Understanding and Managing Respiratory Complications after SCI

The diaphragm, a strong, dome-shaped muscle that separates the abdominal and chest cavities, is normally the main muscle that you use when you inhale. The intercostal muscles are located between the ribs. These muscles help to expand your ribs as you inhale. The neck muscles normally work to expand your upper chest when inhaling. The abdominal muscles work with these other muscle groups to help you breath deeply and cough.

The amount of muscle control that is lost after a spinal cord injury depends on the level of the injury, along with the completeness of the injury. Individuals with injuries below the T12 level do not usually lose any control of the four respiratory muscle groups needed for breathing. This means the respiratory system is not usually affected by injuries in the lumbar or sacral regions of the spinal cord.

Individuals with complete thoracic or cervical injuries do experience a loss of their respiratory muscle control. The higher the level of injury, the greater the loss to the respiratory muscle control.

Complete injuries in the thoracic or cervical regions usually result in the permanent loss of respiratory muscle function below the level of injury. However, if that injury is incomplete, it is impossible to predict whether the individual will regain some or all of their respiratory function below the level of injury.

Injuries in the thoracic area (T1-T12) of the spinal cord affect the control of the intercostal and abdominal muscles. A lower level of injury, such as a T10, results in the individual losing a small amount of muscle control. With a higher level of injury, such as a T2, individuals will lose most of their intercostal and abdominal muscle control.

Complete injuries in the cervical region usually result in a total loss of intercostal and abdominal muscle control. Again, the higher the level of injury, the greater the loss of additional muscle control. For example, a complete injury between levels C3 and C5 loses all control of the diaphragm muscles. With a complete injury at level C3 and higher the individual loses control of all four muscle groups that are needed for breathing. A ventilator is then needed to assist in breathing.

The ventilator does the work of the absent muscles and forces air into the lungs. Many people with a C4 level of injury, and even some people with a C3 level of injury, can eventually breathe without the aid of a ventilator or may only need it for part-time assistance. Those individuals with complete injuries above C3 need a ventilator for full-time assistance.

For persons with high level tetraplegia (C5-C1), ventilatory failure is a common complication after injury. The person typically lacks the ability to breathe without assistance. Another common problem is atelectasis. This is when the lungs partially collapse because not enough air is getting into them. Persons with all levels of injury are at risk for pulmonary embolism. Pulmonary embolism is a blockage in the blood vessels of the lungs by a blood clot. This is the primary disease of pulmonary circulation and the second leading cause of death for persons with SCI within the first year after their injury. In addition individuals with high tetraplegia (C1-C4) are about 100 times more likely to die from diseases of pulmonary circulation, regardless of time after injury, when compared to the general population (See Chart A). Those individuals with paraplegia (T1-S5) are almost 50 times more likely to die from pulmonary embolism. Ventilatory failure, atelectasis and pulmonary embolism are all very serious, life-threatening respiratory complications. However, pneumonia is the leading cause of death for all persons with spinal cord injury. This is true regardless of your level of injury or how long you have been injured.

Chart A
Standardized Mortality Ratio*
for Diseases of Pulmonary Circulation

Time Since Injury	*SMR
<1 Year	210.0
1 - 5 Years	19.1
> 5 Years	8.9
Injury Level	*SMR
C1 - C4	105.0
C5 - C8	64.0
T1 - S5	48.6

from National SCI Statistical Center, 1995

Be aware of the symptoms for pneumonia. They include shortness of breath, having pale skin, a fever, along with a feeling of heavy chest, coughing, and an increase in congestion. If you have symptoms of pneumonia, call a doctor immediately for advice on treatment.

Chart B
Standardized Mortality Ratio*
for Pneumonia and Influenza

Time Since Injury	*SMR
<1 Year	83.8
1 - 5 Years	26.3
> 5 Years	19.0
Injury Level	*SMR
C1 - C4	151.7
C5 - C8	58.7
T1 - S5	12.8

from National SCI Statistical Center, 1995

Because persons with SCI are more likely to develop respiratory complications within the first year after injury, it is very important to take steps to prevent complications during the acute care and rehabilitation stays.

• Treat all symptoms of respiratory complication aggressively to help prevent further complications from developing.
• Everyone with SCI should be vaccinated against (pneumococcal) pneumonia and annually for influenza. 1
• Avoid the buildup of secretion in the lungs. It can be helpful for persons with high level tetraplegia to receive regular treatments with a cough assist machine. Individuals with tracheostomies who are on a ventilator need to have secretions suctioned from their lungs on a regular basis.

Individuals with SCI should also have an ongoing, life-long plan to help prevent respiratory complications.

• Maintain proper posture and mobility. Sit up in your wheelchair everyday and turn regularly in bed to prevent buildup of congestion.
• Cough regularly. You can use a machine to help you cough, have someone perform manual assist coughs, or perform self-assist coughs.
• Wear an abdominal binder to help assist your intercostal and abdominal muscles.
• Follow a healthy diet and manage your weight. Weight management is important because respiratory problems are more likely to occur if you are too underweight or too overweight.
• Drink plenty of water. This helps your body in many ways, and water helps to keep congestion from becoming thick and difficult to cough up.
• Do not smoke. Smoking not only causes cancer, but other harmful effects include a decrease of oxygen in the blood, an increase in congestion in the chest and windpipe, a reduction in your ability to clear secretions from your lungs, a destruction of lung tissue, and an increase in the risk for respiratory infections such as pneumonia and bronchitis.
• Live sensibly. Avoid close contact with people who may have a cold or flu. Avoid areas with dust, smog and other air pollutants.
• See a doctor at least once per year. Your doctor may recommend that you get a chest x-ray or a flu shot.
• Exercise. Every person with spinal cord injury can benefit from some type of exercise. However, it is important to first talk to your doctor to find the right exercise program for you. Participation in athletics and other cardiovascular activities can improve strength and endurance while helping to keep the pulmonary system strong. If you have a high level of injury or do not like strenuous exercise, it may be helpful to do breathing exercises.

Here are 5 breathing exercises that you can do at least 2 times a day to help your pulmonary system.

1. Take a deep breath and hold it for a few seconds before slowly breathing out.
2. Take a deep breath bringing in as much air as you can and as fast as you can before pushing the air out as fast as you can.
3. Take a deep breath and hold it, take another breath and hold it, and take one more before slowly breathing out.
4. Take a deep breath in then breath out counting as long and as fast as you can.
5. If you have a spirometer, use it to both exercise and keep a measurement of your progress.

Secondary Conditions of Spinal Cord Impairment Health Education Video Series - Respiratory Management (2006)
Free video download from the University of Alabama at Birmingham Dept of Physical Medicine and Rehabilitation. Available online at:
http://www.spinalcord.uab.edu/show.asp?durki=97417

Respiratory Management Following Spinal Cord Injury
Guidelines from the Paralyzed Veterans of America designed to meet the needs of persons with recent onset spinal cord injury. Free download at:
http://www.pva.org/site/PageServer?pagename=pubs_main

Common Respiratory Problems in SCI - What You Need to Know (2004)
SCI Forum Reports, University of Washington School of Medicine, NW Regional SCI System
http://sci.washington.edu/info/forums/reports/common_respiratory.asp

CoughAssist® by Respironics
1-800-345-6443 or at http://coughassist.respironics.com/

Vent Users' Support Page
Website that links to information related to ventilators, tracheostomy care and supplies, respiratory care and supplies, research, articles, newsletters, bulletin board and much more.
http://www.makoa.org/vent/index/html