RESPIRATORY REHABILITATION: BRONCHIAL HYGIENE

Bronchial Hygiene - To prevent respiratory complications and treat pulmonary infections, all SCI patients should maintain clear airways by using the manual cough, the self-manual cough, glossopharyngeal breathing, postural drainage, and suctioning.

  1. Manual Cough/Manual Ventilation
    • Manual Cough - To clear secretions and maintain good bronchial hygiene, patients with weak cough force, due to abdominal muscle weakness or paralysis, assume supine. The therapist or other helper places his/her hands over the patient's epigastric area, with the heel of one hand over the abdomen, between the umbilicus and 2 inches below the xiphoid process, and the other hand on top of the first hand, with the fingers spread apart and both hands interlocked. After the patient takes a deep breath, and as he/she attempts to cough, the helper pushes down and inward toward the head, compressing the abdomen quickly. Although supine is the most effective position, the manual cough can be done with the patient prone, sitting, or standing. Patients with high lesions and vital capacities less than 1000 cc supplement the cough with effective glossopharyngeal breathing (GPB) or inflate the lungs with a positive-pressure device, such as the manual ventilation bag, just before the cough.

    • Manual ventilation - To perform manual ventilation in an emergency, abdominal compressions similar to the manual cough are recommended for patients in most any position. However, placing the hands laterally on the rib cage, with one hand on either side of the lower half of the chest, pushing down, and releasing suddenly, using a normal breathing rate, is an alternative technique.

  2. Self-Manual Cough - Patients with full upper extremity function can lock the hands together across the epigastric area and push diagonally toward the head while attempting to cough, in either a supine or sitting position. Patients with C6 lesions can throw the arms across the epigastric area and fall forward while attempting to cough, in the sitting position, and can place a pillow in the lap to increase abdominal compression or use glossopharyngeal to improve cough force.

  3. Postural Drainage - Although standard postural drainage positions are used for most patients with paraplegia, patients with high lesions, or with weak and even "good" diaphragm strength, may not be able to tolerate positions that restrict the movement of the diaphragm or place the weight of the abdominal contents on the diaphragm, such as the Trendelenburg position and upright positions with angles greater than 30 degrees. Corsets may be needed in the upright position, and side lying to drain posterior segments of the upper lobes requires a 1/4th turn onto the chest with the arm over a pillow, placed so the diaphragm is not restricted. All patients with spinal instability must be carefully positioned, and chest auscultation should be performed to indicate the best position, based on the specific lobes that need to be drained.

  4. Suctioning - Suctioning is recommended, in addition to postural drainage:
    • For an excessive accumulation of mucous in the lungs, probably due to poor cough function
    • Before breathing reeducation or glossopharyngeal breathing (GPB) instruction to ensure clear airways
    • For acute tracheostomy patients who are very susceptible to infection during the first 8 weeks and therefore require sterile suctioning techniques
    • For chronic tracheostomy using clean techniques

    Patients with known bradycardia should be carefully monitored during suctioning, since suctioning may stimulate the vagus nerve and further decrease the heart rate. Adjunct prophylaxis with IPPB (intermittent positive pressure breathing) is recommended for patients who continue to retain secretions and/or develop atelectasis. Immediately following SCI, tracheal suctioning can cause a rapid fall in heart rate and cardiac arrest, if oxygen is not administered prior to these procedures.

The PoinTIS SCI Physical Therapy site of the SCI Manual for Providers is based on information in Spinal Cord Injury: Functional Rehabilitation, by M.F. Somers, Norwalk, CT, Appleton & Lange, 1992, and information in "Respiratory Rehabilitation of the Patient with a Spinal Cord Injury", by J.L. Wetzel, B.R. Lunsford, M.J. Peterson, and S.E. Alvarez, Chapter 28 in Cardiopulmonary Physical Therapy, S. Irwin and J.S. Tecklin, eds., St. Louis, Mosby, 1995, unless otherwise indicated.