Traumatic Brain Injury & Spinal

Chord Injury Respiratory therapy

Specialty Hospital

Lecture Objectives

• Identify the Respiratory Complications associated with a TBI

• Identify the Respiratory Complications associated with a SCI

• Know the Respiratory Interventions to treat the respiratory complications associate with TBI & SCI

• Know other Nursing Interventions that will help minimize respiratory complications associated with a TBI & SCI

Acute Care Intervention for the

TBI Patient

• Assess initial insult

• Treat acute complications

• Minimize damage from trauma

• Perform invasive procedures to stabilize patient

• Develop treatment regime

Respiratory Complications for

the Post TBI Patient• Ventilatory Irregularity

• Aspiration due to

dysphasia

• Secretion mobilization

• Pneumonia

• Sleep Dysfunction

Ventilatory Irregularity

• Daytime and Night time patterns may be different

• Be careful not to over ventilate. Periods of hyperventilation followed by apnea

• If not compromising, don’t treat apnea, especially on vent

Aspiration Precautions

• Identify High Risk Patientscoughing episodes with meals

reduced lung capacity or small tidal volumes

compromised airway protection

dysphasia

recurrent pneumonias or hospitalizations

• Elevate HOB > 30*

• Adhere to Dietary Restrictions

• Monitor for changes in condition

• Observe for S&S of Infection

• Work with SLP

• Good Regular Assessment

• Enhance swallowing

• Diet Compatible with Functional Level

• Conditions change

• Pneumonia, early identification and intervention

• For swallowing & cognitive issues

Secretion Mobilization

• Poor Cough

• Suction Airway

• Improve Mobilization

• Cough Techniqueshuff cough

breath stacking then cough

quad assisted cough

speaking valve with tracheotomy

• Suctionnasotracheal suction

tonsilar suction

tracheal suction

• TherapyPEP Therapy

CPT

in-exsufflation

pharmalogical

Pneumonia

• Early Identification and

Intervention

• Symptoms

• Treatment

• The sooner we identify a problem the easier & more effective the treatment

• Symptoms:changes in sputum characteristics

fever

increased oxygen requirements

decreased exercise tolerance

change in mentation

breath sounds (diminished or crackles)

reduced appetite

• Treatmenttreat infection (antibiotics specific to

organism)

respiratory therapy (PEP, CPT, Inhaled Medication)

nutrition & hydration

Sleep Dysfunction

• Identify

• Treat

• Continue to Monitorconditions change and periodic monitoring to assure therapeutic intervention is appropriate

• Monitorovernight oximetry

ETCO2

sleep scan ( 6 channel study)

polysomnography

• Interventionoxygen

CPAP

BiPAP

medication or appliances

• Periodic Monitoring to assure prescribed therapy is appropriate

Treatment for TBI Patients

• Prevent aspiration by adhering to proper consistency & diet recommendations, elevating HOB>30*, using speaking valve with eating

• Encourage secretion mobilization with hydration, cough assist techniques & mobilization

• Prevent pneumonia by early identification and treatment

• Identify sleep dysfunction and treat with CPAP, BiPAP and/or medication

• Patient compliance and adherence to therapy.

Spinal Chord Injury and Respiratory Compromise

Acute Care Intervention of the

SCI Individual

• Assess initial insult

• Treat acute complications

• Minimize damage from trauma

• Perform invasive procedures to stabilize patient

• Develop treatment regime

Respiratory Complications due

to Spinal Chord Injury

• Atelectasis

• Aspiration

• Pulmonary Emboli

• Hypoventilation due to compromised respiratory muscles& mucus plugging

• Decreased tidal volumes will increase the incidence of aspiration

• Decreased mobilization will increase the incidence of PE

Level of Dysfunction

T7-T12: abdominal & rib muscles are weakened

• Loss of abdominal

musculature to assist

cough effort

• Thoracic muscles

provide chest recoil

and assist with

exhalation.

