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Spinal CordInjury ManualA publication of theRegional Spinal Cord Injury Centerof the Delaware ValleyThe Regional Spinal Cord Injury Center of the Delaware Valleyprovides a comprehensive program of patient care, communityeducation, and research. It is a federally designated programof Thomas Jefferson University and its affiliated institutionsof Thomas Jefferson University Hospital and MageeRehabilitation Hospital.JG 10-1325

Spinal Cord InjuryPatient-Family Teaching ManualA Publication of theRegional Spinal Cord Injury Centerof the Delaware ValleyResearched and prepared by the clinical personnelof Thomas Jefferson University Hospital andMagee Rehabilitation HospitalAvailable online at:www.spinalcordcenter.org© 1993, 2001 Thomas Jefferson University. This publication is the property of ThomasJefferson University. All rights reserved. This Manual is intended for use in a totalsystem of care that meets all applicable CARF standards for SCI Centers. NeitherThomas Jefferson University Hospital, nor Magee Rehabilitation Hospital is responsiblefor any liability, claims, demands or damages asserted to be the result, either directly orindirectly, of the information contained herein. The use or reprinting of any part of thismanual requires the express permission of Thomas Jefferson University.11.16.09

Regional Spinal Cord Injury Center of the Delaware Valley5-TOC © 2001 RSCIDV 10.23.09

Spinal Cord Injury ManualRespiratoryIntroductionNormalSpinal cord injury can affect normal breathing. The level ofyour injury will determine the effect it will have. It can bedifferent for everyone. For example, the higher the level of yourinjury, the more complications you may face. Good pulmonarycare can assist in keeping you healthy after your spinal cordinjury.The process of breathing (or respiration) is a two-step process:taking in air (inspiration) and exhaling the waste products. Theprocess of taking in air (inhalation) is an active process,requiring the use of many muscles, while the process ofexhaling is a passive process, which occurs when the musclesrelax. The muscles of respiration include the diaphragm, and agroup of muscles called the accessory muscles. The musclesincluded in the “accessory group” include your neck muscles,your chest wall muscles and your abdominal muscles. Thesemuscles are the ones that are used when you run or are stressedand assist the diaphragm in taking in larger amounts of air. Ifyour injury is high enough, the neck accessory muscles maybecome the primary muscles of respiration. By themselves,these muscles are unable to bring in enough air to maintain lifeon a daily basis. When this occurs, assisted ventilation is used.This assistance can be in the form of a ventilator, phrenic (anerve that helps make the muscle of breathing work properly)pacers or other non-invasive methods of breathing. Assistedventilation is used along with other therapies and treatments totry to maintain good pulmonary condition. Without thisassistance, the person could suffer severe tissue damage, braindamage or death.10.16.09 © 2001 RSCIDV 5-1

Regional Spinal Cord Injury Center of the Delaware ValleyDiagram of the Lungs and Alveoli SacsTracheaLungBronchusAlveoli(Air Sacs)RespiratoryComplicationsRespiratory complications with spinal cord injury can occureven with good, every day pulmonary care. Therefore, specialattention should be paid to the respiratory system.5-2 © 2001 RSCIDV 10.16.09

Spinal Cord Injury ManualPotential RespiratoryComplicationsProblem What is it? Symptoms What to doCongestionExcess of mucus inthe lungs.Heavy feeling inyour chestNoisy breathingDry coughWeak/tired feeling• Increase fluidintake.• Respiratorytreatments asordered by yourdoctor.• Get out of bed orat least changeyour positionoften.• Use cough assist,chest vest orsuction as needed• Do yourrespiratoryexercises.Pneumonia /Respiratory TractInfectionA part of the lungthat is invaded bybacteria, food orother substances.Shortness of breathExcess secretionsHeavy feeling inyour chest• Quad AssistCough.• Use cough assist,chest vest orsuction as needed.ElevatedtemperaturePallor• Get out of bed orat least changeyour positionoften.• Increase fluidintake.Mucus PlugAirway that isblocked by thickmucus.Sudden difficultybreathing• Get helpimmediately tohelp clear your airpassage.• Call 9-1-1.10.16.09 © 2001 RSCIDV 5-3

