Pulmonary
complications post
SCI
By
Melanie Boulet
SCI fellow
Objectives
Mempunyai pengetahuan yang
tinggi terhadap :
• Anatomi dan fisiologi paru.
• Pemeriksaan komplikasi
pernafasan akibat SCI
• Analisa masalah dan
menentukan apa yang
dapat dilakukan untuk
membantu peningkatan
fungsi respirasi.
Epidemiology
Epidemiology
• 67% of acute SCI experience some respiratory
complications;
– Atelectasis 36%
– Pneumonia 31%
– Respiratory failure 22.6%
• Increased prevalence with:
– Age
– Level of injury
– Completeness of injury
Anatomy
• Lungs
– Trachea =
windpipe
– Bronchus+bronc
hioli = branching
of windpipe
– Alveoli = air sacs
Anatomy
• Muscles involved in inspiration
– Diaphragm
– Intercostal
– Accessory muscles
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Scalene, Platysma, Mylohyoid
Sternocleidomastoid
Trapezius
Pectoralis
Latissimus dorsi
CRANIAL NERVES
12 pairs of nerves from the brain
Numbering the Nerves
• In classic anatomy we use Roman numerals
to number the cranial nerves:
• I is one, II is two, III is three, IV is four, V is
five, VI is six, VII is seven, VIII is eight, IX is
nine, X is ten, XI is eleven and XII is twelve
• The modern way of numbering the cranial
nerves is by using CN followed by an Arabic
number. For example: VIII is written CN 8.
I - Olfactory Nerve
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Provides sense of smell
Damage causes impaired sense of smell
Test with coffee grounds, spice not perfume, Why?
Test for smell NOT recognition of smell. (Ch. 16)
II - Optic Nerve
• Provides vision
• Damage causes blindness in visual field
III - Oculomotor Nerve
• Provides eye movement, opening of eyelid
• Damage causes ptosis (drooping eyelid), double
vision
IV - Trochlear Nerve
• Moves eye down and out
• Damage causes double vision & inability to
look down and out
VI - Abducens Nerve
• Moves eye laterally (ABduction)
• Damage results in inability to move eye
______
Innervation of Eye Muscles
V - Trigeminal Nerve
• Main sensory nerve to face (touch, pain and
temperature) and muscles of mastication
• Damage produces loss of sensation & impaired chewing
or can cause increased pain = trigeminal neuralgia
VII - Facial Nerve
• Provides facial expressions, sense of taste on anterior
2/3’s of tongue, salivary glands and tear, nasal & palatine
glands
• Damage produces sagging facial muscles & disturbed
sense of taste (missing sweet & salty) called Bell’s Palsy
VIII - Vestibulocochlear Nerve
• Provides hearing & sense of balance
• Damage produces deafness, dizziness, nausea,
loss of balance & nystagmus
IX - Glossopharyngeal Nerve
• Provides control over swallowing, salivation, gagging,
sensations from posterior 1/3 of tongue, control of BP
and respiration
• Damage results in loss of bitter & sour taste & impaired
swallowing.
X - Vagus Nerve
• The wonderer
• Provides swallowing, speech, regulation of 2/3 of GI tract
• Damage causes impaired voice, swallowing and digestion
XI - Accessory Nerve
• Contracts upper trap muscles (I don’t know)
• Damage causes impaired shoulder movement
XII - Hypoglossal Nerve
• Provides tongue movements of speech, food
manipulation & swallowing
• Damage results in inability to protrude tongue,
TEST – Stick tongue out and it points right then
the _____ XII is broken
CN 1- 12 (Summary)
(Know the number and the nerve)
• On Old Olympus Towering Tops A Famous Vocal
German Viewed Some Hops
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CN 1- Smells like an old factory.
CN2- Two eyes see
CN 3, 4, 6- moves the eyes
CN 5- Trigeminal, three finger on face
CN7- Facial, closes eye lids
CN 8 Vestibulocochlear, ear
CN 9 Glossopharyngeal, G looks like a nine
CN 10 Vagus, two Vs
CN 11 Accessory- Trapezius muscle, shoulders up
CN 12 Hypoglossal
Anatomy
• Diaphragm
– Phrenic nerve
– c3-C4-c5
– Contributes to 65% of Vital Capacity
Anatomy
• Intercostal
– Intercostal nerves
– T1-T11
• Both layers act as inspirators at low volumes, and
expirators at large volumes
Anatomy
• Scalene
– C4-C8
• Platysma
• Mylohyoid
Anatomy
• Pectoralis
• Latissimus dorsi
Anatomy
• Sternocleidomastoid
• Trapezi
– Cranial nerve XI
Anatomy
• Muscles involved in expiration
– Abdominal muscles
• Recti
• Obliques
• Transversus-abdomini
• Clavicular portion of pectoralis muscle
Anatomy
• Abdominal muscles
– T6-L1
Physiology
• What is Breathing?
