Respiratory Management Following Spinal Cord Injury - 11

CLINICAL PRACTICE GUIDELINE

Intrapulmonary percussive ventilation (IPV). Continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP). Bronchoscopy with bronchial lavage. Positioning the patient in the supine or Trendelenburg position. Abdominal binder. Medications.
(Scientific evidence–III/IV; Grade of recommendation–C; Strength of panel opinion–Strong)

machine will go, but not exceeding 40cm of pressure (see Appendix A on page 31). Glossopharyngeal breathing can be used to help the patient obtain a deeper breath. Glossopharyngeal breathing is accomplished by “gulping” a rapid series of mouthfuls of air and forcing the air into the lungs, and then exhaling the accumulated air. It can be used to help with coughing, often along with assisted coughing. Montero et al. (1967) showed improvement from 35% predicted to 65% of predicted vital capacity after training in glossopharyngeal breathing and also improvements in maximum expiratory flow rate, maximum breathing capacity, and breath-holding time. Loudness of the voice also improved (Montero et al., 1967). Incentive spirometry is a technique that uses a simple bedside device allowing the patient to see how deep a breath is being taken. It is widely used with other patients as well, such as the ablebodied patient who is post-op. It is something that the tetraplegic patient’s family members can help with, thereby involving them in the daily care of their loved one. The concept is a good one, although there are no documented studies indicating efficacy in tetraplegic patients. Chest physiotherapy, along with positioning of the patient, is a logical form of therapy to prevent and treat respiratory complications. However, some patients may not be able to assume the head down position to facilitate drainage of the lower lobes because of the effect of gravity pulling their abdominal contents against their diaphragm, thereby further compromising their already limited ability to take a deep breath. Also, positioning of the patient with the head down may increase gastroesophageal reflux or emesis. Positioning is sometimes difficult for patients with halo-vest immobilization. There are no studies indicating the efficacy of chest physiotherapy and positioning in tetraplegic patients. Intrapulmonary percussive ventilation (IPV) can be done with the ventilator, and a similar concept can be used in the form of a “flutter valve” during nebulizer treatments. Patients report that secretions are loosened with these techniques; however, there are no reports that objectively document the efficacy of these procedures. CPAP and BiPAP can be used to rest the nonintubated patient and also to give the patient a deep breath to help with managing secretions. A facemask or a mouthpiece can be used. These techniques are used extensively in some institutions. CPAP and BiPAP may be useful in the short term

Deep breathing and voluntary coughing is a standard treatment for any patient in the postoperative state and for those with pneumonia, atelectasis, or bronchitis. There are no studies documenting effectiveness in people with tetraplegia. The vital capacity often improves with time after injury, which should help with lung inflation. Assisted coughing is used extensively. Its use is often associated with use of IPPB or insufflator treatments, but it can also be helpful with postural drainage or simply to clear secretions from the throat. Manually assisted coughing has been shown to result in a statistically significant increase in expiratory peak airflow (Jaeger et al., 1993; Kirby et al., 1966). No study shows that assisted coughing by itself results in a lower incidence of atelectasis or pneumonia. Insufflation—exsufflation treatment with a “coughalator” or an “in-exsufflator” machine has been used extensively. This machine delivers a deep breath and assists with exhalation by “sucking” the air out. It is often accompanied by “assisted coughing.” The object is to improve the rate of airflow on exhalation, thereby improving the clearance of mucus. The effectiveness of increasing the rate of airflow has been documented. The pressure for inspiration and the negative pressure on expiration can be set on the machine. Normally, pressures are set at a low level, perhaps 10cm H2O to start, and then increased to as high as 40cm as the individual becomes used to the sensation of the deep breath and the suction on exhalation (Bach, 1991; Bach and Alba, 1990a; Bach et al., 1998). IPPB “stretch” is similar to the in-exsufflation treatment described above. IPPB is administered, usually with a bronchodilator, starting at a level of pressure of 10–15cm and increasing the pressure as the treatment progresses to as high as the

Respiratory Management Following Spinal Cord Injury

Table of Contents for the Digital Edition of Respiratory Management Following Spinal Cord Injury