Respiratory disease main cause of death in Spinal Cord Injury

A & P Refresher Acute phase –Respiratory Physio Techniques Weaning –Cardiovascular –Tracheostomies –Prognosis

68 patients >C5 88% needed intubating C5-C8 60% needed intubating Velmahos gc et al American surgeon 2003 Harop et al Journal of neurosurgery spine Patients Injuries C2-C8 107 required tracheostomies Respiratory compromise  Level of injury  Age  Premorbid resp. disease

MAG (myelin-associated glycoprotein), Omgp (oligodendrocyte myelin glycoprotein), KDI (synthetic: Lysine–Asparagine– Isoleucine ‘g-1 of Laminin Kainat Domain’), Nogo (Neurite outgrowth inhibitor), NgR (Nogo protein Receptor), the Rho signaling pathway (superfamily of ‘Rho-dopsin gene including neurotransmitter receptors‘), EphA4 (Ephrine), GFAP (Glial Fibrillary Acidic Protein), different subtypes of serotonergic and glutamatergic receptors, antigens, antibodies, immune modulators, adhesion molecules, scavengers, neurotrophic factors, enzymes, hormones, collagen scar inhibitors, remyelinating agents and neurogenetic/plasticity inducers Trauma ↓ Haemorrhage/Inflammatory mediators ↓ Oedema ↓ Ischaemia ↓ Oedema ↓ Ischaemia ↓ Oedema ↓ Ischaemia ↓ Pathophysiology

Cardiorespiratory physiology

Respiratory Afferents Intrapulmonary receptorsVagus Stretch/proprioreceptors ribs/intercostalsT1-T12 ClaviclesLow Cervical ChemoreceptorsCarotid body ChemoreceptorsBrainstem

Acute changes Damaged cord becomes unresponsive Flaccid, areflexic Lasts for 6 days to 6 weeks

Respiratory Can’t breath Can’t cough

LumbarUnable to cough100-70% Low thoracic  chest wall compliance  Vital capacity High thoracic  chest wall compliance30-50%  Vital capacity poor expansion. Basal collapse C5/C6Diaphragms, Scalenes, 20% C3/C4/C5Sternomastoid and partial diaphragm Above C3Sternomastoid only5-10% Acute VC1 Year VC % 40-50% 60-70%

Acute changes respiratory autonomic Bronchial hypersecretion Bronchial hyper-responsiveness

Not forgetting… Head injuries Chest wall trauma Pulmonary contusion Haemopneumothorax PE / Fat embolus

Acute Respiratory monitoring Lung functionFVC, PEFR, Speech, RR, Resp Pattern FVC> 1L FVC < 1L FVC= Tidal volume Pulse oximeter Blood gases Watch closely in an appropriate environment for several days

Acute Respiratory Treatment Oxygen A good physiotherapist !

Early Respiratory System Complications Atelectasis Hypersecretion Bronchospasm Pulmonary Oedema Pneumonia Chest Trauma Respiratory Failure Pulmonary Thromboembolism

Respiratory assessment FVC Observations - mode of ventilation, FiO 2, SaO 2, RR ABGs, CVS CXR Auscultation Cough?

Observation of breathing pattern Paradoxical breathing Unilateral breathing Abdominal breathing Respiratory rate Cough

Importance of FVC Around or less than 1L

Non Invasive Management? Regular FVC Chest physiotherapy Cough assist + manual techniques IPPB with the nurses Spinal stability? Nutrition? Don’t wait to intubate if it is inevitable…

Less than 500ml…

Intubation? The Neurological level of Injury and completeness of injury are the most important predictors of requirement for tracheostomy Early semi-elective intubation during the day by senior experienced staff is preferable to emergency intubation Care should be taken when considering extubation of high cervical cord injured patients following stabilisation surgery

Ventilation? Some evidence that higher inspiratory pressures reduce the effects of atelectasis Rather than a high PEEP PEEP aim for 5 cmH2O ETv around 500ml or 15-20ml/kg NICE Guideline 6-8ml/kg LPV

Secretion Management

Secretion management Carbocysteine N acetylcysteine nebs Saline nebs ? Bronchodilator nebs Hyoscine? Azithromycin / colistin nebs for colonisation Supraglottic suction tubes

Positioning: Supine vs Sitting FVC must test in supine In head tilt down increases by 6% Sat upright decreases by 14% Use of a binder helps in sitting Roll your patients… Combine therapy with nursing requirements

Aggressive Management of Atelectasis Expansion / loosening of secretions to reduce mucus plugging Use of ‘ sighs ’ within Mechanical Ventilation Four hourly bronchodilation, heated humidification & Mucolytics The Vest? Intrapulmonary Percussive Ventilation?

