Traumatic Brain Injury & Spinal Chord Injury Respiratory...
Transcript of Traumatic Brain Injury & Spinal Chord Injury Respiratory...
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