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Respiratory Treatment of the Adult Patient

with Spinal Cord Injury

SUSAN ENRIQUEZ ALVAREZ, BS,


MARGERY PETERSON, MS,
and BRENDA RAE LUNSFORD, MS

The respiratory program of the Spinal Injury Service at Rancho Los Amigos
Hospital has demonstrated effective respiratory treatment to be a prerequisite
for comprehensive rehabilitation. To facilitate program planning, patients are
classified according to functional neurosegmental levels and residual respiratory
muscles. Breathing mechanics are the basis of evaluation and treatment. Eval-
uative elements are strength of residual respiratory muscles, respiratory rate,
vital capacity, breathing pattern, chest expansion, and cough. Respiratory func-
tions of patients with spinal injury are compared with respiratory functions of
healthy subjects. Treatment objectives are prepared according to the individual
patient's functional classification and evaluation. Specific methods are dis-
cussed, including strengthening, chest wall mobilization, external support de-
vices, and bronchial hygiene.

Key Words: Spinal cord injuries, Breathing exercises, Respiratory therapy, Physical
therapy.

Rehabilitation of patients with paralytic respiratory culature and mechanics of breathing in patients with
involvement has had two historical phases. The first spinal injury. A functional respiratory classification
phase was a consequence of the paralytic sequelae of has been developed to represent neurologic levels of
poliomyelitis. During the polio epidemic, patients injury and the associated respiratory muscle pattern
were cared for in hospital centers in large metropoli- (Fig. 1). The major emphasis of physical therapy is
tan areas of the country. Massive efforts by many for the patients in Classes II through V. Class I
professionals engaged in the care of these patients patients are totally respirator dependent and Class VI
resulted in enormous clinical expertise. Thus we have patients have all respiratory muscles intact. However,
a legacy of evaluation and treatment techniques, patients in Class VI may have abnormal vital capac-
many of which can be used appropriately for patients ities secondary to pelvic floor muscle involvement.2, 3
with spinal cord injury. The second historical phase Great emphasis must be placed on the respiratory
in the development of rehabilitation of patients with care of patients with injury to cervical or high thoracic
paralytic respiratory involvement began in the early
1970s with the establishment of regional spinal cord
injury centers: patients with paralytic respiratory RANCHO LOS AMIGOS HOSPITAL
FUNCTIONAL RESPIRATORY CLASSIFICATION
problems are again receiving treatment in selected
centers across the country. The current treatment CLASS INSPIRATION EXPIRATION
approach combines the expertise learned in polio- DIAPHRAGM INTERCOSTALS NECK ABDOMINALS

myelitis rehabilitation with the experience gained in 0 0 0 0


treating large numbers of patients with spinal cord
I C2
II C4 +/- 0 + 0
injuries.1
III C6 + 0 + 0
Before discussing evaluation and treatment tech- +
IV T4 + +/- 0
niques, we will review the primary respiratory mus-
V + + + +/-
Mrs. Alvarez is Supervisor I, Spinal Injury Service, Department VI TT 10
12 + + + +
of Physical Therapy, Rancho Los Amigos Hospital, 7601 E Imperial
Hwy, Downey, CA 90242 (USA). MUSCLE KEY: 0 = ABSENT, - = WEAK, + = N O R M A L

Mrs. Peterson is Physical Therapy Instructor, Spinal Injury Ser-


vice, Department of Physical Therapy, Rancho Los Amigos Hospital,
Downey, CA. Fig. 1. Chart of functional respiratory classification
Mrs. Lunsford is Supervisor II, Spinal Injury Service, Department showing neurological levels of injury and associated res-
of Physical Therapy, Rancho Los Amigos Hospital, Downey, CA. piratory muscle pattern.