– Movement of air, in and out, through nose or
mouth
• To get oxygen to feed our tissues
• To remove waste product: carbon dioxide
Physiology
• Inspiration:
– Diaphragm contraction becomes flattened
moves downward abdominal content creation of
negative pressure passive movement of air
– Diaphragm in better biomechanical posture if rib
cage stabilized by other respiratory muscles
Physiology
• Expiration:
– Passive exit of air after diaphragm relaxation
• Forced expiration:
– Contraction of abdo muscles increased
intraabdominal pressure superior movement of
diaphragm expiration and cough
– Clavicular portion of pectoralis major can act as
expirator in tetraplegia
Physiology
• Restrictive pulmonary syndrome
– Decreased TLC, VC, ERV, FRC
– Increased RV
• VC of newly injured = 24-31% of predicted
– Halo may further restrict VC by up to 8%
Physiology
• Chronic improvement with:
– Improved strenght
– Intercostal and abdominal tone
• Doubling of VC 3 months after injury for C4-C6
Impairment by level of injury
L1 or lower: no impairment
T5 to T12: Impairment of forceful ventilation and
cough
T1-T5: Impairment of quiet respiration
C4-C8: Greater impairment of quiet respiration
C4: important impairment of quiet respiration
C3: usually need ventilation assistance in acute
phase
C2 and above: no diaphragm function
3 main categories
• 1) C2 and above: no funtion of diaphragm,
need ventilatory assistance
• 2) C3-C4: potential to wean from ventilatory
assistance
– 83% wean eventually
• 3) C5 and below: Breathe without respiratory
assistance. Any compromise can result in
ventilatory insufficiency.
Acute complications
• Pneumothorax and chest injuries
– From initial injury
– From barotrauma
– Keeping long-term and short-term risks of treatment in mind, it is
recommanded that the patient with a pneumothorax be treated
with large tidal volumes (<1000cc)
– Risk of barotrauma is small if PIP <40ccH2O
• Atelectasis
– 40% of high tetras
• Pneumonia
– Risks: high levels, age, atelectasis
– 63% of high tetras
Acute complications
• Pulmonary embolism
– Increased risk
• Aspiration
– 5% of SCI (13% if > 60yo)
– Higher risk:
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High level
Anterior-approach surgery
Age
Trachestomy
Sedation and immobilisation
Halo
– Cause pneumonia and ARDS
Acute complications
• Pleural effusion
– Atelectasis lower lobe pulls away from diaphragm
and parietal pleura space filled by fluid
• Empyema
– Atelectasis + effusion + pneumonia empyema
• Trapped lung
– Caused by scarring and fusion of parietal and visceral
pleura, or organisation of exsudate in pleural space
• Ex: post chest tube
• Worse if ventilated at low tidal volumes
Acute complications
• Respiratory failure
– Muscle paralysis
– Fatigue of remaining muscles
• Abdominal complications
– Abdominal distention can prevent diaphragm to
descend
Acute complications
Pulmonary Complications
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
Paraplegia (incomplete)
Paraplegia (complete)
Tetraplegia (incomplete)
10.00%
5.00%
Tetraplegia (complete)
0.00%
Aspiration Atelectasis Pneumonia Ventilatory
Failure
Bad comorbidities
• Tobacco
– Increases secretions
– Increases likelyhood of infection
– Decreases clearing capacity
• COPD
• Narcotics and sleep med.
Tests
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Pulmonary function tests
Nocturnal oxymetry
Arterial blood gas
X-ray
Ct-scan
Fluoroscopy
Tests
Management
• 3 main issues:
–Secretion management
• Reduced ability to cough
• Unopposed vagal nerve
–Atelectasis
–Hypoventilation
• Weak inspiratory muscles
• Unopposed vagal nerve
Management
• Causes of Problems with secretion management
– Acute phase secretion production with unopposed
vagal tone
– Infection
– Poor cough flow
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Vital capacity below 1.5 L
Weak abdominal muscles
Loss glottic control
Weakened bulbar muscles
Trachestomy
Tracheal stenosis
COPD
Management
• Assistance in secretion clearance
– Hydration
– Limit dairy products?
