Topic of the Month - Respiratory Management

Topic of the Month: Respiratory Management For Persons Following A Spinal Cord Injury

As of May 2001, the National Spinal Cord Injury Database estimates approximately 11,000 individuals sustain a SCI per year. Of those individuals, 51.6% are diagnosed with a tetraplegia and 46.3% are diagnosed with a paraplegia. One of the leading causes of death in people with SCI is respiratory disease (20.4%). The SCI SIG had an open forum discussion on respiratory management post SCI. Several areas were discussed and will be summarized below.

Abdominal Binders

There is paucity of literature regarding the use of abdominal binders and their effectiveness for persons with SCI. The use of abdominal binders appears to be an area of controversy among clinicians. Some clinicians support the use of abdominal binders for all levels of injuries above the T12 level while others support the weaning of binders even for persons with complete cervical injuries. Some references in support of using abdominal binders are listed:

Boaventura, C.D., A.C. Gastaldi, et al. (2003). "Effect of an abdominal binder on the efficacy of respiratory muscles in seated and supine tetraplegic patients." Physiotherapy 89(5): 290-5. Upper spinal cord injury provokes a decrease in respiratory function of the denervated respiratory muscle. Abdominal binders have been reported as beneficial when used with tetraplegic patients with paralysis of the abdominal muscles. Ten patients with cervical cord injury (C4 to C7) were evaluated by measuring maximal inspiratory pressure, maximal expiratory pressure, and forced vital capacity with and without an abdominal binder in the supine and seated positions in random sequence with a "blind" examiner. Values of maximal inspiratory pressure (-57.25 +/-17.68 cm H20), maximal expiratory pressure (24.35 +/-7.28 cm H20) and forced vital capacity (2.35+/-0.62 litres) were lower than expected. Values of forced vital capacity were higher in the supine than in the seated position. Maximal expiratory pressure and forced vital capacity showed higher values in the seated position when the binder was used. We therefore conclude that an abdominal binder improves the efficacy of respiratory muscles in increasing maximal expiratory pressure and forced vital capacity when used by patients with tetraplegia in the seated position. Bottom line: testing pre/post conditions for patients with SCI with and without an abdominal binder would be a very easy clinical research project.

Bodin P, Fagevik Olsen M, Bake B, Kreuter M. Effects of abdominal binding on breathing patterns during breathing exercises in persons with tetraplegia. Spinal Cord. 2004. Looked at 20 patients with complete cervical injuries. Breathing patterns and static lung volumes were measured with and without abdominal binders. This study showed that with an AB, static lung volumes decreased and vital capacity increased, while breathing patterns changed only marginally. "Evidence supporting the general use of an AB to prevent respiratory complications by means of respiratory training is questionable. However, the interindividual variation in our results indicates that we cannot rule out that some patients may benefit..."

Goldman JM, Rose LS, Williams SJ, Silver JR, Denison DM. Effects of abdominal binders on breathing in tetraplegic patients. Thorax. 1986 Dec; 41 (12): 940-5. Findings suggest that binders assist in increasing VC in the more upright position (70 degrees on a tilt table and upright sitting).

Hoit, J. D., R.B. Banzett, et al. (1990). "Speech breathing in individuals with cervical spinal cord injury." Journal of Speech & Hearing Research 33(4): 798-807. Ten men with cervical spinal cord injury were studied using magnetometers to record surface motions of the chest wall during speech breathing. Individual speech breathing patterns reflected inspiratory and expiratory muscular sparing. Subjects compensated for expiratory muscle impairment by speaking at large lung volumes, presumably to take advantage of the higher recoil pressures available at those volumes. Similarly, subjects used larger lung volumes to increase loudness. Abnormal chest wall behavior was attributed in large part to loss of abdominal muscle function. Because of this, speech breathing in individuals with cervical spinal cord injury may be improved by the use of abdominal binders.

Kerk JK, Clifford PS, Snyder AC, Prieto TE, O'Hagan KP, Schot PK, Myklebust BM. Effect of an abdominal binder during wheelchair exercise. Med Sci Sports Exerc. 1995 Jun; 27(6): 913-9. The purpose of this study was to determine whether the use of an AB would affect O2 uptake, trunk ROM and duration of the stroke phase during wc propulsion. The binder did not appear to significantly affect the binder on any of the variables. These individuals were highly trained athletes. I wonder if the results would have been similar with untrained individuals.

