We're having a few technical difficulties this morning, so, but I'll go ahead and get this rolling. Welcome everybody to AAP Virtual Didactics. Let's see if we can... There we go. It's more fun if maybe you can see who you're talking to. Welcome everybody to AAP Virtual Didactics. Excited to have everybody today. As always, I want to recognize people who have been most affected by the COVID-19 pandemic, recognize that not all of us have been affected equally. So those of you who have been professionally or personally affected by this more than most, we appreciate your efforts and your hard work on all of our behalf. If there's anything that we can do for you, please let us know. The goals of this series are to augment the didactic curricula that are ongoing at your home institutions, to offload overstretched faculty due to some of the logistical challenges associated with the COVID-19 pandemic, and then to provide additional learning opportunities for off-schedule residents. We recognize that many of us have been pulled off of outpatient rotations or just been shuffled around in general, and we wanted to be able to provide some additional learning opportunities for those who have been affected, as many of us have, to develop further digital learning opportunities and to support physiatrists in general during the COVID-19 pandemic. We are going to keep everybody video and audio muted once we get started here. Again, we're waiting for our speaker to get connected. He was having some difficulty with his connection. If you have any questions, my name is Sterling Herring. I'm a PGY-3 at Vanderbilt. If you click on your participant list, that should be up near the top somewhere. It should say Sterling Herring. You can double-click me and send me a message that I can convey to our presenter. And if you have any bigger questions about the lecture series, any concerns, any suggestions, please reach out to me or to Candice Street. Her email is there on the screen, cstreet.physiatry.org, or you can track us down on Twitter. I do want to – yes, I just got a question. I actually want to address that issue. So upcoming lectures. The last one we have right now is scheduled for the 29th. The plan right now is to go until on or about the 29th. We are reaching out to program directors to kind of get a better feel for – sorry, we're working on these technical difficulties also – get a better feel for when people are going to be kind of ramping back up their clinical schedules and be back kind of on schedule. But it looks like June is the consensus, so we are right now planning to wind these up at the end of May. We do have some fantastic lectures coming up. We just added Dr. Walter Frontera, for example, who many of you know. He's the editor-in-chief of the AJPM&R. If I'm not mistaken, I think he's been the president of every major PM&R society. So we're looking forward to that lecture. He's gracious to speak to us. I think we are ready to go. So if anybody has any questions about any of these lectures, again, we're going to keep all these recordings up through the end of this calendar year. Through 2020. So if you have been unable to watch these or if some of your colleagues have been unable to watch them, please pass that along. Again, physiatry.org slash webinars is where all of those will be located. So without further ado, we're excited to have Dr. Jesse Lieberman back with us. Good morning, Dr. Lieberman. Good morning. How is everybody? Doing well. Thank you for joining us today. Thank you. I'm trying to figure out how to get out of this screen. Sure. I want the PowerPoint. You should be able to click that green arrow, and then it will ask you which screen you want to share. And you kind of take it over from me. So this will stop other screen sharing? Yes. Do you want to continue? Is this good? Looks great. Okay. The talk today is Restorative Management for Spinal Cord Injury. The objective is I'm going to review the respiratory system anatomy and review the components of respiratory dysfunction in SCI. Define the methods to overcome the components of respiratory dysfunction in SCI. Review diaphragmatic pacemakers. I like to always make this patient-related and start out with a case of a 25-year-old male sustaining a C4 complete spinal cord injury where a vehicle crashed four weeks ago. He was in ICU for three weeks and transferred to the floor for two days and hours on your rehab unit. What system is most likely to cause him the most mortality and morbidity? What can we do about it? Of course, this could be respiratory since that's what the title of this talk is. Pulmonary is the number one cause of mortality and morbidity in the first year post-injury. Variety of causes, pulmonary