RESPIRATORY COMPLICATIONS AFTER SCI
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1 SHEPHERD.ORG RESPIRATORY COMPLICATIONS AFTER SCI NORMA I RIVERA, RRT, RCP RESPIRATORY EDUCATOR SHEPHERD CENTER 2020 Peachtree Road, NW, Atlanta, GA
2 DISCLOSURE STATEMENT I have no relevant financial or nonfinancial relationships in the products or services described, reviewed, evaluated or compared in this presentation.
3 OBJECTIVES Discuss the effect of SCI on pulmonary physiology Describe two strategies to reduce complications associated with ventilator management in SCI population
4 INNERVATION OF THE RESPIRATORY NERVES
5 INTERNATIONAL STANDARDS FOR NEUROLOGICAL CLASSIFICATION OF SCI (ASIA) A = Complete: No motor or sensory function B = Incomplete: Sensory function is preserved below the level of injury ( but no motor function) C = Incomplete: Motor function is preserved below the level of injury; the majority of muscles below the level can have ROM with gravity eliminated D = Incomplete: Motor function is preserved below the level of injury; the majority of muscles below the level can have ROM against gravity E = Normal
6 FACTS AND RESPIRATORY CONCERNS CATASTROPHIC Number of respiratory complications during initial acute care hospitalization is a more important determinant of length of stay than the level of injury for cervical injuries Respiratory complications are the most prevalent source of morbidity and mortality after SCI (Pneumonia, PE, and Septicemia) Within 3-5 days after injury Pneumonia can set in % of high injury levels will develop atelectasis usually in the LLL
7 FACTS AND RESPIRATORY CONCERNS Most common levels of injury C 4 and C5 and T 11 and T12 Studies found that 51.1% of patients with T1 T6 develop respiratory complications vs.34.5 % of T7 to T12 Neurogenic Pulmonary Edema may occur due to systemic and pulmonary vasoconstriction which can cause left ventricular overload and reduce alveolar ventilation Bronchospasms seen in cervical injuries due to autonomic changes Hypersecretions of mucus increases within 1 hour after an injury caused by loss of sympathetic control
8 FACTS AND RESPIRATORY CONCERNS Effects of Chest Trauma (lung contusion, rib fractures, pneumo s, pleural effusions), MVA s account for 36.5% of SCI Pulmonary emboli / DVT Spinal Shock -à Bradycardia, Hypotension, Hypothermia Occurs minutes post traumatic SCI Unstable Cervical Injury -à Possible worsening of injury Gastric Distention associated with vomiting, aspiration, and decreased lung expansion Dysphagia Preexisting Pulmonary disease (COPD, Smoker, Neuromuscular, Chest wall abnormalities) Sleep Apnea / Obesity
9 RESPIRATORY ASSESSMENT 1. Vital Capacity = Volume measured on complete expiration after a deep inspiration (> 10 to 15 ml/kg body weight or normal 3 5 liters) 2. Negative inspiratory force = measures maximum inspiration pressure (> -20, normal > -60) 3. Arterial Blood Gas 4. Sputum Sample 5. Chest X-Ray 6. EKG 7. Injury Level / Predictable lung function 8. Progress notes from discharged facility
10 Can occur within 1 hour after injury ***HYPERSECRETIONS*** Secretions abnormal in amount and viscosity Imbalance between the sympathetic and parasympathetic systems Beating rate of airway cilia function decreased Mucus will block the inflow of air due to weak or no cough Bronchospasms due to narrowing of the airways Lung compliance is reduced due to airway closure Mucus plug Loss of surfactant due to state of atelectasis All of the above will make it difficult for the patient to breathe, fatigue sets in, and develops respiratory failure. Therefore, keep the lungs expanded and clear!
11 AGGRESSIVE PULMONARY TOILET 9. Switch to manual suctioning technique, avoid inline suction catheters 10. Do use the resuscitator bag and wetting agents (Normal Saline, Sodium Bicarbonate) lavages 11. Implement aggressive pulmonary toilet with assisted coughing techniques 12. If possible use Inexsufflator / Assist Cough Machine 13. Bronchoscopy
12 AGGRESSIVE PULMONARY TOILET
13 CONTRA-INDICATIONS for INEXSUFFLATION ABSOLUTE CONTRA-INDICATIONS Hemoptysis Untreated or recent Pneumothorax Bullous Emphysema Severe COPD Recent Lobectomy Increased intra cranial pressure including ventricular drains Non artificial airway patient with impaired consciousness / inability to communicate RELATIVE CONTRA-INDICATIONS Tachypnea Large Pleural Effusion Unclear cervical spinal injury Hemodynamic instability
14 Tracheostomy tube MECHANICAL VENTILATION Mode of Ventilation / CPAP + PRESSURE SUPPORT Need high volume ventilation between ml/kg 1. Prevents and treats atelectasis 2. Avoids air hunger 3. Compensates for tracheal cuff leaks, monitor cuff pressures (<20cm) Keep peak airway pressures < 35 cm H2O Low PEEP
15 VENTILATOR WEANING / SPONTANEOUS BREATHING TRAILS - CPAP/PS Spontaneous Tidal Volume > 5 ml / kg (70 kg (154 lbs.) X 5 = TV 350) Spontaneous Vital Capacity > 8 ml / kg (70 kg X 8 = VC 560) Minute Ventilation < 10 L / min or 2X normal ( TV 350 X RR/12 = 4.200) Spontaneous Respiratory Rate < 30 Rapid shallow breathing index < 100 ( RR 12 divide by TV 350 = 34 ) RSBI is the ratio of respiratory rate to tidal volume (f/vt). People on a ventilator who cannot tolerate independent breathing tend to breathe rapidly (high frequency) and shallowly (low tidal volume), and will therefore have a high RSBI CROP index > 13 (Compliance, Rate, Oxygenation, Pressure)
16 CHALLENGERS OF VENTILATOR WEANING Hemodynamically unstable Septic ***Hypersecretion levels *** Depression / Anxiety / Family dynamics Pain / Sedation Airway injury / Artificial airway complications / Aspiration Acquired Brain Injury (inability to follow commands) Sleep Apnea
17 Capnography MAINTAINING VENTILATOR WEANING Sputum monitoring Use intrapulmonary vibrating devices ( Vest, MetNeb, IPV, Flutter Valve ) Bronchodilators Positioning and turning Encourage fluid intake and eating Incentive Spirometer use Education
18 TEAMWORK
19 VENTILATOR DEPENDENT AND HARD TO WEAN PATIENTS NeuRX Diaphragm Pacing System Synapse Biomedical Inc.
20 References Paralyzed Veterans of America Consortium for Spinal Cord Medicine Clinical Practice Guidelines Respiratory Management following Spinal Cord Injury: A clinical Practice Guideline for Health-Care Professionals; January 2005: 5-25 Zadoff A. Pulmonary Issues in Spinal Cord Injuries. Tri State Medical Conference Medical Conference of Thoracic and Pulmonary Healthcare Professionals Mechanical Ventilation and Weaning Protocols Web site. Published February 16, 2016 Lehman, C. Traumatic Injuries: Traumatic Brain Injury and Spinal Cord Injury The Specialty Practice of REHABILITATION NURSING. 7 th ed.; 2015:
Pulmonary Rehabilitation in Acute Spinal Cord Injury. Jatuporn Jatutawanit Physical therapist, Physical therapy unit, Prince of songkla university
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