Volume 61 / Number 12, December 1981 1737


the abdominal contents and intra-abdominal pressure
increases.
The external intercostal muscles, innervated by the
intercostal nerves,7 elevate the ribs during quiet in-
spiration by their oblique attachment from the distal
border of one rib to the proximal border of the rib
below. The contraction of the external intercostal
muscles causes an increase in lateral and anteropos-
terior diameters of the thorax. A negative intratho-
racic pressure gradient, created as a result of the
increased thoracic volume, causes air to flow into the
lungs (Fig. 2).
The diaphragm contributes 40 percent of the tidal
volume and the intercostal muscles contribute 60
percent, while the diaphragm contributes 60 to 75
percent of the vital capacity.6, 9-12 Several accessory
muscles—the sternocleidomastoid and scaleni—assist
the elevation and fixation of the ribs during forced or
maximal inspiration.13, 14 The use of these muscles
during quiet breathing is a useful indication of im-
paired breathing.5, 13, 15
The major muscles that contribute to expiration are
8
Fig. 2. Diagram showing diaphragm motion and affected the abdominals and internal intercostals. Normally,
thoracic volume. Expansion of chest wall is lost when quiet expiration is a passive process rather than an
there is paralysis of the intercostal muscles. active process like the muscle contraction in inspira-
tion. However, postural tone of the abdominal mus-
parts of the spine. Both inspiration and expiration are cles plays an important role in expiration by provid-
affected inasmuch as the diaphragm remains active ing support to the abdominal contents.16 This support
as the main functioning respiratory muscle.4-6 De- causes the viscera to push the relaxed diaphragm back
pending on the injury level, the diaphragm may also to its resting position. Active contraction of the expir-
be affected because of its innervation by the phrenic atory muscles usually occurs during forced or maxi-
nerve (C3-5).7 Full comprehension of the serious mal expiration as in coughing and sneezing.5 During
respiratory implications of quadriplegia and high par- forced expiration, the diaphragm is pushed further up
aplegia requires an understanding of the normal me- in the thoracic cavity by contraction of the abdominal
chanics of respiration and the function of the respi- muscles and the ribs are depressed by contraction of
ratory muscles. the internal intercostal muscles.8 Positional changes
do not seem to have any great effect in normal
MECHANICS AND ANATOMY OF NORMAL individuals. The resting level of the diaphragm is
VENTILATION lower with an individual erect when compared to
supine.6 The effects of gravity on normal persons
Ventilation has two phases: inspiration and expi- when sitting are minimal; often breathing is easier
ration. The major muscles that contribute to inspira- due to a redistribution of visceral weight and changes
11
tion are the diaphragm and the external intercostals.8 in lung volumes.
The diaphragm is a dome-shaped muscular sheet that As previously mentioned, the diaphragm is the
separates the abdominal and thoracic cavities. It orig- major muscle contributing to ventilation in patients
inates from three areas: the sternal portion arises from in Classes II through IV. In a patient with cervical or
the dorsal aspect of the xiphoid process, the costal high thoracic spinal injury, the intercostal muscles are
part originates from the last six ribs and the inner paralyzed. When the intrathoracic pressure is de-
cartilage, and the lumbar portion arises from the creased, by action of the diaphragm, the ribs are
bodies and transverse processes of the upper lumbar depressed and a paradoxical breathing pattern is ob-
vertebrae.7 From this series of origins, the fibers of served. This breathing pattern results in reduction of
the diaphragm converge to insert into the central inspiratory volume (Fig. 2).2, 4-6, 16, 17 The intercostal
tendon. and abdominal muscle paralysis creates a series of
Contraction of the diaphragm causes it to descend. problems resulting in decreased inspiratory ability
Therefore, the vertical diameter of the thoracic cavity with a subsequent decrease in expiratory flow.2, 4, 6
increases and as a result, intrathoracic pressure is Intercostal paralysis directly diminishes chest mobil-
reduced. The descent of the diaphragm compresses ity, resulting in decreased compliance, while abdom-