embolism, hydrolysis, pneumonia, respiratory failure, and overall 67% of individuals with acute SCI will have some type of pulmonary condition. And since the respiratory complications of spinal cord injury, most of these are in Asia A's and most of these could be in the high levels. The C1 and C4's are almost all going to have some respiratory issue. C5, I'm a C5, so C5 or C8 is less but still common. And the T1 through T12 less but also still common. Most commonly seen, respiratory complications are most commonly seen in patients with decreased tidal capacity. Our roots export volume. These patients are at great risk for pneumonia. Just going back to our anatomy, the diaphragm comes from C3, C4, and C5. In a pneumonic, most people know from medical school, we know that the diaphragm comes from C3, C4, and C5. Keep the diaphragm alive. Then your intercostals are T1 through T11. Your abdominals are T6 through T1. And you can use your sternocardioid muscle and your scalenes and those with high textoplasia. Just briefly again, the anatomy up top is the sternocardioid muscle and then through the ribcage, you have all the intercostals. At the front, you have the abdomen muscles. Impairments in ventilation and cough, T12 and below typically don't have any, but T5 to T12 will have a weaker cough. As you move up, the cough gets weaker and weaker. In C3s, there's somewhat of a cough, but it's usually very weak. Oftentimes, they require full-time ventilation. In C1 and C2, most of the time, C3. So with this decreased movement strength you have restrictive ventilatory defect. So decrease in all lung volumes and there's an increase in residual volume. You get a paradoxical breathing pattern which is typically when a blind person takes a big uh breath of air the abdomen comes in but in spinal cord injury at least in the more tetraplegia the belly goes out and allows for breathing that way. The higher the diaphragm is the end of expiration of the deeper the breath. There's increased parasympathetic drive, which increases secretions. The sympathetic's come out with the cervicals and so when they're knocked out, it is increased parasympathetic drive. Similar to why you have problems with autonomic dysreflexia. There's a loss of muscles necessary for forceful exhalation. Results in a cough. Adalectosis, or is there adalectosis, can occur from diaphragmatic elevation and hypoventilation due to impaired muscular respiration are all the reasons that those of us with SCI have more respiratory problems. Acute pulmonary management, you want to make sure you secure the airway. These are people who are just injured. Monitor for any patients developing an alexis or infection. Increase in temperatures, change respiratory rate. Increased pulse. The anxiety that comes along with not being able to breathe or feeling air hungry. Increased secretions, overall decreased vital capacity and decreased peak expiratory flow. Consider mechanical ventilation. When the respiratory rate is going up, that's higher as long as you're going down. Typically people need to be mechanically ventilated with a vital capacity less than 1.2. Look also at maximal expiratory pressure. PCO2 levels, PO2 levels. Anybody with a vital capacity, we said you want to give it a 1.5. It looks like we should be on a ventilator at least temporarily. So this is an important slide. If there are no associated pulmonary injuries or respirations at the time of admission, then lung tissue is normal in these patients. If we use a protocol that includes high tidal volumes, unless it's to encourage your patient to later develop ARD asthma pneumonia. But if you're not sure if you're going to be able to breathe or feel air hungry, that's ARD asthma pneumonia. But you really want to ventilate these people with high tidal volumes. The low tidal volumes have been shown to cause adalectosis and spinal cord injury, while high tidal volumes can successfully treat adalectosis. Low tidal volume patients weaned an average of 15.7 days, while the high tidal volumes weaned in 21 days less than that, 37. Low tidal volumes can increase patient anxiety and sensation of distress. And high tidal volumes may increase release of surfactant-driven pulmonary compliance. You start with 15 milliliters per kilogram ideal body weight, based on height, weight, and then increase small increments like one or two milliliters per day, with a maximum of 25 milliliters per kilogram ideal body weight. You want to keep the rate relatively low. Hopefully they're breathing some on their own. And those with C1 and C2s, you may not be able to do that. Peak airway pressure should not exceed 40. Some measures show this can cause embryo trauma. So you have to kind of balance when you're increasing the tidal volumes with