Respiratory Management Following Spinal Cord Injury - 12

RESPIRATORY MANAGEMENT FOLLOWING SPINAL CORD INJURY

to get the patient over the acute phase after injury and may keep some patients from needing intubation or a tracheostomy. Bronchoscopy can be useful in clearing the lungs of mucus that the patient cannot raise, even with the help of the above listed modalities. The bronchoscopy can be performed whether the patient is on or off the ventilator. It should be kept in mind that the bronchoscopy is used to clear the airway of secretions, not to inflate the lung (unless it is done with a method for inflating the lung through the bronchoscopy). Just clearing the lungs of the mucus will not be adequate treatment by itself. Other treatments must be instituted to inflate the lungs and prevent reaccumulation of secretions. Positioning the patient in the supine or Trendelenburg position improves ventilation. Forner et al. (1977) studied 20 patients with C4–8 tetraplegia and found that the mean value of the forced vital capacity was 300ml higher in the supine or Trendelenburg positions than in the sitting position. Linn et al. (2000) studied the vital capacities of patients when supine and when sitting. They found that most tetraplegic patients had increases in vital capacity and FEV1 when supine, compared to the erect position. Abdominal binders offer no pulmonary advantage for the typical patient with cervical spinal cord injury when positioned supine in bed. However, the observed 16–28% increment of vital capacity of tetraplegic patients when supine, compared to sitting, can be eliminated by wearing an abdominal binder (Estenne and DeTroyer, 1987; Fugl-Meyer, 1971). An abdominal binder acts to keep the abdominal contents from falling forward and exerts a traction effect on the diaphragm. Therefore, especially in the early phases of injury, it is helpful for the patient to wear a binder when sitting up in a chair. Some patients will regain some muscle tone in the abdomen and/or adapt to the problem in time after the injury; these patients can sometimes stop using the abdominal binder.

promote the production of surfactant and help diminish atelectasis. Studies have not assessed the long-term benefits of bronchodilator therapy in this population but do suggest that use may mimic the reduction in respiratory symptoms seen with airway hyperactivity in able-bodied patients. Spungen et al. (1993) and Almenoff et al. (1995) demonstrated that greater than 40% of nonacute dyspneic tetraplegics administered metaproterenol or ipratropium responded with an improvement in FEV1 of at least 12%. Although the use of ipratropium is recommended initially, it should be discontinued after stabilization since the anticholinergic effects may thicken secretions and diminish optimal respiratory capacity. There is also evidence in the literature that atropine blocks the release of surfactant from the type II alveolar cells. Because ipratropium is an atropine analogue, some experts believe that ipratropium should not be used in spinal cord injured patients, since the production of surfactant is essential for prevention and treatment of atelectasis. Cromolyn sodium. Cromolyn sodium is an inhaled anti-inflammatory agent that is used in asthma. Theoretically, since tetraplegic patients have bronchospasm and inflammation, it would be helpful in tetraplegia; however, there are no studies of cromolyn sodium in tetraplegia. Steroids. Other than in the setting of acute spinal cord injury and those with an asthmatic component of reactive airway disease, these agents should be reserved for short-term use in acute respiratory distress. Aged patients administered intravenous high-dose methylprednisolone in the acute setting post injury were noted to be more prone to develop atelectasis and pneumonia (Matsumoto et al., 2001). Antibiotics. Although pneumonia commonly occurs in the post-injury period and has a high mortality rate among pulmonary complications in SCI patients (DeVivo et al., 1989; Lanig and Peterson, 2000), in the absence of signs and symptoms of infection, the use of antibiotics for treatment of bacterial colonization will only foster the development of resistant organisms and is not recommended. When treatment is warranted and culture results are not yet available for optimal antibiotic selection, empiric therapy should be directed to cover nosocomial bacteria (Montgomerie, 1997). Anticoagulation. Current guidelines established by the Consortium for Spinal Cord Medicine call for prophylaxis with low molecular weight heparin or adjusted dose unfractionated heparin and should begin within 72 hours of injury. Treatment

Medications
Consider the following in a comprehensive medical management program. Bronchodilators. Long-acting and short-acting Beta agonists should be used concomitantly to reduce respiratory complications in tetraplegics and those with lower level lesions that are prone to respiratory complications. In addition to the direct benefits of bronchodilation, these agents

Respiratory Management Following Spinal Cord Injury

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