Regional Spinal Cord Injury Center of the Delaware ValleyPulmonaryEmbolismA blood clot thatdetaches from ablood vessel andtravels to the lung,blocking a portion ofit.Shortness of breathSudden and sharpchest painBloody secretionsSweating• Call 9-1-1.Fast pulseRapid breathingPulse ox stays lowPrevention ofComplicationsIn order to help prevent respiratory complications, there areseveral things you can do. Many of these things will be taught toyou by the nurses and therapists. These prevention measuresare things you can do to help prevent problems throughoutyour lifetime.CoughingCoughing helps by clearing thick mucus from the respiratorytract. Make sure you know and understand correct coughingprocedures. These include quad assist cough and incentivespirometer.Breathing ExerciseDeep breathing should be practiced three to four times a day. Itmay be helpful to have a routine and do it the same time everyday. The incentive spirometer should be used.MobilityMoving around as much as possible prevents mucus frompooling in one place. Being active helps to keep the secretionsthin and moving freely.Fluid IntakeLiquids help keep your respiratory tract moist. This helpsprevent your secretions from becoming too thick. You shoulddrink as much fluid as your Bladder Management Programallows. By looking at the color of your urine, you will be able totell if your liquid intake is adequate. Your urine should be paleyellow and clear.Do not smoke! Smoking irritates mucus cells and increasesmucus.5-4 © 2001 RSCIDV 10.16.09

Spinal Cord Injury ManualMoisture HumidityMoist air helps to prevent drying of respiratory tract. If the airis dry around you, it may be helpful to use a cool misthumidifier.HealthBy being in overall good health, you will not only help yourrespiratory tract, but your whole body. Therefore, it is essentialto have good habits of eating, sleeping and exercising regularly.Also, getting yearly flu shots, pneumonia vaccines and stayingaway from other sick people helps your health.Pulmonary CareProper pulmonary care is made up of many factors. Byperforming these, many complications can help to be avoided.Chest Physiotherapy — (CPT) (Clapping)To help loosen mucus in your lungs, you may need someone tohelp you by clapping on your back — over your lungs, and onyour sides below your arm pits.Steps1. Have caregiver remove all jewelry.2. Cover back with towel or sheet.3. Hold hands in cupped shape with fingers curvedand thumb against index finger.4. Clap on your back along the ribs.5. Do not clap over breastbone or spine.10.16.09 © 2001 RSCIDV 5-5

Regional Spinal Cord Injury Center of the Delaware ValleyNote: Clapping should sound hollow — not like you’reslapping someone.Chest Physical Therapy - Back Clapping “Target” Areas5-6 © 2001 RSCIDV 10.16.09

Spinal Cord Injury ManualPostural DrainagePostural drainage is a way of letting gravity help bring up yoursecretions.1. Stay in position for at least five minutes, and then doclapping (CPT)Postural Drainage PositionsOR2. Do clapping while in this position by moving side to side.Note: Postural drainage and CPT are most effective if donein the morning. Do not attempt postural drainageand CPT right before or after a meal because it canupset your stomach.Figure 1 Figure 4Figure 2 Figure 5Figure 3 (Do both sides, only one side shown here)Depending on the extent and nature of your injury, you maynot be able to assume all of the positions as shown. Forexample, an individual who is on a ventillator is restricted bythe air tubes. You may not, for example, be able to get intothe position shown in figure 2. Remember the basic principle isto have gravity assist you in clearing your lungs, to allowadequate time for the secretions to move, and to assist theirmovement by using the clapping or vibration techniques ofChest PT as you are taught by your therapist. Your therapistwill help you adapt these general principles based on yourparticular abilities to meet your individual needs You may findthat using more pillows than shown here is beneficial.10.16.09 © 2001 RSCIDV 5-7