watching the peak pressures. You want to avoid PEEP, because we really just want high tidal volumes. We don't necessarily need more pressure. PEEP may not stimulate release of surfactant. Increases main airway pressure, which again goes with this could be a problem as we're increasing tidal volumes. So prognosis for weaning, poor prognosis with high neuroinjury, particularly C3 and above, a greater age, greater than 50, and vital capacity less than one. I want to help them with secretions as much as possible. So the ability to clear secretions could be best on a physical exam. You ask them to check their cough and see how much strength they have in a cough. Watch the accessory muscles while they do that. There are lots of ways we have to clear secretions. One is a CIS cough or a quad cough, where you have the patient try to take a breath in and you do an abdominal thrust and they're laddered and pushing up. This could be very helpful along with, I said, them trying to cough at the same time. Then there's a cough assist machine. I'll show this later. IPVB. Lots of other techniques. There's costopharyngeal breathing, which is breathing like a frog. Deep breathing, a cough. It says spirometry is very important. Chest PT. It's really a combination of all these things that should be done. In and out of diaphragm paralysis, we increase likelihood of developing anaphylaxis on the side of paralysis. This would be assessing things if your methods are not working or not improving. Abdominal complications can put pressure on the diaphragm and add alexis. So we're gonna prevent analexis. We're gonna do all those things I just talked about on the slide before. Let's just cough. Cough assist machine, chest PT. And it says spirometry. So manual assisted cough improves peak respiratory flow about 15 or 33%. Again, you have them start like they're coughing. You push on their abdomen and thrust up and help them assist with the cough. Here's the picture of what I'm talking about. That's what it looks like in bed. Hopefully this looks familiar to some of you. This is a cough assist machine or also known as insufflation, exsufflation. And it's gonna be used on people on the ventilator as well as people not on the ventilator. It was developed in the 1950s for polio patients. Rapid shift in pressure produces high expiratory flow rate. So when you cough, it improves clearance of mucus. You start just with 10 centimeters of H2O and then it gradually increases over time up to 40 centimeters. What does this do? Well, provides higher peak cough flow than manual assisted cough maneuvers. It's already up to 11 liters per second of manual augmentation, showing clear obstructions and plugs. No reported barotrauma or abdominal wound effects. Again, when do you use this? When your patients are unable to cough or clear secretions effectively. When they reduce peak cough expiratory flow less than three to five liters. Those with high spinal cord injuries. Neuromuscular deficits also can be used in ALS and other similar diseases. And severe fatigue associated with intrinsic lung disease. When do we not use mechanical assistance? Issue of bolus emphysema. Known as susceptibility to pneumothorax or pneumoomegastinum. Our recent barotrauma. And those with impaired consciousness and inability to communicate. Should also be used with caution on a cardiac instability. When do they use it? So will patients use the insufflation, exsufflation or cough assist machine? This was published almost 20 years ago. But the answer is yes. 89% preferred mechanical insufflation, exsufflation to suctioning. Almost 90% felt like it was faster, more convenient, more effective. So in order to get powerful clearance for severe weight and global bronchi, this article just added more evidence. This went all the way back to anesthetized dogs in the 1950s. Cane can also be used in other conditions. There are different interfaces to use with the insufflation, exsufflation. Face mask or kind of almost like a suction or tracheostomy. I guess what the machine looks like. Has all the dials and adjustments right on the front. Protocol settings. It takes some experience to adjust by feel, watching the eyes or chest wall. There are typical for adults with inhalation every three seconds, exhalation every two and a pause by one second in between. So it's a little bit more complicated than that. Exhalation every two and a pause by one second in between. Usually you want to do three to five cycles and give them a rest back on the ventilator if appropriate. But you can do this as often as every 10 minutes or usually it's in every couple hours. Saline can also be used to help thin the secretions. So, initially you want to go off slow. Up slow increases tolerated. Always