• Encourage Cough &

Deep Breathing

Techniques

• Educate for signs of

Infection

• Encourage Nutrition &

Hydration

• DVT Prophylaxis

T1-T7: abdominal muscles paralyzed & chest and arm

muscles maybe paralyzed

• Abdominal muscle

paralysis eliminates

abdominal support for

diaphragm.

• Intercostal muscle

paralysis eliminates

elastic recoil of chest

• In-Exsufflator

• Quad Cough Assist

• Abdominal Binder

• Inspiratory Muscle

Trainer

• Incentive Spirometer

• PEP Therapy

C4-C7: rib & abdominal muscles

may not functioning

• Abdominal

Musculature Paralysis

• Thoracic Muscle

Paralysis

• Accessory Muscles

Affected

• In-Exsufflator

• Quad Coughing

• Huff Coughing

• Breath Stacking

• Abdominal Binder

• Inspiratory Muscle

Trainer

• PEP Therapy

C4 & Above: diaphragm is involved

• Diaphragm Involved

• Abdominal Muscle

Paralysis

• Thoracic Muscle

Paralysis

• Accessory Muscle

Paralysis

• Ventilatory Support

• BiPAP or CPAP

Support

• PEP Therapy

• In-exsufflator

• Cough Assist

Techniques

• Mucolytics

Treatment of Spinal Chord

Respiratory Complications• In-exsufflator to treat atelectasis and

improve secretion mobilization

• IPV: for lung recruitment and secretion mobilization

• Mobility: position changes help to mobilize mucus and change areas of ventilation in the lung

• IMT: strengthen respiratory muscles

• Anticoagulation Therapy for DVT’s

Other Interventions to

Minimize the Respiratory

Complications

Important Consideration

• Hydration

• Diet

• Mobility

• Pulmonary Monitoring

• Sleep Dysfunction

• DVT Prophylaxis

• Avoidance Techniques

• Infection Education

• Emotional Stability

• Family Dynamics

Hydration

• 6-8 glasses (8 oz.) of fluid per day

• Signs of Dehydration poor skin turgor, shriveled tongue

thick mucus

thirst

decreased urine output & constipation

sunken face and eyes

lack of sweat or tears

confusion or lethargy

• Treatmenthydrated with Electrolyte Enriched

Fluid

Diet

• Normal or Prescribed Dietnormal 2000 calorie diet

45-65% carbohydrate (energy)10-35% protein (muscle)20-35% fat (wt gain)

• Signs of Malnutritionweight loss

fatigue & somnolence

muscle loss

lack of concentration

• Treatmentnutritional supplements

nutritional consults

Mobility

• Improve Pulmonary

Statusbetter distribution of ventilation

improve mucus clearance

• Improved Circulation reduce venous pooling

reduce DVT formation

reduce pressure compromised areas

• Improve Muscle

Toneassist with venous tone and circulation

reduce spasm

Infection

• Changing Sputum Characteristicsvolumes

color

consistency

• Fatiguewith ADL’s

increased daytime somnolence

• Fever

• Mental Acuity

• Appetite

• Agitation

• Increased Work of Breathing

Psychological Challenges

• Ability to deal with

Physical Changes

• Changes in Lifestyle

• Family Dynamicsincome alterations

ability to care for family

• Relationships

• Dependencies

• Caregivers

Pulmonary Monitoring

• Respiratory

MechanicsNIF & Vc

• Oxygenationintermittent pulse oximetry

• Sleep Studiessleep scan

full polysomnography

Respiratory Therapy Used in

the Treatment of TBI & SCI

Acapella or Flutter Therapy

• A type of PEP therapy

with a percussing

quality.

• Used to mobilize

secretions and recruit

alveoli.

• Can be used in

combination with

medicated aerosols

In-Exsufflator or Coughalator

• A 2 phase machine

used to hyperinflate

the lung and assist

with a patient's cough

effort.

• Administered with a

mask, mouthpiece or

through a trach

• Used in conjunction

with Quad Coughing

Quad Coughing

• An abdominal thrust

that is coordinated

with a patients cough

effort.

