Respiratory muscle training with spinal cord injury: impact on … 17... · ·...

EXPLORE THE WORLD. START WITHIN.EXPLORE THE WORLD. START WITHIN.

Respiratory muscle training with spinal cord

injury: impact on pulmonary and cardiovascular

function

Brittany Back. Karianna Huff, Mike Zylik

EXPLORE THE WORLD. START WITHIN.

Objectives

1. Discuss common pulmonary and cardiovascular symptoms and complications that arise in patients with an SCI

2. Identify differences in symptoms based on vertebral level of the SCI with explanation of the ASIA scale

3. Highlight appropriate intervention strategies to address cardiovascular and pulmonary complications


Prevalence

• Currently estimated that 243,000 to 347,000 people in the US have a spinal cord injury (SCI)5

–Around 12,000 new cases of SCI arise in the United States each year4

• Leading cause of mortality in patients with a SCI = Respiratory Dysfunction3,6,8

–Respiratory dysfunction causes high healthcare cost with a low quality of life for the patient2


Pulmonary and CV Symptoms

• About 2/3 of patients with acute SCI will experience atelectasis, pneumonia, and respiratory failure1,4,8

– Pneumonia accounts for about 50% of deaths8

• Symptoms depend on type of lesion and vertebrallevel– Common symptoms include1:

• Decreased vital capacity (VC)

• Ineffective coughing

• Autonomic dysfunction (bronchospasms and pulmonary edema)

• Increased productions of secretions






• According to Alabed et. al, pulmonary embolism

(PE) risk after an SCI (complete or incomplete)

is increased significantly during the first 3

months after the injury5

– Patients with a complete SCI (ASIA A) have a

slightly higher rate of incidence of PE


Diagnostic Tests

According to Galeiras et. al, the most important

markers that predict the need for intubation1:

1. Vertebral level of the injury

2. ASIA scale classification

3. Completeness of the injury


Diagnostic Tests

http://www.scientificspine.com/spine-scores/asia-classification.html

http://www.scientificspine.com/spine-scores/asia-classification.html


Diagnostic Tests

The ASIA

Impairment

Scale defines

the extent of

the SCI

http://slideplayer.com/slide/8184976/

http://slideplayer.com/slide/8184976/


Pulmonary Function Tests

• Digital spirometer can be used to assess

pulmonary function and can be used in the

clinic

https://en.wikipedia.org/wiki/Spirometer


Digital Spirometry

• Most common pulmonary function test

• Can be used in an outpatient or home health setting

• Assesses a patient’s volumes and flows as the patient

inhales and exhales into a measuring device

• Spirometric measures may also be a good predictor of

cough strength6

https://www.youtube.com/watch?v=yNDKD_xI684


Treatments

• A prompt multidisciplinary approach reduces

respiratory complications2

• PT interventions that may help reduce

respiratory complications and risk for infection:

– Exercise/mobilization

– Breathing maneuvers and re-training

– Airway clearance techniques/devices

– Suctioning


Treatment- exercise

http://www.dailytech.com/

Goals:

• Reduce risk of

DVT or PE5,6,7

• Minimize muscle

atrophy

• Maintain VC, ERV,

RV, FVC, FRC


Treatment- breathing re-training

• Breathing exercises to increase muscle

force/inspiratory capacity1,6

– Stacked breathing

– Inspiratory muscle training4,6

– Inspiratory hold technique

• VC is a predictor of overall pulmonary function

and should be preserved in order to avoid

assisted ventilation1


Treatment- airway clearing techniques

• Manual percussions or vibrations along with

postural drainage positioning6,8

• Positive expiratory pressure devices used for

secretion removal6,8

– Acapella

– Flutter

http://www.medicalsupplygroup.com/p-18092-

acapellareg-vibratory-pep-therapy-devices.aspx


Treatment- suctioning

• With a higher level SCI, patients may not be able

to produce an effective cough (especially if the

patient has an endotracheal tube)8

– 60% of VC required for a productive cough

– Tracheal and bronchoscopic suctioning to reduce

secretions would be beneficial for these patients6,8


Clinical Takeaways

• Patients with an SCI will have varying levels of

pulmonary and cardiovascular dysfunction

dependent upon level of injury and

completeness of lesion

• Multidisciplinary treatment is necessary to

preserve the highest quality of life possible for

these patients


Clinical Takeaways

• Ways to reduce pulmonary and CV complications and risk for infections:

– Mobilization (decreases risk for DVT and PE and helps maintain muscle mass)

– Breathing re-training (beneficial for hypoventilation, atelectasis, ineffective cough, uncoordinated breathing pattern, weak inspiratory mm)

– Airway clearance techniques and suctioning (to avoid infection)


References

1. Galeiras Vázquez R, Rascado Sedes P, Mourelo Fariña M, Montoto Marqués A, Ferreiro Velasco M. Respiratory management in the patient with spinal cord injury. Biomed Research International [serial online]. 2013;2013:168757. Available from: MEDLINE, Ipswich, MA. Accessed September 26, 2017.

2. Gundogdu I, Ozturk E, Umay E, Karaahmet O, Unlu E, Cakci A. Implementation of a respiratory rehabilitation protocol: weaning from the ventilator and tracheostomy in difficult-to-wean patients with spinal cord injury. Disability And Rehabilitation [serial online]. June 2017;39(12):1162-1170. Available from: MEDLINE, Ipswich, MA. Accessed September 26, 2017.

3. Jaiswal PB, Tester NJ, Davenport PW. Effect of acute intermittent hypoxia treatment on ventilatory load compensation and magnitude estimation of inspiratory resistive loads in an individual with chronic incomplete cervical spinal cord injury. The Journal of Spinal Cord Medicine. 2016;39(1):103-110. doi:10.1179/2045772314Y.0000000277.

4. Legg Ditterline B, Aslan S, Randall D, Harkema S, Castillo C, Ovechkin A. Effects of Respiratory Training on Heart Rate Variability and Baroreflex Sensitivity in Individuals with Chronic Spinal Cord Injury. Archives Of Physical Medicine And Rehabilitation [serial online]. August 9, 2017; Available from: MEDLINE, Ipswich, MA. Accessed September 26, 2017.

5. Alabed S, de Heredia L, Naidoo A, Belci M, Hughes R, Meagher T. Incidence of pulmonary embolism after the first 3 months of spinal cord injury. Spinal Cord [serial online]. November 2015;53(11):835-837. Available from: Academic Search Complete, Ipswich, MA. Accessed November 2, 2017.

6. Reid, WD. Physiotherapy secretion removal techniques in people with spinal cord injury: a systematic review. October 1, 2010. Journal of Spinal Cord Medicine. 33 (4): 353-370. Available from: PubMed Central. Accessed November 2, 2017.

7. Agarwal, N. K., and N. Mathur. “Deep Vein Thrombosis in Acute Spinal Cord Injury.” Spinal Cord, vol. 47, no. 10, Oct. 2009, pp. 769–772. Academic Search Complete, EBSCOhost, doi:10.1038/sc.2009.37. Accessed 10 Nov. 2017.

8. Berlly M, Shem K. Respiratory Management During the First Five Days After Spinal Cord Injury. The Journal of Spinal Cord Medicine. 2007;30(4):309-318.

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