1738 PHYSICAL THERAPY


inal paralysis affects the diaphragm's position for
inspiration.18 The clinical significance of intercostal
and abdominal muscle paralysis is a decrease in in-
spiratory volume during quiet breathing, and the loss
of expiratory force during cough (Fig. 3). Mainte-
nance of good bronchial hygiene is dependent upon
these expiratory muscles inasmuch as lack of an
expulsive force and loss of chest wall mobility
prevent a functional cough.5, 10, 12, 17, 19 Positional
changes now can create problems. The main reason
for ventilation difficulties is that without the assist-
ance of intercostal and abdominal muscles the descent
of the diaphragm is hindered by postural redistribu-
tion of viscera and changes in lung volumes.2, 4, 5, 11 Fig. 3. Flow chart showing influence of paralysis of the
intercostal and abdominal muscles on ventilation.
While the patient is supine, the abdominal contents
force the diaphragm to a higher resting level than if the patient may be using at the time of the evaluation.
the patient were erect.7, 11, 20 The supine position al- The six specific items for the physical therapist to
lows for greater diaphragmatic excursion when com- include in a clinical respiratory examination are mus-
pared to the erect position: when the patient is erect, cle strength, respiratory rate, breathing pattern, chest
the demand on the diaphragm increases because it is mobility, cough function, and vital capacity.
in a lower resting position due to weight of the
abdominal contents being affected by the downward Respiratory Muscle Strength
force of gravity.20 Because of the lack of abdominal
tone, the diaphragm cannot return to its normal
Before pursuing the functional aspects of the res-
resting position, and the inspiratory capacity is de- piratory evaluation it is important to establish a base-
creased. Therefore, the patient will continue to have line by measuring the strength of the muscles in-
diminished ventilation unless some mechanism is volved. Neck and trunk musculature are evaluated
used to substitute for the abdominal tone and ade- using standard manual muscle testing techniques.21, 22
quate support is provided for the viscera. The patient A simple technique for assessing diaphragm function
will also have a diminished vital capacity, that, despite is to observe the supine patient for epigastric rise
normal lung conditions, creates a potential for atel- during a maximal inspiratory effort. If the patient is
ectasis.6 in Class III through VI, a normal epigastric rise will
be observed (Fig. 4). A normal epigastric rise indicates
EVALUATION that the diaphragm is contracting through its full
excursion. For the patient in Class II, the normal
Before comprehensive respiratory care of patients epigastric rise may be present. If the normal epigastric
with spinal injury can begin, a thorough evaluation rise is not noted, the diaphragm is too weak to com-
is mandatory. Important general criteria include: 1) plete a full excursion. When the presence of the
strength of the respiratory muscles, 2) compliance or diaphragm is questionable, the patient should be
mobility of the chest wall, and 3) any inspiratory observed for Litten's sign. This sign is a rippling
substitution occurring during quiet breathing.5 The action observed between the 8th, 9th, and 10th ribs
therapist should be aware of any prior or current indicating the presence of a weak diaphragm.16 The
respiratory complications related to the spinal injury sign is created as the intrathoracic pressure decreases
and should be familiar with the respiratory equipment and can be observed best in thin individuals. While

Fig. 4. Contour of epigastric area of a patient with Class III respiratory function shown during a) relaxed expiration
and b) maximal inspiration.

