Q. About Respiratory Muscle Weakness

[gogo]

Hi every one

My Brother was injured 5 months ago and he is C5-C6 comp. He is in Hospital in Saudi Arabia.
Up to today he Still has problems with his chest and breathing ,

I would like to ask if any one knows any medication or way of therapy to help him get over his problems
He is so anxious to Start rehab and go on with his life.

Below what his Dr. Said.
My brother gets Intermittent Shortness of breath, week cough, reflux,
beside Respiratory Muscle Weakness, infected Trachestomy..

What they are doing Now is:
Physiotherapy 4 hourly.
Ventolin, Atrovent Nebulizer
Ceftazidime/ Ciprofloxacin
Daily Care for Trachestomy tube.

I would like to ask if any one knows any medication or way of therapy to help him get over his problems.

SCI-Nurse and Dr. Wise Young please comment..
Any help will be great.
thank you

[SCI-Nurse]

I am going to move this over to the Acute SCI forum and lock it here. Here is the link:

(KLD)

[SCI-Nurse]

Shortness of breath and weak breathing is very common at this level of injury. Normally we breathe with the use of 4 sets of muscles:

-Diaphragm: innervated at C 3-5
-Accessory Muscles (in the neck): innervated at C2-5
-Intercostal muscles (between the ribs): innervated at T1-7
-Abdominal muscles: innervated from T7-T12

With a cervical injury that is pretty complete, the abdominal and intercostal muscles are paralyzed. There may be partial paralysis of the diaphragm. Breathing only with the diaphragm and accessory muscles is very inefficient, and most people's muscles in these areas are weak even before the injury. Ineffective breathing can cause atalectasis, or collapse of small areas of the lung. If this gets bad, and there is a lot of secretion accumulation as well, pneumonia is a very real threat.

Weak or absent abdominal muscles are especially a problem as these are the muscles we use for coughing and forceful expiration (breathing out). This can result in accumulation of secretions and mucous in the lungs. This can add to the atalectasis problems above.

It has been estimated that it takes from 8-9X as much energy for someone with tetraplegia to breathe as it does for an AB. This can also lead to respiratory muscle fatigue and failure, especially early after the injury.

Interventions that are recommended include:

1. Early mobilization: get the person out of bed as much as possible, and as early as possible after the injury.

2. Use IPPB (intermittent positive pressure breathing) therapy to treat atalectasis and help with secretion mobilization. We usually do this every 4-6 hours. If there is a restrictive component (ie, wheezing or asthsma) then a bronchodilator can be added to this treatment, but usually this is not needed. If secretions are very thick, a mucolytic drug could also be added. Thick secretions are often a symptom of dehydration though, so be sure he is getting enough fluids (at least 3 liters daily).

3. Chest physical therapy (percussion and postural drainage) can be very helpful for secretion mobilization. We do this prior to the IPPB treatments above, and as needed in between.

4. "Quad" (assisted) coughing. Many health care professionals do not know how to do this technique, but it is critical to replace the paralyzed abdominal muscles using this technique. This can be done using a machine called an inexsuffilator (Cough-Assist) or manually. If your physician or nurses or respiratory therapists do not know how to do this, contact me again and I will provide instructions. Family, friends, etc. should learn how to do this. It should be done whenever he feels the need to cough as well as every 2 hours around the clock...more often if he has a lot of secretions. It should always be done prior to any tracheal suctioning.

5. Use of a diaphragmatic resistive strengthening device. The P-Flex is an excellent one. Diaphragm strengthening can also be done by having him lay on his back with 3-10 lb. sand-bag type weights on his abdomen. This gives resistance to the diaphragm, making it stronger. This should be started very slowly (30 seconds) and gradually increased until he can go 10-20 minutes with the weights or exercise device 2-3 times daily.

6. Be sure that he is not aspirating. A videofluoroscopic swallow study should be done on anyone with a tracheotomy before any oral fluids or food are taken. Silent aspiration is often a factor in recurrent pneumonia. Out-dated tests for this like adding dye to tube feeding have been proven unreliable in testing for this problem.

7. If he is very underweight, the addition of short term (4-6 weeks) oxandralone (an anabolic steroid) has also proven helpful for some, and there is good evidence that the addition of theophyline can also be helpful for many in developing a stronger diaphragm.

Lastly, tracheostomy care should be done at least every 8 hours, not just daily.

I hope this is helpful. Dr. Young may be able to add some more.

(KLD)

[gogo]

Sci_ Nurse
Thank you for your post it really help out very much,

My brother breathing Improved very good for a week or so and have the same truable or more ,
it just going back and force for 5 month, I thought that he Dr. is not doing enght for him

Would you please email me more info. about "Quad" (assisted) coughing.
you mention in your Post regarding, Q. About Respiratory Muscle Weakness,

If you do have more info. I would be greatful

[Wise Young]

Great summary, KLD. The only thing that I would add is possible consideration of theophylline. See Clinical Trial of Theophylline to Improve Recovery of Paralyzed Breathing Muscles at Wayne State University (http://carecure.org/forum/showthread.php?t=39745) in the clinical trial forum (http://carecure.org/forum/forumdisplay.php?f=62). Wise.

[gogo]

Originally posted by gogo:

Sci_ Nurse
Thank you for your post it really help out very much,

My brother breathing Improved very good for a week or so and have the same troable or more ,
it just going back and force for 5 month, I thought that his Dr. is not doing enght for him

Would you please email me more info. about "Quad" (assisted) coughing.
you mention in your Post.

If you do have more info. I would be greatful

[SCI-Nurse]

I am sorry I do not have the diagrams that go with this electronic (I really need to get them scanned so I can fix this), but I hope this is helpful to you or your brother's caregivers: