Respiratory Management Following Spinal Cord Injury - 10

RESPIRATORY MANAGEMENT FOLLOWING SPINAL CORD INJURY

7. If the vital capacity shows a measurable decline, investigate pulmonary mechanics and ventilation with more specific tests.
(Scientific evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

The quickest and simplest way to follow the patient is to perform the vital capacity serially at the bedside. If the patient’s vital signs deteriorate, especially the heart rate and respiratory rate, or if the vital capacity declines, confirmatory measurement of peak expiratory flow rate, FEV1, and NIF may suggest that the patient is developing atelectasis or pneumonia and that a chest radiograph is indicated. A change in the chest radiograph may indicate that a change in the medical management of the respiratory problems is warranted. Deterioration of the patient’s vital capacity, peak expiratory flow rate, FEV1, or NIF may also indicate an ascending level of injury. Therefore, deterioration in respiratory status needs to be correlated with any ongoing changes in level of injury as well as with changes in the patient’s lung status. Whatever the reason, if the ventilatory status deteriorates significantly, the patient may need mechanical ventilation. (See Mechanical Ventilation on page 13.) Abdominal complications, such as distended bowel, can put pressure on the diaphragm and thus add to the problem of basal atelectasis. Therefore, abdominal complications need to be diagnosed and treated expeditiously. 8. Implement the following steps to clear the airway of secretions: Assisted coughing. Use of an in-exsufflator/exsufflator. IPPB “stretch.” Glossopharyngeal breathing. Deep breathing and coughing. Incentive spirometry. Chest physiotherapy.

The ability of the patient to clear secretions can be assessed in the physical examination. The patient can be asked to cough, and the forcefulness of the cough can be estimated. The movement of the chest and of the abdomen with deep breaths can also be observed. These signs can be used singly or in combination, and also together with medications. (See Medications on page 12.) 9. Determine the status of the movement of the diaphragm (right and left side) by performing a diaphragm fluoroscopy.
(Scientific evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

Patients with unilateral diaphragm paralysis may be more likely to develop atelectasis on the side of the paralysis of the diaphragm. Whether diaphragmatic paralysis is present can usually be inferred from the level of injury noted on radiological examinations of the cervical spine and from the neurological examination, which defines the level of sensation and paralysis of the extremities, neck, and chest muscles. However, there are some patients with unexpected bilateral or unilateral diaphragmatic paralysis. Respiratory complications may be treated whether the patient is on or off the ventilator. If a patient has intractable unilateral atelectasis, this is a good indication for performing fluoroscopy of the diaphragms. Also, if a patient is unable to wean from the ventilator, diaphragm fluoroscopy may indicate whether there is paralysis of one or both diaphragms. Basal atelectasis, if it is adjacent to the diaphragm, can obliterate the diaphragm radiographically, and movement of the diaphragms sometimes may not be detectable fluoroscopically. In this situation, the atelectasis may have to be radiographically cleared before adequate fluoroscopic evaluation can be performed. 10. Successful treatment of atelectasis or pneumonia requires reexpansion of the affected lung tissue. Various methods include: Deep breathing and voluntary coughing.

Intrapulmonary percussive ventilation. Assisted coughing techniques. Continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP). Bronchoscopy. Positioning (Trendelenburg or supine).
(Scientific evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

Insufflation—exsufflation treatment. IPPB “stretch.” Glossopharyngeal breathing. Incentive spirometry. Chest physiotherapy.

Respiratory Management Following Spinal Cord Injury

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