Volume 61 / Number 12. December 1981 1739


the presence of Litten's sign confirms active motion Breathing patterns should be observed with the
of the diaphragm, the lack of a sign is not a definite patient in supine and sitting positions to determine
indication the diaphragm is absent. Further exami- the effects of gravity. Diaphragm muscle weakness
nation of a weak diaphragm may be done through may not be obvious when the patient is supine and at
palpation, double exposure roentgenogram, and rest. When the patient is erect, the effect of weak or
fluoroscopy.10, 16 During a fluoroscopy evaluation, the paralyzed abdominal muscles is most pronounced
diaphragm can be observed during quiet breathing and a change in the breathing pattern may occur
and deep breathing. During quiet breathing, the nor- because of the decreased efficiency of the diaphragm.
mal range of movement of the diaphragm is at least The breathing pattern also may change when the
1 to 5 cm while during deep inspiration, the range of patient engages in activities such as talking or exercise
movement is at least 7 to 13 cm.6 A difference may because these activities increase the need for ventila-
exist between the diaphragm's descent during quiet tion. Usually, the major change in the breathing
and deep breathing as well as between both sides of pattern is the added use of the neck accessory muscles.
the diaphragm. The fact that a patient is able to A patient's breathing pattern can be evaluated in
increase the diaphragm's descent during deep inspi- various ways, such as 1) placing one of your hands
ration indicates inspiratory reserve. While more ob- on his chest and the other over his abdominal area to
jective measures of inspiration may be obtained, the feel changes in motion; 2) direct observation; and 3)
equipment to acquire this data is not easily available placing both your hands on his chest, thumbs touch-
to the therapist and the test results do not isolate ing, to check for chest expansion. A patient may be
diaphragm from intercostal function.23, 24 Intercostals momentarily disconnected from a mechanical venti-
are assessed indirectly by noting chest expansion and lator to evaluate his diaphragm function.
vital capacity (see following sections).
Chest Mobility
Respiratory Rate
A mobile chest wall is extremely important to the
With a normal diaphragm muscle the respiratory patient with impaired intercostal muscle function.
rate remains regular at approximately 12 to 16 breaths Because the resulting paradoxical motion of the ribs
per minute. With a weak diaphragm a common decreases chest expansion, there is a natural predis-
change is an increase in respiratory rate. The purpose position to chest tightness in these patients.2, 5, 10, 25
of evaluating the respiratory rate is primarily to de- Chest measurements are taken at the axilla and xiph-
termine the efficacy of the remaining musculature to oid process levels with a cloth tape measure to eval-
ventilate the patient. The therapist should know the uate excursion of both the upper and lower rib cage.
signs and symptoms of hypoventilation and hyper- Chest expansion measurements are the difference
ventilation as either may occur secondary to extreme between chest measurements at maximal exhalation
changes in rate. Hypoventilation may result in drow- and at maximal inhalation. These measurements may
siness, irritability, or a decrease in appetite, while produce a negative value, such as —0.5 in (—1.3 cm)
hyperventilation may result in faintness and in tin- because of the paradoxical chest motion; whereas,
gling and numbness in the extremities.5 The respira- normal chest expansion is 2.5 to 3 in (6.5-7.6 cm).26
tory rate should be observed while the patient is at These measurements provide an objective indication
rest and unaware that the therapist is counting of intercostal strength when compared with normal
breaths. chest expansion. Chest expansion should also be mea-
sured with an airshift. An airshift is a maneuver
Breathing Pattern during which a person inhales maximally, closes the
glottis, relaxes his diaphragm, and allows the air to
The purpose of determining the breathing pattern shift from the lower to upper thorax. Airshifts may
is to evaluate the "quality" of the active muscles as increase chest expansion 0.5 to 2 in (1.3-5.1 cm).
well as their contribution to inspiration. A normal Initially, the airshift maneuver allows most patients
breathing pattern consists of rib elevation with tho- to achieve a 0.5-in chest expansion.
racic expansion resulting from intercostal muscle con-
traction and of epigastric rise resulting from dia- Cough Function
phragm motion.16 The most common breathing pat-
tern observed in patients in Classes II through IV is The purpose of assessing the cough is to evaluate
diaphragmatic, because the diaphragm is the only the patient's ability to clear secretions. The abdominal
efficient muscle remaining. When the diaphragm is muscles are the major muscles creating the expulsive
weak, however, the neck accessory muscles, such as force necessary for a cough. When abdominal muscle
the sternocleidomastoid or scaleni muscles, may assist function decreases, coughing is impaired.5 Coughs
the weak diaphragm in ventilation.5, 15, 16 may be classified as functional, weak functional, and

1740 PHYSICAL THERAPY


nonfunctional. A functional cough is adequate to TABLE
clear all secretions and no assistance is required. A Vital Capacity (% of Normal)ValuesaBefore and After
weak functional cough is adequate to clear the throat Treatment
and small amounts of secretions, but assistance to Vital Capacity
cough would be required to clear mucous with a Class
respiratory infection. A nonfunctional cough means Before After
the patient is unable to generate any cough force. Treatment (%) Treatment (%)
Inability to clear secretions because of an impaired II ≤25 40
cough may result in inadequate bronchial hygiene III 35 60
IV 50 80
and potentially serious pulmonary complications. The V 70 90
importance of adequate bronchial hygiene must be VI 80 95
stressed, because complications arising from respira­ a
Values are approximate and intended to provide a
tory infection are a major cause of death in the patient guideline of expected values to observe at initial evalua­
with spinal cord injury.1,10,12,19, 27 tion and for reasonable expected outcome.

Vital Capacity
provement of ventilation, 2) prevention of chest tight­
Routine vital capacity measurements provide an ness, 3) improvement of cough force, and 4) preven­
objective base-line for defining respiratory muscle tion of substitute breathing patterns that interfere
weakness.5, 10 This measurement can be used to mon­ with function.
itor a patient's progress and can be easily measured The treatment program used to accomplish the
with a handheld spirometer. Vital capacity is recorded stated goals includes: diaphragm reeducation and
as a percent of predicted value or as a volume (cubic strengthening, use of appropriate abdominal support,
centimeters).16 While the percent value is useful in chest mobilization, and bronchial hygiene including
most cases, the volume is an important measurement cough and bronchial drainage. This program is simple
in the patient with severe impairment. Inasmuch as and straightforward but requires careful monitoring
phasing a patient from use of a respirator is an and frequent reevaluation of the patient. Specific
individual process, the volume measurement provides techniques and considerations for each aspect of the
valid indication of progress. Any prior history of lung program are discussed separately.
disease is important to consider to make correct in­
terpretations. Vital capacity should be determined Strengthening
with the patient in both supine and erect positions to
determine the effects of gravity. Initial vital capacity After evaluating the patient, the therapist should
measurements vary depending on the functional clas­ know the functional strength of the diaphragm. To
sification and range from less than 25 percent of train the patient to rely only on the diaphragm for
normal in Class II to 80 percent of normal for patients breathing, we have him do diaphragm strengthening
in Class VI (Table). exercises separately from neck strengthening.5, 16 Also,
any assistance from the neck accessory muscles is
TREATMENT initially discouraged while the diaphragm is being
strengthened.15 This precaution is common for Class
The overall treatment goals for patients with res­ II patients who use their neck muscles to assist a weak
piratory dysfunction from spinal injury are 1) im- diaphragm. The primary method of mobility for this

Fig. 5. Subject positioned with weights for diaphragm strengthening a) during relaxed expiration and b) attaining full
epigastric rise during inspiration.

Volume 61 / Number 12, December 1981 1741


a gradually increasing resistance should be stressed.1
The patient should be able to lift the weight with
diaphragmatic contraction for the full treatment time
without obvious fatigue before more weight is added.

Abdominal Support

Use of a properly fitting corset is important in


treating patients with decreased abdominal strength
(Fig. 6).5, 16, 20 With paralyzed or weak abdominal
Fig. 6. Patient with properly fitted and applied corset. muscles, a corset will support the abdominal contents
against the effects of gravity, allowing the diaphragm
to assume a normal resting position while the patient
class of patients is driving a wheelchair, by chin
is erect (Fig. 7).17 Therefore, proper application and
control, and certain functional tasks are possible only
fit of the corset are essential. The corset should lie
by using a mouthstick. Therefore, breathing with their
over the lower floating ribs and extend over the iliac
neck muscles may interfere with attaining some func-
crests bilaterally. If the corset is placed too high, it
tions and mobility. For the patient with paralyzed
impedes inspiration by restricting the epigastric rise.
intercostal and abdominal muscles, use of the dia-
If the corset is applied too low, it impedes diaphragm
phragm alone for ventilation is more efficient than
function by allowing abdominal protrusion. The
use of the neck accessory muscles and the diaphragm
lower buckles of the corset should be tighter than the
together.15 The patient must be allowed to develop
upper ones to provide appropriate support. The corset
fully an efficient breathing pattern before resorting to
should fit snugly, yet one should be able to slip a
use of another less efficient one.5 If the diaphragm is
hand between the corset and abdomen. Corsets can
unable to tolerate progressive resistive exercises, then
be custom fitted or can be a stock size if they give
deep breathing or manual resistive exercises are be-
adequate support. Some patients develop sufficient
gun. "Unable to tolerate" means that the signs and
abdominal muscle tone to substitute for the corset.
symptoms of fatigue (such as use of neck accessory
Use of the corset may be discontinued when there is
muscles) develop during the strengthening program.15
no difference in the ease of breathing during func-
Too much resistance can overload a weak diaphragm
tional activities with or without the corset.
and prevent further strengthening. Therefore, careful
monitoring is important to avoid any fatigue. A pneumobelt can be used to assist ventilation for
patients unable to eliminate the neck accessory mus-
With the patient supine, resistance should be ap-
cles from the breathing pattern because of inadequate
plied directly over the epigastric area. This area can
diaphragm strength.5, 10, 16 The pneumobelt is a corset
be identified by palpating the lower ribs and noting
with an inflatable bladder placed over the abdomen
a triangular-shaped area just below the xiphoid proc-
(Fig. 8). The bladder is connected to a respirator by
cess. The weights are applied directly or by a weight
a hose. The respirator must deliver an intermittent
pan that holds the weights on the epigastric area (Fig.
positive pressure and have rate settings. The bladder
5). The daily treatment is 15 minutes. Endurance with
inflates during expiration and pushes the abdominal
contents inward, thus displacing the diaphragm up-
ward to an optimal resting position from which to
function. Expiration becomes active by using the
pneumobelt, and inspiration occurs by using the weak
diaphragm as the bladder deflates. In this way the
pneumobelt protects the diaphragm against the ad-
verse effects of gravity. With assistance during expi-
ration, the diaphragm is more efficient during inspi-
ration and is not overchallenged, thereby decreasing
or eliminating the patient's use of neck accessory
muscles in the breathing pattern. Two important con-
cepts are 1) the pneumobelt assists during expiration
and 2) patients can be benefited only if in the erect
position. In our clinical experience, the pneumobelt
has been used successfully on many patients with an
Fig. 7. Diagram showing improved resting position of initial vital capacity of 500 cc. Most of these patients
diaphragm with corset supporting abdominal mass. achieved a vital capacity of about 2000 cc after two

1742 PHYSICAL THERAPY


to three months and then discontinued use of the
pneumobelt.