• Assist abdominal

muscles to make

exhalation more

forceful

• Can be done in chair

or low fowlers position

Cough Technique

• Proper cough

technique

• Huff Cough

• Machine gun

Breathing Techniques

• Proper breathing

technique

• Pursed Lip Breathing

• Diaphragmatic

Breathing

• Stacking breaths

Inspiratory Muscle Trainer

• Used to strengthen

the intercostals and

abdominal muscles

• Resistance when a

patient inhales

• Used for

progressively longer

periods of time

Opti Flo

• High flow oxygen at a

specific FiO2

• Need 50 PSI O2

source

• 1 cm CPAP with every

10 lpm flow

• Heated system due to

high flow of gas and

nasal irritation

Incentive Spirometry

• A device that

measures inspiratory

capacity. Good gauge

of progress or

deterioration

• Used to encourage

slow, deep breaths

• Breath hold after

taking deep breath

Intrapulmonary Percussing

Ventilation (IPV)• Positive Pressure

Treatment that uses

percussive airwaves

to loosen and

mobilize secretions.

• Medication is

delivered with this

treatment

• Used to recruit alveoli

Oscillating Vest

• Use of an external

vest or wrap that

oscillates the chest

wall and helps to

loosen secretions and

improve aeration to

the distal airways.

• Improves mucus

clearance and

reduces atelectasis.

NIOV; Non Invasive Ventilation

• Used to assist

spontaneously

breathing individuals

that require

ventilatory support

with ADL’s

• Used to augment

ventilation with those

individuals that

require high O2 flows

Tracheostomy

• Cuffed trach to

protect airway and

ventilate

• Uncuffed trach to

maintain patent

airway from OSA &

secretion

mobilization

Ventilation

• Mechanical Ventilation may be

required intermittently or

continuous depending on the

patients injury.

• Ventilator needs to be

portable, simple to operate and

reliable.

• User friendly to accommodate

caregivers, family and patient.

• Versatile with settings and

alarms to meet the patient

safety & ventilatory needs.

• Invasive or Non Invasive

Diagnostic Studies

• Pulse Oximetry

• End Tidal Carbon

Dioxide Monitor

(ETCO2)

• 12 lead EKG

• Sleep Scan

• Pulmonary Function

Test (PFT)

• NIF & Vc

TBI Case Study

• 24 yr old MVA with closed head injury and rib fractures with Rt pneumothorax

• Intubated, ventilated and chest tube insertion in trauma room,

• Trached & PEG’ed 10 days later

• Difficult to wean due to rapid shallow breathing pattern and secretion retention

• Transferred to LTACH

• Secretions controlled with systemic mucolytic and hydration

TBI Case Study Continued

• Weaned to trach collar for short periods of time BID with high RR accepted and HR, B/P and SpO2 values monitored

• Trach collar weaning trials increased with use of speaking valve and PEP therapy to improve secretion mobilization and reduce alveolar decruitment

• Trach collar weans increased to all day with speaking valve, HS trial initiated with success.

• RR rate gradually reduced

TBI Case Study Continued

• Trach downsized from #8 cuffed to #6 uncuffed and capping trial begun

• Apnea 10-15 seconds observed with SpO2>90% and no bradycardia, apnea tolerated

• Pt decannulated after 2 successful night of capping trials

• Transferred to Acute Rehab

• Discharged to home

Respiratory Care Protocol Overview

Physician orders ”Respiratory Consult”

RCP reviews patient’s chart and perform physical assessment

Determine Therapy Care Plan

Aerosolized

Medication

Bronchial

Hygiene

Hyperinflation Oxygen Tracheotomy

Wean

Indications Indications Indications Indications Indications

Reduced Peak Flow Flow Flow

Bronchospasm

Respiratory H(x)