Lin KH, Lai YL, Wu HD, Want TQ, Wang Y H. Effects of an abdominal binder and electrical stimulation on cough in patients with spinal cord injury. J Formos Med Assoc. 1998 Apr; 97(4): 292-5. Subjects included 12 complete paraplegics and 12 complete tetraplegics. They measured the PEFR during forceful expiration in a sitting position under different conditions: 1) voluntary coughing, 2) voluntary coughing with AB, 3) voluntary coughing with AB and e-stim applied to the abdominal wall. The results indicate that e-stim combined with an abdominal binder improves the cough ability in patients with cervical and thoracic injuries.

McCool, F.D., B. M. Pichurko, et al. (1986). "Changes in lung volume and rib cage configuration with abdominal binding in quadrplegia." J Appl Physiol 60(4): 11

Unpublished Data

Studied 12 patients with complete tetraplegia-levels C6-C7 and found that when wearing the abdominal binder the patients were able to propel a greater distance (significantly significant: p<. 01) than when not wearing the binder. The heart rate was much greater during propulsion without the binder than when wearing the binder, also although the number did not reach clinical significance (P=. 054). It appears the patient's do have and endurance advantage when wearing the abdominal binder.

A criticism of the research is often times there is no attention to posture or position. The use of a binder on a person seated in a kyphotic position may not be as effective. The clinician must consider acute injury versus chronic injury. There is not consensus with clinicians-this is in large part because the binder is often considered in the accessories that are needed early in rehabilitation and intended to be weaned from.

Another similar issue is the abdominal/trunk flexibility and duration of SCI. Adding a binder on an individual who has been injured many years and not using one who has a migration of the abdominal contents and decreased A-P dimension of the thoracic cage with diaphragmatic-flattening may not help, and may actually hinder respiration.

Therapeutic Intervention

It appears that many facilities us a fairly aggressive CPT program with postural drainage and assistive cough for secretion management for persons with higher levels of SCI. Some therapists have used an in-exsufflator and a "Vest" device (hi-frequency chest wall oscillation) to assist with secretion management. These devices have been helpful with mobilizing and removing retained secretions in patients with weak and ineffective coughs.

Exercises for the intact respiratory system are also valuable. Patients with neuromuscular impairments will be influenced by gravity and the change in length-tension relationships than "normals". Use pre/post measurements to assess improvements. Measures used should be sensitive to change for that patient doing that activity. In other words, if the goal is to increase time off the ventilator, measure things such as O2 saturation and respiratory rate in different postures to determine which posture is most successful. If the patient is independently breathing, and the goal is to work on increasing the efficiency of breathing, then O2 saturation would not be the best measurement choice, as it probably would not change. What would change is the oxygen cost of breathing. Oxygen consumption tests would be ideal but are usually too expensive and not readily available. The clinician, in this instance, may measure respiratory rate and/or chest wall excursion. In addition, functional measures such as the ability to talk and breathe (number of syllables/breath, fatigue with talking, how may sentences the patient can read and support) can be used. These measurements would be sensitive enough to reflect the desired outcome Some activities can include maintained audible tone-timed, table top soccer (with the "ball"is moved by blowing through straws), reading out loud something funny. Other therapist may use devices such as party blowers. For lower levels of injury the therapist can measure the ability to push a wheelchair for longer distances or faster, etc.

As described above, chest wall measurements can be used to measure the effectiveness of your interventions. One suggestion for chest wall measurement included measuring 3 landmarks:

3 rd rib (upper accessory muscles except the traps)
Xiphoid process (intercostals)
Half the distance from the xiphoid to the umbilicus (intercostals and diaphragm)
It was identified if the patient has a high respiratory rate and very shallow breaths, sometimes chest wall expansion cannot be obtained with accuracy. It's a motor skill, so it definitely helps to practice.

References provided included the following:

LaPier, T.K. (2002). "Chest wall expansion values in supine and standing across the adult lifespan." Physical and Occupational Therapy in Geriatrics 21(1): 65-81.

Massery, M.P., H.E. Dreyer, et al. (1997). "Chest wall excursion and tidal volume change during passive positioning in cervical spinal cord injury. (Abstract)." Cardiopulmonary Physical Therapy 8(4): 27.

Raichura, N., J. Entwisle, et al. (2001). "Breath-hold MRI in evaluating patients with pectus excavatum." British Journal of Radiology 74(884): 701-8.

Tucker, B. and S. Jenkins (1996). "The effect of breathing exercises with body positioning on regional lung ventilation." Australian Journal of Physiotherapy 42(3): 2127.

Resisted breathing

Clinicians have had some experience with equipment for the purpose of respiratory training:

DHD exerciser,
The Breather
Other "fun" toys from PDP products
Web sites for this equipment are as follows:

The Breather: Information: http://www.pnmedical.com

Ordering: http://www.betterairways.com/order.html

DHD Inspiratory Muscle Trainer: http://www.dhd.com/

Respiratory Toys: PDP Products http://www.pdppro.com