Moderator: Michael Richardson, MD, FACP Presenters: Toni Chiara, PhD, MHS, MSPT Charles J. Gutierrez, PhD, RRT, FAARC Jim Hunziker, MSN, ARNP
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1 Moderator: Michael Richardson, MD, FACP Presenters: Toni Chiara, PhD, MHS, MSPT Charles J. Gutierrez, PhD, RRT, FAARC Jim Hunziker, MSN, ARNP 1
2 CVP may be used with quad cough, or MI/E, with patient in Trendelenburg, NOT Fowler s position. Promotes cephalad mobilization of lung secretions. 15 Hz for 15 to 30 minutes. For Unilateral Pathology
3 Ventilator (Lung Expansion): Maintain patient on A/C or SIMV at Vt = 15 ml/kg IBW while maintaining PIP < 40 cm H20 and Pplat < 30 cm H20. Increase to Vt = 20 ml/kg during aerosol nebulization with SVN while maintaining PIP < 40 cm H20 and plat < 30 cm H20. Transition to Therapy Vent Protocol Prior to Discharge: Lap top ventilator via trach tube or mouthpiece.
4 Liters PREper minute POST cm H2O/L/sec n = Albuterol and Atrovent Unit Doses C3 C3 C3 C3 C3/4 C3/4 C3/4 C4 C4 C4 C4 C4 C4/5 C4/5 C4/5 C4/5 C5 C5/6 C5/6 C6/7 26% decrease P <
5 Performed with abdominal weights while on VT 1200 / SIMV 2 FiO2 21% / PSV 5 / PEEP 5 for 15 minutes BID. Patient maintains minimum spontaneous exhaled VT ~ 400 ml on PSV 5, while maintaining SpO2 94%, on FiO2 21%.
6 Off-Vent resistance training performed with inspiratory and expiratory resistance strength trainer Expiratory Indicator Incentive Spirometer Adjustable Spring-loaded Valves Mouthpiece
7 M = 87.7 SD = M = 87.7, SD = n = 12 Trendelenburg SBT Supine SBT M = 33.5 SD = minutes Significant difference, t(11) = 6.26, p =.0001
8
9 3 2.5 Not Weaned Weaned Number of Patients M = 87.7, SD = C3 C3 C4 C4 WEANING CONTINUUM n = 7 Mean age = 28 Diurnal Nocturnal BID PRN
10 Liberation from Ventilator Theophylline, Oxandrolone, Nerve Growth Factors, BDNF, etc. Diaphragmatic Pacing, Stem Cell Implantation, ERIGO, Functional Electrical Stimulation, etc. Daily Resistance and Endurance Training Daily Lung Expansion Protocol
11 Representative Case Study - Wounded Warrior C3 ASIA A - Nocturnal Mechanical Ventilation Projectile Injury
12
13 Laparoscopic Surgery
14 Mapping of Motor Points
15 Pacer Is Coupled - Programmed For 18 BPM
16
17 Whole olfactory mucosa implanted into SC tissue.
18 Adult Stem Cells & Olfactory Ensheathing Cells C3
19
20
21 Measure Baseline Cardiopulmonary Parameters In Supine Position On Marching Machine Cardiopulmonary Parameters BP HR PImax PEmax RSBI (f/vt) Volumetric Capnograph SpO2 MValv VCO2 Pressure Manometer
22 Cardiopulmonary Mean p Parameters PImax with Pacer Off cm H20 PImax with Pacer On cm H SpO2 with Pacer Off 92.5 % SpO2 with Pacer On 94.9 %.029 VCO2 with Pacer Off ml/min VCO2 with Pacer On ml/min.046
23 Adjunctive Therapy While Upright On Marching Machine Pneumatic Calf Splints To Maintain BP Biofeedback During March Session E-stim To Calf Muscles
24 Mvalv During 30-Minute Upright Marching Session Pacer Off and Pacer On Cardiopulmonary Parameters BP HR Pacer On - 2% decline Pacer Off - 25% decline RSBI (f/vt) SpO2 MValv VCO2 30-minute March
25 IRST ERST Cardiopulmonary Mean p Variables IRST Valve Pacer Off IRST Valve Pacer On cm H cm H20
26 Cardiopulmonary Variables April 2011 Olfactory Mucosal Autograft May 2011 Pacer ON Pacer OFF Sitting Sitting FVC (ml) 640 ml 510 ml PEF (L/s) 1.72 L/s 1.60 L/s October 2011 Pacer ON Pacer OFF Sitting Sitting FVC (ml) (+15%) 850 ml (+25%) 730 ml PEF (L/s) (+43%) 3.01 L/s (+43%) 2.81 L/s
27 Weight-supported walking
28 Application of Chest Cuirass Transition Toward Intensive Neurorespiratory Care Continues Starting 6-week trial of oral Theophylline to further enhance diaphragmatic function
29 Focused on the role of neurorespiratory care (lung expansion protocol) in: 1) mitigating atelectasis, mucus plugging and pneumonia, and 2) enhancing cardiopulmonary function in ventilator-dependent veterans striving to achieve liberation from mechanical ventilation. Proposed Intensive Neurorespiratory Rehabilitation as a nextgeneration clinical model for liberating ventilator-dependent wounded warriors with high cervical spinal cord injury.
30 James A. Haley Veterans Hospital Department Neurorespiratory Care Bilirakis Spinal Cord Injury Center / Polytrauma Program (128C) Bruce B. Downs Blvd Tampa, Florida Charles.Gutierrez@va.gov
31 If you would like to receive continuing education credit for this activity, please visit: 31
Moderator: Michael Richardson, MD, FACP Presenters: Toni Chiara, PhD, MHS, MSPT Charles J. Gutierrez, PhD, RRT, FAARC Jim Hunziker, MSN, ARNP
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