Respiratory Management Following Spinal Cord Injury - 22

RESPIRATORY MANAGEMENT FOLLOWING SPINAL CORD INJURY

Comella et al. (1992) reports that 50% of patients treated with botulinum toxin had new pharyngeal dysfunction by videofluoroscopic swallowing studies. The authors caution that muscle fibers can be adversely affected by medications, such as corticosteroids, lipid-lowering agents, colchicines, and L-tryptophan. Many of these medications are used frequently by people with tetraplegia; if there is dysphagia or aspiration and these medications are being used, consideration should be given to alternative treatment. 24. Prevent aspiration by involving all caregivers, including respiratory therapists, speech therapists, physical therapists, pharmacists, nurses, and physicians, in the care of the patient. Institute an alert system for patients with a high risk for aspiration. Position the patient properly. Ensure easy access to a nurse call light and alarm system. Have the patient sit when eating, if possible. Screen patients without a tracheostomy who have risk factors or signs and symptoms of dysphagia. If the patient is found to be aspirating and is on large ventilator tidal volumes, monitor the peak inspiratory pressure closely.
(Scientific evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Moderate)

notify the staff that this patient is susceptible to aspiration. Any of the above-mentioned staff members should be able to activate the alert, perhaps based on guidelines established by the institution or by a working group composed of members of the various disciplines. The alert could consist of a large and/or brightly colored sign on the front of the chart, a sign outside the patient’s door, or a sign over the patient’s bed. 25. Consider a tracheostomy for patients who are aspirating. If the patient has a tracheostomy and is aspirating, the tracheostomy cuff should only be deflated when the speech therapist—and possibly a nurse or respiratory therapist as well—is present. (All involved personnel should be expert in suctioning.) Monitor SPO2 as an early indicator of an aspiration impact.
(Scientific evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

Prevention of aspiration needs to be a paramount consideration in the tetraplegic patient. Respiratory therapists, speech therapists, physical therapists, pharmacists, nurses, and physicians all need to be cognizant of this risk. Positioning is important. It would be helpful if the patient could be positioned with the head down. However, most often this is not a possibility because, with the head down, the abdominal contents and diaphragm press on the lungs, thereby further compromising the breathing in a patient who is already suffering from compromised breathing. Also, these patients may have gastric atony; putting the head down may encourage reflux or vomiting. Whatever the position, it is imperative that patients have a mouth-operated alarm always within reach, so they can call for help if they reflux or vomit. The pharmacist needs to be vigilantly involved with all tetraplegic patients and should monitor them for medications that slow the gastrointestinal tract or cause nausea (e.g., narcotics). Consideration should be given to an alert system that can

If the patient is at risk of aspiration or is actually aspirating, swallowing must be monitored by a speech therapist. The patient needs to be monitored closely for aspiration pneumonia by watching clinical signs, such as increased sputum production, increased shortness of breath, and elevated temperature. Chest radiographs should be done when appropriate. For the patient who is found to be aspirating and does not have a tracheostomy, consideration can be given to performing a tracheostomy for easy access for suctioning of aspirated material. If the patient has a tracheostomy, the cuff on the tracheostomy tube should be left inflated to reduce the chance of significant amounts of material being aspirated. The cuff should only be deflated when the speech therapist is present. If the speech therapist is not trained in endotracheal suctioning, a nurse or respiratory therapist should be present at the time the cuff is deflated. It may also be helpful to insert the suction catheter prior to deflating the cuff and then to suction as the cuff is deflated. This will catch any material that has accumulated above the cuff that may fall into the lower trachea when the cuff is deflated. Patients who are aspirating must be monitored closely for ARDS (Acute Respiratory Distress Syndrome Network, 2000).

Respiratory Management Following Spinal Cord Injury

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