check settings prior to initiation. Give the patient a break if they seem fatigued. Other devices can be used, IPPB, IPPV, that's intermittent positive pressure for breathing. Usually can be administered with bronchodilator. You can start at 10 to 15 centimeters and increase the pressure. As treatment progresses to 40 centimeters. Cost of aerogel breathing. I mentioned earlier it's taking several gulps of air on top of that. This can improve vital capacity for training. Cost of aerogel breathing and improvements in maximum respiratory flow. Chest PT. It does take a little bit of expertise but can be very helpful. It's best with my inpatient on side. Go side to side. Not everybody is going to tolerate laying their head down side to side. But that's how it should be done ideally. Supine positioning as well as for Nellenberg. This can help with increases in vital capacity of IPPV1. Some postural drainage, people on either side, even someone on their stomach, I think, is tolerated. Orcoscopy can be used, if necessary, and clear out the lungs of mucus for patients not able to bring up. BiPAP and CPAP can also be initiated. Suctioning, this is pretty uncomfortable. We do it when we need to. Adverse effects come with it, too. You can see, because of irritation, increased secretions, hypoxia, you may have cardiac arrhythmia. Other things we can use, abdominal binders can improve the PQX for us. There's also preventing a decrease in bladder capacity when sitting. Medications, bronchodilators, antibiotics for those who have infections, eucalyptics to break up the secretions, and antibiotics for those who have heart disease. Eucalyptics to break up the secretions and vaccinations like the flu shots. Diaphragmatic pacemakers, briefly, it's been around for some time now. It was first used in 1971. Our current model was the first one FDA approved. I think this talk has some more data than they've had ever since then. You have to have an intact front end curve, so you have to do an EMG and make sure the front end curve is intact. Then electrodes are placed on diaphragm near front end curves. The wires were connected to external batteries about the size of a remote control. You set a predetermined rate. It should be very cost effective because they prevent pneumonias or prevent hospitalizations. Those who qualify for diaphragmatic pacers or cervical spinal cord injuries usually depend upon mechanical ventilation. Adults have to be medically stable. They have adequate front end curve again. You have to do an EMG to assess that. Adequate oxygenation on the rear of the ear. And get social support. They're excluded for DPS for an unstable diaphragm on the EMG. If they already have a cardiac pacemaker or a specific cardiovascular disease as well as seizure disorder and not approved for children. Here are some pearls. You want to know the level of injury. You want to know the anatomy from the beginning. You're starting at the top and the bottom. You know that the C1s and C2s are going to be completely dependent on the diaphragm. C3, C4, and C5 benefit from the diaphragm, but don't have intercostals or abdomen muscles. As you move down, you get a little stronger. You also want to pay attention to secretions. Increasing pulmonary toilet exams for rheumatria as well as cough assist and mechanical insufflation. Preventing anaphylaxis is key. And providing long-term prevention with vaccinations and smoking cessation programs. So typical orders. We have these in an order set now, but if you had to write them out, you're ready for insufflation, exhalation, or cough assist. Give you four hours a period and prescribe the IPVB abdominal binder for any attempt to stay up. Chest PT with breastfeed drainage. A lot of capacity checks. And gradually increasing tidal volume. Again, let's start at 15 milliliters. Per kilogram, I'd evaluate increase by one to two milliliters per day. Patients just feel better with this. Typical tidal volume we write usually 500, 600. And when you get over 1,000, 1,200, 1,500 if possible, it would just feel much better with those adequate breaths. And you have to keep those pressures down, so PEEP usually has to stay below five. That was all I have. Is there a way for me to ask questions? Yes, I have a question for you. And if anybody has any further questions, they will send them to me and I can kind of pass them along. You mentioned specifically on that last slide or one right there toward the end, you mentioned NIFs and FDCs. First question is, is one preferred over the other? I know you mentioned both of them daily. So part one is, is one preferred over the other? And part two, how long are you doing them daily? When do you expect that to kind of level out? I'm more familiar with the