Non-Ventilator Support

1. 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).

2. 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).

3. 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.

4. 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).

5. 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).

6. 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 1996)
   • 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, 1997).
   • Oxybutynin chloride (Singas, et al 1999) and beta2-agonist can inhibit airway hyperreactivity in patients with cervical SCI (DeLuca, et al 1999).

7. Proper nutrition -- malnutrition can cause muscle weakness and increased susceptibility to infections. Hypercalcemia can cause muscle weakness and interfere with respiration.

8. 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 the electrodes.

9. 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).

10. Intercostal to phrenic nerve transfer with diaphragmatic pacing can liberate patients with high cervical SCI from long-term mechanical ventilation (Krieger & Krieger, 2000).