– Postural drainage
• Prone
• Rotating beds
– Chest physical therapy
• Chest clapping, percussion, vibration
– Suctionning
Management
– Assisted cough techniques
• Improves peak cough flow by 15-33%
• Provide max insufflation if VC < 1.5L
– Glossopharyngeal breathing can help
• Self assist, manually or electrically assist cough
– Similar to Heimlich
• Contraindications:
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Fractured ribs
Chest trauma
Abdominal complications
New IVC (reports of displacement with cardiac compressions)
Management
– Mechanical assisted cough
• Insufflation-exsufflation
– Delivery of positive pressure followed by negative pressure
» +40 to -40 cm H2O
– Especially useful if on noninvasive ventilatory support
» Because succionning difficult
– Can clear out larger mucus plugs than succion cath and more
efficient with left main bronchus
– Indicated if VC < 1.5L, or inability to cough or clear secretions
– Contrindications:
» History of bullous emphysema
» Susceptibility to pneumothorax
» Recent barotrauma
Management
• Assistance in secretion clearance
– IPV
• Vibrations (200cycles/min) with constant pressure
– Bronchodilators
– Fiberoptic bronchoscopy if large mucus plug
• Risk of tracheobronchial irritation, edema, hypoxemia,
aspiration
Management
• Atelectasis prevention and treatment
– IPPB
• Gradual increase of pressure delivery (15cmH2O to 40
cm H2O)
• Can be used to deliver nebulizer treatments
– IPP
• Nasal or oral interface
– BiPAP or CPAP
– Incentive spirometry
Management
• Assistance in ventilation
– Muscle training
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Inspiratory resistance training
Abdominal weights
Incentive spirometry and resistive devices
Clavicular portion (C5-7) of pectoralis major (expiration)
Management
• Assistance in ventilation
– Positionning of patient
• Supine for tetras
• Head up for central cords with no diaphragm
– Abdominal binder
• When in chair
• Below rib cage
Management
– Non invasive ventilation
• Glossopharyngeal breathing
– Take 6-9 small gulps with thong and pharyngeal
muscles
– Can help to assist cough and prolong vent-free time
if no cuff on trach
• Pneumobelt
– Good cosmesis
– Pump noise, stomach gas, positionning difficulties
Management
• Assistance in ventilation
– Invasive ventilation
• High tidal volume to prevent atelectasis
– Faster weaning an average 21 days for thoses with Tidal
Volume >20ml/kg compare to <20ml/kg
– Decreased atelectasis problems (16% vs 52%)
• AC prefered to SIMV when weaning
– Success in weaning: 68% vs 35%
• Many possible complications with invasive ventilation
– Nosocomial pneumoniae, mucus plugging, cardiac
arrhythmias, accidental disconnection, granulation tissue
formation, tracheomalacia, vocal cord paralysis….
Weaning
• Prognosis:
– Initial VC on admission > 1L
Management
• Assistance in ventilation
– Pharmacology
• Mucolytics
– Guaifenesin
– SSKI
– Acetylcysteine
» Nebulized or injected in trachea diluted with saline
» Tastes like rotten eggs
» May cause bronchospasm
Management
• Pharmacology
– Theophylline
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Relaxes smooth muscles
Stimulates medullary respiratory centers
Can improve diaphragmatic contractility
Can reduce diaphragmatic fatigue
Stimulates the release of surfactant
Potential deleterious effects:
– Arrhytmias
– Seizuree
– Nausea
Management
– Pharmacology
• Bronchodilators
– Long and short acting B-agonist
» Offset unopposed parasympathetic stimulation
» Reduce inflammation
» Stimulate secretion of surfactant
– Ipratropium
» Theorically blocks effects of parasympathetic stimulation
» However, atropine has been shown to block production of
surfactant
• Smoking cessation program
Management
• Assistance in ventilation
– Electrophrenic pacing
• Indications
– Disruption of central control over phrenic nerve motoneurons
– Malfunction of respiratory control centers
• Contraindications
– Lower motoneurons injuries
– Parenchymal lung diseases
– Acute respiratory failure
• Full time support often achieved after 3-4 months of
progressive bilateral pacing
• Permanent tracheostomy usually necessary
Management
• Risks:
– Electrical failure
– Not being able to develop deep enough breaths to
prevent atelectasis
Management
• Vaccination
– Influenza yearly
– Haemophilus influenzae yearly if splenectomy
– Streptococcus pneumoniae yearly
• If you get a cold
– Do more breathing exercises
– More assistive cough
Chronic complications
• Sleep apnea (stop breathing while sleeping)
– 15-60% (10 times more in the SCI)
– Complications:
• Hypertension, cor pulmonale, congestive heart failure,
deterioration of mental function, daytime sleepiness,
cognitive changes, impotence
– Test: overnight oxymetry  formal sleep study
– Tx:
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CPAP or BiPAP
Stop alcohol and sleep medicine
Lose weight
Sleep on side
Chronic complications
• 55% of vent dependent experience yearly
pulmonary problems with average hospital
stay of 22 days
– 37% mortality in 3 years
• Risks of late onset respiratory insufficience
– Hx of ventilator usage at onset
– VC < 2L
– Nocturnal hypercapnia
– SaO2 < 95%
Follow up
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Level of injury
VC
X ray
Oxygenation
Symptoms of sleep apnea
Take home messages
• Breathing can be seriously impaired after a
spinal cord injury
• To prevent dangerous complications:
– Stop smoking
– Do your breathing exercises and treatments
– Get vaccinated every year
– Take your bronchodilators regularly
– When you have a cold, do more breathing
exercises and assistive cough
Bibliography
• Respiratory Dysfunction in Spinal Cord Injury, Sassoon and
Baydur, Spinal Cord Medicine, 2003, pp155-168
• Pulmonary management of Spinal Cord Injury, Peterson and
Kirshblum, Spinal Cord Medicine, pp 135-152
• Nuts and Bolds of SCI management, Dr Gregory Nemunaitis
• Respiratory management following Spinal Cord Injury: a
clinical practice guideline for health-care professionals,
Consortium for Spinal Cord Medicine, 2005
DAERAH
PERTUKARAN
O2 Dan CO2:
1. Brokus respiratoris
2. Ducctus
3. Succus dan
4. Alveoli
Pertahanan Respiratory system
1
Inhalasi melalui hidung
Mempunyai keuntungan
1.Udara disaring.