Chest Mobility

Patients in Classes II through IV have decreased


function of the intercostal muscles; therefore, other
methods must be used to expand the chest. These
methods are classified as active or passive. The two
active means to expand the chest are airshifts and
glossopharyngeal breathing.
Airshift maneuvers give the patient an independent
means of expanding the chest without using the in-
tercostal muscles. This technique provides for self-
range-of-motion of the costal articulation, is conven-
ient, requires no equipment, and is easy to learn.
Airshift maneuvers are taught shortly after admission
and are closely monitored until the patient becomes
proficient. Responsibility to perform the airshifts is
placed upon the patient with periodic reevaluation
from the therapist.
The second active means for chest expansion is
glossopharyngeal breathing (GPB).12, 15, 17, 25-28 This
breathing technique is accomplished by the oral, pha-
ryngeal, and laryngeal structures. The main goals of
GPB are to increase lung volume and maintain chest
mobility for improved cough force, and to achieve
independent respiration for patients being phased
from respirators.15, 28 With GPB, the vital capacity
can be increased as much as 1000 cc. Teaching GPB
requires a highly motivated patient and a trained
therapist to provide persistent and careful follow-
through.
The passive methods used for chest mobility in-
clude routine intermittent positive pressure (RIPP)
and manual chest stretching.5, 17, 27, 29 During chest
Fig. 8. Pneumobelt system a) disassembled and de-
mobility with positive pressure, the patient is supine flated, b) inflated, and c) applied to patient (without corset
and wears an abdominal corset or cloth binder to closed for demonstration only).
insure maximal chest expansion. The therapist con-
trols the rate and pressure of air delivered to the processes. The other hand is placed on the anterior
patient. Initial treatment begins with an inspiratory chest wall. With a wringing or twisting action, the
pressure of 5 cm H2O and progresses to a maximum therapist brings his hands together as the patient
of 40 cm H2O pressure.1 Most patients achieve chest exhales. Chest stretching is performed once or twice
expansion of 2.5 to 3 in (6.5-7.6 cm) after four to six daily to maintain or increase range of motion, respec-
weeks of daily treatment. After the patient can sit in tively.
a wheelchair daily and can actively participate in the
rehabilitation program, RIPP is usually discontinued. Bronchial Hygiene
If the patient is placed on bedrest, RIPP is reinsti-
tuted. Common contraindications for RIPP are Because of the abdominal muscle paralysis com-
chronic obstructive airway disease, acute respiratory monly seen in spinal injury and the resultant lack of
infection, or recent removal of a tracheostomy tube. a functional cough, a manually assisted cough is
Manual chest stretching can be done when RIPP is needed to raise secretions.10, 19, 30 The technique and
contraindicated or in conjunction with RIPP. Manual timing of the assisted cough are critical. The hands of
chest stretching is done segmentally on the lower, the person assisting are placed over the patient's
middle, and upper chest areas. With the patient su- epigastric area, avoiding the xiphoid process. As the
pine, the therapist places one hand underneath the assistant pushes quickly on the epigastric area, diag-
patient's back until the fingertips touch the spinous onally inward toward the head, the patient attempts

