over the ribs and pressure is applied, or, a
manual resuscitator or IPPB (Intermittent Positive Pressure
Breathing) is used to first expand the lungs, followed by
the application of a forceful abdominal thrust with glottic
opening. The latter can increase flow by 190% and obviate
the need for suctioning inpatients with and without a tracheostomy
tube (Viroslav, et al 1996).
IPPB can also be used to deliver medication to patients with fatigue as a result of SCI (Sorenson & Shelledy, 2003).
- Medications to prevent and treat respiratory problems:
- Pneumococcal vaccine should be administered during
initial hospitalization to prevent pneumonia, which is
37 times more prevalent in individuals with SCI (Waites,
et al 1998).
- Aminophylline may improve diaphragmatic contractibility
and fatigue resistance
- Bronchodilators, including anticholinergic bronchodilator
agents such as ipratropium bromide (Almenoff,
et al 1995), can improve pulmonary function
- Recombinant human DNase (rhDNase) has been used to
successfully resolve atelectasis and concomitant respiratory
failure (Voelker, et al
- 4-Aminopyridine (4-AP) can improve pulmonary function
by increasing forced expiratory volume, forced vital capacity,
minimal inspiratory pressure, and maximal expiratory pressure
(Segal & Brunnemann,
- Oxybutynin chloride (Singas,
et al 1999) and beta2-agonist can inhibit airway
hyperreactivity in patients with cervical SCI (DeLuca,
et al 1999).
- Proper nutrition -- malnutrition can cause muscle
weakness and increased susceptibility to infections. Hypercalcemia
can cause muscle weakness and interfere with respiration.
- Neuromuscular stimulation
- Functional electrical stimulation (FES) can increase
maximal expiratory pressure which enhances cough, approximately
to the same extent as manual assistance (Linder,
1993; Jaeger, et al 1993).
- Mechanical insufflation-exsufflation (MIE) can produce
air flow and velocity that more approximates normal values
with less abdominal and intrathoracic pressure.
- Functional magnetic stimulation (FMS) of the expiratory
muscles produces significent expired pressures, volumes,
and flow rates when compared with voluntary maximum efforts
and is therefore an effective method to restore cough
in tetraplegic patients (Lin,
et al 1998; Lin, et al 2001).
- Neuromuscular electrical stimulation (NMES) over the pectoralis and abdominal muscles might improve cough capacity and pulmonary function in cervical spinal cord injury with tetraplegia. This improvement might last for 6 months and reduce pulmonary complications (Cheng, et al 2006).
- Daily phrenic nerve stimulation can prevent prolonged
inactivation of the diaphragm which can result in atrophy
(Ayas, et al 1999).
Phrenic nerve pacing involves stimulating the phrenic
nerve by surgically placing a stimulating electrode on
the phrenic nerve and attaching it to a radio frequency
receiver, also implanted subcutaneously and supplied by
an external transmitter. Stimulating the phrenic nerve
causes the diaphragm to contract in patients with lower
motor neurons of the phrenic nerve that are still intact,
following the spontaneous recovery phase. It may not,
therefore, be effective in patients with C3-5 injuries.
Advantages include improved cosmesis and lighter and more
comfortable equipment. Disadvantages include system failure,
phrenic nerve damage, and scarring and fibrosis around
- Invasive ventilation -- endotracheal intubation,
orotracheal intubation (Shatney,
et al 1995), and/or tracheostomy are used in acute
respiratory failure due to SCI or any cause. Consideration of early intubation and tracheostomy for patients with complete C-SCI, especially for those with levels of C5 and above, is recomended (Como, et al 2005). Percutaneous
tracheostomy can be safely performed in patients without cervical
spine clearance and neck extension (Mayberry,
et al 2000). The use of mechanical insufflation/exsufflation in tracheostomy subjects with upper spinal cord injuries (C1-C7), ASIA classification grade A and bronchial hyper secretion is shown to be an effective adjunct to manual respiratory kinesitherapy, since it makes it possible to achieve adequate bronco-pulmonary clearance, even removing thick, deep secretions and making it possible to insufflate any areas affected by atelectasis (Pillastrini, et al 2006).
Speech is possible with a tracheostomy,
by using a leak around the tube and timing speech with inspiration
(rather than expiration), one-way inhalation valves, or other
augmentive communication systems. However, ventilators support
natural voicing, can be less expensive, and avoid tracheostomy
and intubation complications, such as mucous plugging of the
tube, tracheomalacia, tracheal stenosis, and pulmonary infections.
Transferring SCI patients to noninvasive ventilation requires
the input of speech pathologists and respiratory therapists
(Viroslav, et al 1996).
Leak speech alone or with the addition of PEEP or a tracheostomy speech valve can facilitate functional communication for the ventilated patient, though PEEP and valve speech were found to be superior in the current study. (MacBean et al, 2009).
- Intercostal to phrenic nerve transfer with diaphragmatic
pacing can liberate patients with high cervical SCI from long-term
mechanical ventilation (Krieger
& Krieger, 2000).
- Normocapnic hyperpnoea training can improve respiratory muscle strenght and endurance and decrease frequency of respiratory complications (Van Houtte, et al, 2008).
The Pulmonary Problems site of the PoinTIS
Spinal Cord Medicine site of the SCI Manual for Providers is based on information
in Spinal Cord Injury: Medical Management and Rehabilitation, G.M. Yarkony,
ed., Gaithersburg, MD, Aspen Publishers, 1994, except for information where
other papers are cited.