Regional Spinal Cord Injury Center of the Delaware ValleyQuad Assist CoughThis technique is used to help bring up secretions if yourdiaphragm muscles do not work correctly. The diaphragmmuscle is the major muscle of breathing.StepsQuad Assist Cough1. Have a helper place the heel of his or her handunder your rib cage and above your belly button.2. Place their other hand over the first.3. The helper should thrust his or her hands up at thesame time you try to cough.4. Repeat that at least three times or until secretionsare cleared.5. This technique assists the diaphragm muscle.Deep Breathing with Incentive SpirometerDeep breathing helps increase the amount of lung you use. Italso helps bring up extra secretions that are at the bottom ofyour lungs.Steps1. Hold the mouthpiece of the Incentive Spirometerbetween your teeth and close your lips around it.2. Breath out as much air as you can, then take a deepbreath in.3. Attempt to raise and hold the ball as long as youcan.4. Repeat 10 times.5-8 © 2001 RSCIDV 10.16.09

Spinal Cord Injury ManualDeep Breathing without Incentive Spirometer.1. Take deep breath, and hold it as long as you can.2. Blow out air in forceful manner.3. Repeat 10 times.Cough Assist MachineThe cough assist device is a machine that can help spinal cordinjured patients clear their secretions. It is a machine that issimilar to a vacuum that when placed on a tracheotomy or overyour mouth and nose for a few seconds, can bring upsecretions.The cough assist machine is a non-invasive device, whereastracheal suctioning is invasive. The cough assist machine worksby adding positive air pressure, which in turn inflates the lungs.Quickly, this positive pressure is changed to negative airpressure, which contracts the air sacs to get rid of their sputum(mucus coughed up from the lungs). This produces a cough andbrings up secretions. If used often and correctly, the need forinvasive suctioning will be minimal.Benefits of this device include increased patient comfort,improved airway clearance, more cost-effectiveness andcaregiver efficiency.Not all patients with spinal cord injury and tracheotomieswould be appropriate for this device. Patients who have asignificant history of emphysema, chronic obstructivepulmonary disease, major chest trauma or significant heartrhythm problems are not advised to use this machine. Consultwith your doctor.Caregivers and patients can be taught how to use this device.This machine can be rented or purchased. Seewww.coughassist.comThe Vest Airway Clearance SystemThe Vest Airway Clearance System is a device that can helpspinal cord injured patients clear their secretions. It is a noninvasivedevice consiting of an inflatable vest connected bytubes to an air-pulse generator. The generator rapidly inflatesand deflates the vest , compressing and releasing the chest wall.This process is called high frequency chest wall oscillation.Using the Vest System generates increased airflow that createsrepetitive cough like forces and helps the flow of secretions intothe upper airways where they can be more rapidly expelled.10.16.09 © 2001 RSCIDV 5-9

Regional Spinal Cord Injury Center of the Delaware ValleyBenefits of this device include simplicity of operation,consistently effective and reliable treatments of all lung areassimultaneously, and it permits the use of aerosolizedmedications and mechanical ventilation while in use.Typical treatments last from 10 to 20 minutes, and can be usedfrom once a day to every four hours depending on the patient’sclinical condition.Not all patients with spinal cord injury would be appropriatefor this device. Patients with unstable head and neck injury oractive bleeding would not be advised to use this device. Consultwith your doctor.Caregivers and patients can be taught how to use this device.This machine can be rented or purchased. Seewww.thevest.com5-10 © 2001 RSCIDV 10.16.09

Spinal Cord Injury ManualGlossaryBronchiolesBronchusDiaphragmEmphysemaExpirationIncentive SpirometryInspirationPostural DrainageQuad Assist CoughRespiratory TreatmentSecretionsSputumTracheostomySmall air sacs within the lungs.Pathway that air follows into each lung.Muscle that helps with breathing.Abnormal lung condition.Act of exhaling.Device used to assist with deep breathing.Act of inhaling.Technique of positioning the body to drain secretions from thelungs.Manual technique using hands underneath the rib cage to assistin clearing secretions.Inhaler or aerosol medications used to open bronchioles.Mucus in the lungs.Material coughed up from the lungs.A plastic tube surgically implanted to open the trachea to thelungs.10.16.09 © 2001 RSCIDV 5-11