2.Udara dilembabkan.
3.Udara dihangatkan.
4.Cegah peradangan
jalan nafas bag atas.
Proses pernafasan.
1. External Respiration
a. Inspirasi.
b. Expirasi.
2. Internal Respiration.
a. Tranportasi (sirkulasi).
b. Buffer
1. Exchange O2
1. Air to blood
2. Blood to cells
2. Exchange CO2
1. Cells to blood
2. Blood to air
3. Regulate blood
pH
4. Vocalizations
5. Protect alveoli
External and cellular respiration
Oksigen
= 20,93 %
Carbon diaksida= 0,03 %
Nitrogen
= 79,04 %
TEKANAN
OKSIGEN
Di Daerah
SEA
LEVEL
Pulmonary ventilation
(breathing) is the proses by
which air is moved into and
out of the lungs.
It has two phases: inspiration
and expiration.
Inspirasi is an active process
in which the diaphragm and
the external intercostal
muscles increase the
dimensions, and thus the
volume, of the thoracic cage.
This decreases the pressure
in the lungs and draws air in.
Tekanan alveoli minus 3 s/d
10 mmHg < dari 760 mmHg.
• Normal expiration is the
passive process. The
inspiratory muscle relax and
the elastic tissue of the lungs
recoils, returning the
thoracic cage to its smaller,
normal dimensions. This
increases the presure in the
lungs and forces air out.
 Forced or labored inspiration and
expiration are active proceses,
dependent on muscle actions.
 Aktif inspirasi dibantu otot-otot:
Scalani, Sterno cledo mastoideus,
pektoralis, membantu angkat sternum
dan costae ke depan atas. Tekanan
alveoli turun sampai 100-80 mmHg.
 Aktif ekspirasi dibantu otot-otot :
Abdominalis, Latisimus dorsi
Inspirasi. Ekspirasi
1. Tranportasinya
2. Pertukaran oksigen
dan carbondioksida
di cells
3. buffer
Perfusi eksterna
Eksteranal respirasi:
paru Dipengaruhi:
respirasi Dalam
1. Cairan surfaktan
2. Tebal membran.
3. Volume darah
4. Hb darah
5. Kecepatan sirkulasi.
6. Vicositas darah.
7. pH darah
Tranportasi O2 dan CO2
dalam darah
• Kemampuan jantung
(COP= HR X Stroke
volume).
• Tahanan perifer.
• Fleksibilitas pembuluh
darah.
• Lumen.
• Vikositas.
• Hb.
• Saturasi darah dll.
Ventilation: The Pumps
1. Inspiration
2. Expiration
3. Diaphragm
1. Low energy pump
2. Concavity – flattens
4. Thorax: ribs & muscles
5. Pleura: double membrane
1. Vacuum seal
2. Fluid-lubrication
Pengaruhi internal terhadap
kemampuan tubuh suply O2
1. Jalan nafas yang adeguat.
2. Fleksibilitan otot, fasia, kulit
sangkar thorax.
3. Perfusi O2 dan CO2
4. Volume, Hb, Ph, Plasma darah
5. Keadan pleurae
6. Pusat kontrol fungsi pernafasan
7. Fungsi bufer.
Pengaruh eksternal terhadap
kemampuan tubuh suply O2
1. Kadar Oksigen udara.
2. Posisi tubuh
3. Usia jenis kelamin.
2. Pembersih jalan nafas oleh cillia dan fungsi
menelan
Factors Affecting Ventilation
1.
2.
3.
4.
5.
6.
Airway Resistance
Diameter
Mucous blockage
Bronchoconstriction
Bronchodilation
Alveolar compliance
1. Surfactants
2. Surface tension
7. Alveolar elasticity
Base of
Plan
• Epidemiology
• Anatomy-physiology
• Acute complications
and their
management
• Chronic
complications and
their management