The Vest

Respiratory techniques Suctioning - unopposed vagal stimulation: atropine nearby Expiratory vibs / shakes / percussion The Cough Assist Machine? Assisted cough MHI Inspiratory Muscle Training VFB/Weaning

Insert expanding lung please! RIK!

Please Do… ASIA charting Refer to MASCIP guidelines for moving & handling Positioning and skin care Pressure care mattress Bowel routine: More MASCIP guidelines Limb care

Please Don’t… Sit patients up - yet Use a Tilt Table – yet Sit your patient on the edge of the bed – ever!

WEANING…

Ventilated spinal injured patients 15-20% Initially ventilated 98% Weanable 1% Nocturnal ventilation 1% Fully ventilator dependant = 8-12 patients/yr ~ 120 patients in UK

Weaning Based on little evidence but vast experience Prerequisites Good pulmonary compliance Low FiO2 requirement Awake and cooperative Some respiratory activity Committed team

Any respiratory activity? Testing Volume measurement Beware sensitive ITU Vents Modified brainstem death test

Progressive ventilator free breathing Measure Vital Capacity VCTime off Vent <250 mls5 Mins -500 mls15 Mins -750 mls30 Mins mls60 Mins Measure VC Post weaning >70% pre weaning Southport Spinal Injury Centre Weaning Increase duration and/ or frequency

Weaning Wait for spasticity Bronchodilators ?High TV Ventilation (>20 ml/Kg)? 1 Supine 1.The effect of tidal volumes on the time to wean persons with high tetraplegia from ventilators Peterson W. et al spinal cord (4):

Weaning Off vent requires PEEP/CPAP to reduce atalectasis Best option cuff  with speaking valve. Ditch the ITU vent Don’t reduce pressure support too far Try to stick to plan Aim for off all day, support at night

Speech essential Eating optional

How to wean BIPAP/ PS laryngeal function vs resp function Cuff down on vent VFB speaking valve VFB Cuff up VFB Cuff down speaking valve Downsized uncuffed tube Decannulate Fast weaners Slow weaners

How successful ? Southport spinal injuries unit 246 patients over 20 years 63% weaned 33% Ventilator dependant 4% Died

Post weaning Maintenance ‘ Maintain Range of Movements’ Manual hyperinflation IPPB Cough Assist/ Clearway Improve muscle strength Inspiratory muscle training

Cardiovascular Can’t squeeze Can’t speed up

Sympathetic Parasympathetic VasodilationVasoconstriction  T6 Balance point Hypotension, bradycardia, tendency to asystole

Acute changes cardiac Be careful….. Neurogenic pulmonary oedema Postural hypotension Vagal stimulation (tracheal suction) Pressure sores

Aim to maintain adequate perfusion Vale et al, Journal of neurosurgery aug 1997 Combined medical and surgical treatment after acute spinal cord injury: results of a prospective study To assess the merits of aggressive medical resuscitation and blood pressure management Hypotension Bradycardia (Pacemakers) How high? How long?

Other common problems… Nutrition and GI tract Renal function Temperature control Psycological DVT –30% incidence Documentation Pain

Chronic Changes Respiratory VC Improves Cough improves Secretions lessen Long term ? Sleep disordered breathing

Chronic Changes Cardiac Postural hypotension stays Vagal hypersensitivity fades Bradycardia remains

Chronic Changes Cardiac Autonomic dysreflexia Autonomic hyperreflexia Sympathetic discharge due to autonomic stimulus Peripheral and central vasoconstriction below injury level Compensatory vasodilatation above injury level Severe hypertension, headache, Bradycardia T6 and above Sweating above injury level Asystole, myocardial infarction, cerebral haemmorhage

Chronic Changes Cardiac Autonomic dysrefflexia Triggered by………. Bladder distension Bowel distension Minor infections Major infections Treat by……….. Remove cause Nifedipine GTN

Tracheostomy Surgical may be better than percutaneous –Safer if unstable spine –Anatomically accurate –Easier changes long term –Worse scar –Logistically difficult

Trachy Tubes Use what you are used to but… Avoid fenestrations

Trachy Tubes Definitely avoid

Trachy Tubes Definitely consider supraglottic suction tubes

Trachy Tubes If they need a tube long term

Trachy Tubes

Don’t dismiss

Speaking valves Are not all the same

When to decanulate No respiratory support required Secretion clearance guaranteed

National Spinal Cord Injury Statistical Centre, University of Alabama Hospitalised 1 year mortality 15%

Prognosis – Function C1-3, C4 Ventilator Assisted Communication Verbal Independence Powered chair Environmental Controls Full time carers

C5 Drink, wash groom with adaptions Hand control power chair, some self propel Full time carer