Regional Spinal Cord Injury Center of the Delaware ValleyReferences1. Frownfeller D, Dean E. (Eds): Principles and Practice ofCardiopulmonary Physical Therapy. 3rd edition. St. Louis,MO: Mosby Publishers, 1996.2. Morris KV, Hodgkin JE. Pulmonary RehabilitationAdministration and Patient Education Manual.Gaithersburg, MD: Aspen Publisher, 1996.3. Wilkins RL, Krider SJ, Sheldon RL. Clinical Assessment inRespiratory Care. St. Louis, MO: Mosby Publishers, 2000.4. Consortium for Spinal Cord Medicine. Clinical PracticeGuidelines: Respiratory Management Following SpinalCord Injury: A Clinical Practice Guideline for HealthcareProfessionals. Washington, DC: Paralyzed Veterans ofAmerica, 2005.5-12 © 2001 RSCIDV 10.16.09

Spinal Cord Injury ManualComments and FeedbackThe staff of the center has recently spent a lot of time and effortin revising this manual. However, we realize that those who areactively reading and using the manual can improve it. As a partof our program of continuous quality improvement, we ask youto help guide our efforts to improve the manual.In the next section of the chapter are two forms. The first formis an overview by chapter that seeks to identify those areas ofthe manual that could benefit the most from additional work.We also seek to identify any major areas of concern that havenot been addressed.The second section is a more focused questionnaire that has asits goal the specific items that should be targeted. For example,should an item be added to the glossary or the definitionchanged. Should a drug be added to the discussion of bowelprograms?The more specific the comments are the more likely that we willbe able to make the improvements that form the basis of youridea. By communicating with the Regional Spinal Cord InjuryCenter of the Delaware Valley, however, users grant uspermissionto use any information, suggestions, ideas, drawingsor concents communicated for any purpose we choose,commercial, public or otherwise, without compensation oracknowledgement whatsoever.Thank you for taking the time to assist us in improving thismanual.Sincerely,SCI Manual CommitteeRegional Spinal Cord Injury Center of the Delaware ValleyThomas Jefferson University Hospital132 S. 10th Street375 Main BuildingPhiladelphia, PA 1910710.21.09 © 2001 RSCIDV

Regional Spinal Cord Injury Center of the Delaware ValleyFeedback FormRate each chapter by placing an “X” on the scale underneaththe term that best captures your opinion. Using the next page,provide specific comments regarding your ratings. Feel free tomake copies of the next page.Credits / Front MatterTable of ContentsIntroductionSpinal Cord InjuryBladderBowelRespiratoryRespiratory DependentSkinCardiovascularNutritionActivities of Daily LivingEquipmentMobilityPsychologyVocational ServicesRecreational Therapy /Resource GuideTravel and TransportationSexualitySpinal Cord Injury Follow-UpCare SystemMaster GlossaryNo Opinion Fair Satisfactory Good Excellent© 2001 RSCIDV 10.21.09

Spinal Cord Injury ManualSuggestions and CommentsChapter:Page(s):Comments:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Any terms that need to be added to the glossary? How would you define the terms?Any section or paragraph that was not clear?Any drawing or sketch that would help to illustrate the material being covered?Any additional topic that should be covered?Any questions you have that you feel should have been answered by the manual?What is the question?What is the suggested answer?Any references that should be added? Any other resources that should be mentioned?By communicating with the Regional Spinal Cord Injury Center of the DelawareValley, however, users grant us permission to use any information, suggestions,ideas, drawings or concepts communicated for any purpose we choose,commercial, public or otherwise, without compensation whatsoever.10.21.09 © 2001 RSCIDV

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