Medicina pulmonar y respiratoria

Respiratory Dysfunction in Spinal Cord Injury: Physiologic Changes and Clinically Relevant Therapeutic Applications

Abstract

Baydur A and Sassoon CSH

Spinal cord injury (SCI) can result in serious respiratory compromise, impaired cough ability and respiratory failure. Complications include atelectasis and pneumonia. Respiratory failure is the primary cause of morbidity and mortality in high cervical cord injuries. Various methods have been used to assist coughing in SCI, including manual and mechanical techniques. Physical therapists can apply certain exercises and maneuvers to augment tidal breathing and expiratory effort, such as respiratory muscle training. For patients with vital capacities <10 to 15 mL/ kg, noninvasive methods such as abdominal binding, the pneumobelt, and face mask-applied ventilators are used to maintain adequate respiration. Phrenic nerve and diaphragmatic pacing provide increased patient mobility, comfort and lower health care costs; breathing pacemakers have increased survival and improved quality of life in individuals with upper cervical cord and brain stem lesions. Tracheostomy should be used only for those patients that have severe bulbar impairment and cannot successfully use airway clearance methods. Even patients with tracheostomyassisted ventilation can be eventually weaned off respirators, provided they meet criteria for spontaneous breathing. Peak expiratory flows should exceed 160 L/m to assure expulsion of airway secretions and the negative inspiratory pressure should exceed -20 cm H2O (variables measured with the tube cuff inflated) before the patient is decannulated. Appropriate vaccinations should be provided for any individual with compromised respiratory function, particularly with regularly scheduled influenza and pneumococcal pneumonia vaccines. Management of the physically impaired patient can be a major challenge for family, leading to adverse physical and psychological consequences. Long-term management requires a multidisciplinary approach that includes respiratory, physical and occupational therapists, nutritionists, social workers, psychologists, and home health agencies, all of whom contribute to key aspects of maintaining optimum respiratory function. Life satisfaction is a major consideration in this group of individuals, but it may have a more positive outlook than one would think in someone with significant physical and psychological challenges.