Home Therapy

Retained Secretions

Productive Cough

H(x) mucus producing

disease

Rhonchi

Difficulty clearing

secretions

Atelectasis

H(x) Restrictive Lung

Disease

Bed rest or Inactivity

Vc < 60% of predicted

SpO2<93%, PAO2<60

Clinical signs of

Hypoxia:

• Tachypnea

• Tachycardia

• Cyanosis

• Confusion

• Diaphoresis

• Anxiety

Intact cough & gag reflex

PCF > 160 LPM

Pass Swallow Study

Alert and Cooperative

Therapy Therapy Therapy Therapy Therapy

Aerosol T(x) with

Medication

IPPB with

Medication

IPV with

Medication

MDI with spacer

&Medication

Coughalator

Flutter Valve

PEP Therapy

IPV

Cough & Deep

Breath

CPT & PD

Suction

Non-invasive

Ventilation BiPAP

IPPB

Incentive Spirometry

Inspir Muscle Trainer

Coughalator

PEP Therapy

Supplemental Oxygen

CPAP

Passy- Muir Trial

Trach Plugging

Remain Plugged 48hrs

Decannulization

Reduced Secretions

ThermoVent Trial

Downsize Tracheostomy

Cough & Deep

Breath

Relaxation Exercises

IDENTIFIED LEARNING NEEDS AND CODE NUMBERS for SCI/D:

Date identified Respiratory - Affected Bodily Function

Techniques to overcome dysfunction

Level of Dysfunction

•T7-T12: abdominal & rib muscles are

weakened

•T1-T7: abdominal muscles paralyzed & chest

and arm muscles maybe paralyzed

•C4-C7: rib & abdominal muscles may not

functioning

•Above C4: diaphragm is involved

•Abdominal muscles are involved•abdominal muscle paralysis with chest and arm involvement•abdominal and rib muscles are paralyzed•diaphragm is involved

•hydration & signs of impending infections

•Controlled Cough, Huff Cough, quad cough and

Diaphragmatic Breathing

•In-Exsufflator, Flutter Valve, PEP Therapy, CPT,

quad coughing, breathing exercises

•Above techniques and ventilation PRN & HS

Signs and symptoms of Infection

•Change in mucus

•Fever

•Decreased exercise tolerance

•Increased agitation

•Confusion or lack of concentration

•Increased work of breathing & heart rate

Change in mucus color, amount or thicknessPossible PneumoniaPoor oxygenation Poor Oxygenation & increased work of breathingPoor oxygenationPneumonia

Hydration and mucus clearance ( coughalator, PEP

therapy, CPT, Quad Cough )

Call Dr, you need antibiotics

Monitor mucus, energy level, appetite, hydration,

sleepiness, agitation, ability to concentrate,

number of syllables you can speak per breath,

heart rate, respiratory rate, nail bed color (blue is

bad). Changes in these values should be reported

to your Dr ASAP. The sooner the treatment the

shorter the recovery time.

Poor hydration Dry mouth, thick mucus, poor skin turgor

Encourage fluid

Poor Nutrition Poor muscle strength Nutritional Supplements

Improve Ventilatory

Muscle Strength

Abdominal, intercostals and diaphragmatic muscles

Inspiratory muscle trainer, PEP therapy,

diaphragmatic and purse lip breathing, daily

exercise, In-Exsufflator, cough techniques and quad

coughing

Avoidance Techniques Allergies, temperature changes Know what triggers your respiratory problems and

avoid or prepare for the exposure with medication

Blood Clot and Pulmonary Emboli Lower Extremity & Lungs Daily Mobility & anticoagulation therapy

Post Test for the TBI & SCI Patient

Respiratory Therapy1. Name three respiratory complications for the post TBI

patient: _________________ _______________ & ________________

2. Name two respiratory complications for the post SCI patient: __________ & ________

3. Mobility, hydration and infection prevention are important issues for the SCI patient. T F

4. Inexsufflation, cough techniques & breathing training are helpful to improve outcome with the SCI patient. T F

5. Periodic re-evaluation of the patient’s respiratory status is essential to good care> T F