NIFs. And so, yeah, I more look at those. We're only talking about people who are just really teetering. Yeah, that's somebody with tetraplegia who's still breathing on their own, but they're kind of worried about, if they'll need mechanical ventilation or not. Oh, okay. So kind of right on the edge there. Yeah. Okay. Now, so you go with NIFs. Do you know if there's any relative advantage to one over the other or any studies that have supported one over the other? This is something that's come up on our service recently. I think the inpatient or the acute, I wanna say our children's hospital does one and our rehab hospital was leaning toward the other or something like that. So this came up. No, I'm sorry. I don't, I was right. I've heard of a phonologist on that. No, it's fine. I think it's an interesting topic. Well, I appreciate all of this. This has been very interesting. There are a lot of, I think, intricacies to this particular part, and we address this issue, I think, in piecemeal too often. So I appreciate you kind of going through this all together in one lecture. If anyone does have any questions, oh, here's one came up. You mentioned Trendelenburg. Can you explain how that's helpful? Just keeping the drain. So Trendelenburg, we're talking about with the head down on the body, you know, higher. So just helping the drainage, you know, from the lower parts of the lungs, you know, come up more towards the head and be able to come out through suctioning or cough or cough assist, I guess. Oh, okay. Is that something that's done? So I know the idea of using abdominal binder to assist with breathing was explained to me kind of akin to the Frank Starling curve where stretching the diaphragm is going to improve its contractile force. A, I mean, I don't know if that's how that actually works, but that's how it was explained to me. I would think that with Trendelenburg, it would be a similar effect, kind of pushing upward on the diaphragm. Is that something that's done outside of just when you're doing kind of pulmonary toilet? Yeah, I don't see these patients very often, so I can't say yes, we do it all the time. These patients fortunately are few and far between. Okay. I think those things, the abdominal binder, I always wear my abdominal binder when I'm up and then, yeah, the Trendelenburg can both be used. You don't have to use those, they can just be helpful. Okay. Another question came through. What has been your experience with ICU using higher tidal volume when vented? The questioner is saying they've had a challenging time getting them to change to a typical lower tidal volume since the ARDSNet trial. Yeah, yeah, they're always worried about pressures and peak pressures, that's usually the pushback. Unfortunately, if it's not done relatively soon, then people develop pneumonia and ARDS and you can no longer use it. So we have a good relationship with, I'm in Charlotte Carolinas Medical Center, we have a really good relationship with the trauma patients, the trauma team. We don't have to write these orders, they know, you know, we've educated them over time, worked together with them enough that, yeah, they're on board and they know that it works better. If you have a group who's not, just present them an article or two and see if maybe they'll, yeah, read it or be more interested that way. I appreciate that. That's something that we run into too. Even recently, we kind of gently encourage and then kind of gently reinforce in our notes and we printed off copies of articles for everyone on the team. There's, you know, politics involved there as well, but maybe persistence will pay off. Excellent. If anybody else has any questions, feel free to ask. Otherwise, Dr. Lieberman's information is right here. We have his email address, jessie.lieberman at atriumhealth.org. Can they reach out to you directly with any questions that come up? Anytime, sure. Excellent. Thank you very much. For those of you who want to go back and review some of this very helpful information, or if you have colleagues that did not get to see this, physiatry.org slash webinars is where this will be stored. Again, at least through the end of the calendar year 2020. Any questions, please reach out to Dr. Lieberman directly, or if you have any questions about how to access these webinars or anything like that, feel free to reach out to me, Sterling Herring, or you can reach out to AAP on Twitter. Those are our handles. Dr. Lieberman, thank you very much. We appreciate you joining us again today. Thank you. Have a good day. Same to you. Bye. For everyone else.

respiratory dysfunction

spinal cord injury

COVID-19 pandemic

mechanical ventilation

clearing secretions

diaphragmatic pacing

complications prevention