Volume 61 / Number 12, December 1981 1 743


to cough. The manually assisted cough is very similar The natural decrease of rate and volume of respira-
in technique to the Heimlich's maneuver taught in tion during sleep may not be well tolerated in the
cardiopulmonary resuscitation classes. The action of quadriplegic subject with marginal diaphragm func-
the person assisting mimics contraction of the para- tion. The normal decrease in minute volume and
lyzed abdominal muscles. Patients with adequate up- increase in Pco 2 may become relatively excessive in
per extremity strength can assist their own cough by these patients, resulting in the clinical signs noted
quickly compressing the abdominal area. For exam- above.31
ple, this compression can be done with the patient's One proposal in pursuing sleep studies with the
arms, with him leaning forward over a pillow placed quadriplegic patient is to first document selected res-
against the abdomen. The use of GPB can also pro- piratory variables during waking hours and then col-
duce a functional cough by increasing the volume of lect comparable data while the subject sleeps. If sig-
inspired air and letting it out all at once. nificant respiratory changes are noted in certain sub-
Before discharge, bronchial drainage is routinely jects, perhaps some routine measurement could be
taught to the patient, family, or attendant. The family used to predict which patients will have intolerable
is instructed in percussion and proper positioning and respiratory decreases during sleep. The effect of assis-
taught that the patient must cough at least once in tive therapy, including supplemental oxygen and spe-
each position. The patient is taught to demand treat- cial positioning, could also be documented in a similar
ment at the first sign of congestion. manner. The benefit to patients of this effort is to be
able to identify those who have excessive respiratory
FUTURE RESEARCH decreases when sleeping and provide them with the
proper therapy, thereby enhancing their ability to
With a comprehensive respiratory evaluation and participate in daytime activities.
intensive treatment program, the patient with respi- A final topic for study is the total effect of normal
ratory dysfunction has the opportunity to develop his respiratory function on all classes of spinal injured
respiratory capacity and, therefore, maximize his persons. For example, we have just completed a study
functional potential. Evaluation of respiratory me- using an on-line metabolic measurement system to
chanics and physiology has been well-founded. How- determine the maximum exercise abilities of a group
ever, efficacy of treatment is based on the clinical of paraplegic patients. While these patients, when
experience gained over the years. To continue to compared with noninjured subjects, had upper ex-
provide patients with the best possible respiratory tremity strength that was as great or greater and had
care, all types of current treatment should be critically heart rates typical of normal maximum effort, they
analyzed both for short-term as well as long-term consumed less oxygen. Our data show the variable
effectiveness. For example, a mobile or flexible chest most likely affecting this was minute ventilation. With
wall is believed to be a major influence on an indi- growing interest in endurance training and athletic
vidual's vital capacity. The two techniques used to competition among this group of patients, more re-
maintain or gain chest wall flexibility are manual search is needed to define the most effective training
chest stretching and intermittent positive pressure, modes for patients who have loss of muscle as well as
but the relative values of these two techniques have respiratory reserve.
not been documented for either short- or long-term While considerable effort has been placed on eval-
effects. Each technique should be evaluated for its uation and treatment of respiratory deficits, much
individual as well as comparative merits. needs to be done to validate the treatment approach.
Another clinical concern requiring research is With greater understanding of cause and effect, treat-
about patients who have partial innervation to the ment can be more individualized and staff and pa-
diaphragm. While these patients receive much day- tients spared unproductive effort. To ensure optimal
time attention, not much is known about their respi- respiratory care efforts of therapists and patients we
ratory function during sleep. Not infrequently, a pa- must be able to identify those patients for whom
tient with a neurological diagnosis of C4 quadriplegia, specific therapeutic intervention is necessary and
although able to be up in a wheelchair during the those in whom functional training adequately chal-
day, does not start his daytime activities until late lenges the respiratory system. Through research ef-
morning. Such patients are often difficult to awaken forts, effective evaluation and treatment methods will
and once aroused are slow to respond or "grouchy." be preserved and new ones will be developed.

1744 PHYSICAL THERAPY


REFERENCES
1. Stauffer ES, Bell GD: Traumatic respiratory quadriplegia and 17. Kirby NA, Barnerias MJ, Siebens AA: An evaluation of as-
pentaplegia. Orthop Clin North Am 9(4):1081-1089, 1978 sisted cough in quadriplegic patients. Arch Phys Med Rehabil
2. Fugl-Meyer AR: Effects of respiratory muscle paralysis in 47:705-710, 1966
tetraplegic and paraplegic patients. Scand J Rehabil Med 3: 18. Gibson GJ, Pride NB: Lung mechanics in diaphragmatic
141-150, 1971 paralysis. Am Rev Respir Dis 119:119-120, 1979
3. Hemingway A, Bors E, Hobby RP: An investigation of the 19. Siebens AA, Kirby NA, Puolos D: Cough following transec-
pulmonary function of paraplegics. J Clin Invest 37:773, tions of spinal cord at C6. Arch Phys Med Rehabil 45:1,
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