2 RESPIRATORY MANAGEMENT FOLLOWING SPINAL CORD INJURY Intrapulmonary percussive ventilation. Continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP). Bronchoscopy. Positioning (Trendelenburg or supine). 9. Determine the status of the movement of the diaphragm (right and left side) by performing a diaphragm fluoroscopy. 10. Successful treatment of atelectasis or pneumonia requires reexpansion of the affected lung tissue. Various methods include: Deep breathing and voluntary coughing. Assisted coughing techniques. Insufflation—exsufflation treatment. IPPB “stretch.” Glossopharyngeal breathing. Incentive spirometry. Chest physiotherapy. 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. Surfactant, Positive-End Expiratory Pressure (PEEP), and Atelectasis 13. Recognize the role of surfactant in atelectasis, especially when the patient is on the ventilator. Complications of Short-Term and Long-Term Ventilation Atelectasis 14. Use a protocol for ventilation that guards against high ventilator peak inspiratory pressures. Consider the possibility of a “trapped” or deformed lung in individuals who have trouble weaning and have had a chest tube or chest surgery. Pneumonia 15. Employ active efforts to prevent pneumonia, atelectasis, and aspiration. Pulmonary Embolism and Pleural Effusion 16. Monitor ventilated patients closely for pulmonary embolism and pleural effusion. Long-Term Ventilation 17. Evaluate the need for long-term ventilation. Order equipment as soon as possible. If a ventilator is needed, recommend that patients also have a backup ventilator. Weaning from the Ventilator 18. Consider using progressive ventilator-free breathing (PVFB) over synchronized intermittent mandatory ventilation (SIMV). Mechanical Ventilation Indications for Mechanical Ventilation Respiratory Failure Intractable Atelectasis 11. If the patient needs mechanical ventilation, use a protocol that includes increasing ventilator tidal volumes to resolve or prevent atelectasis. 12. Set the ventilator so that the patient does not override the ventilator settings. PVFB Versus SIMV Partial Weaning Electrophrenic Respiration 19. For apneic patients, consider evaluation for electrophrenic respiration. 20. Consider the advantages of acute and long-term use of noninvasive ventilation over initial intubation and long-term tracheostomy if the treatment staff has the expertise and experience in the use of such devices.