NORMAL BREATHING AND THE RESPIRATORY TRACT

NORMAL BREATHING AND THE RESPIRATORY SYSTEM

   The purpose of the respiratory system is to supply oxygen to body tissues and to remove carbon dioxide, which is a waste product, from the body tissues. Breathing is the process by which oxygen in the air is brought into the lungs and into close contact with the blood, which absorbs it and carries it to all parts of the body. At the same time, the blood gives up carbon dioxide, which is carried out of the lungs with air breathed out.

Upper Respiratory System

The parts of the upper respiratory system are illustrated above.

The Nasal cavity or Nose is the preferred entrance for outside air to enter into the respiratory system.

The Oral cavity or Mouth is an alternative way for air to enter the respiratory system.

The Pharynx or Throat collects incoming air from the nose and mouth and passes it downward to the trachea (windpipe).

The Epiglottis is a flap of tissue that guards the entrance to the trachea, closing when anything is swallowed in order to prevent food or fluid from entering the lungs.

The Larynx or Voice Box contains two vocal cords. Air moving through the larynx creates voice sounds.

The Esophagus is the passage leading from the mouth and throat to the stomach.

The Trachea or Windpipe is the passage leading from the pharynx to the lungs.

The Bronchi or Tubes are the two main tubes into the lung that divide from the trachea. The bronchi subdivide into the lobar bronchi -- three on the right side and two on the left. These, in turn, subdivide further.

Lower Respiratory System

The parts of the lower respiratory system are illustrated above.

The Bronchioles are the smallest subdivisions of the bronchi, at the end of which are the alveoli (plural of alveolus).

The Alveoli are the very small air sacs that are the destination of inhaled air. The capillaries are blood vessels that are imbedded in the walls of the alveoli. The blood discharges carbon dioxide into the alveoli and takes up oxygen from the air in the alveoli.

The Lungs are elastic organs with sponge-like tissue. Inhalation requires an active effort, whereas exhalation occurs automatically. The right lung is divided into three lobes and the left is divided into two lobes.

The Pleura are the two membranes (actually one continuous membrane folded on itself) that surround each lobe of the lungs and separate the lungs from the chest wall. The pleural space is the space between the two pleura.

Diaphragm is the strong wall of muscle that separates the chest cavity from the abdominal cavity. By moving downwards, it creates suction to draw in air and expand the lungs.

Ribs are bones separating and protecting the chest cavity. They move to a limited degree, helping the lungs to expand and contract.

Nerve and Muscles of the Respiratory System

    When a spinal cord injury occurs, the lungs and the alveoli remain the same. However, just as the injury affects the nerves that control the muscles of the arms and legs, it also affects the nerves that activate the muscles used for breathing.

There are four sets of muscles that control the respiratory system.

• The Diaphragm
• The Intercostal Muscles
• The Abdominal Muscles, and
• The Accessory Muscles

The Diaphragm is a dome-shaped muscle, which separates the chest from the abdominal cavity. It is the major muscle and the one that begins the inhalation process. During inhalation, the diaphragm contracts and moves downwards, pushing out the abdomen and creating suction which draws in the air and expands the lungs.

The nerves responsible for stimulating and diaphragm and causing it to contract are called phrenic nerves. These nerves originate at the spinal cord at the C-3, C-4 and C-5 level (cervical 3-5) and travel downward, attaching themselves to the diaphragm. Therefore, spinal cord injury, which occurs at the C-1 through C-5 levels, may result in partial or complete paralysis of the diaphragm.

The Intercostal muscles are located between the ribs, and are activated by the intercostal nerve, T-1 through T-11 (thoracic 1-11). These muscles act to increase and decrease the diameter of the chest cage. The ability to take a deep breath and cough is affected by the loss of the intercostal muscles.

The Abdominal muscles originate at the T-6 through L-1 (lumbar) levels, and are the most essential for an effective cough. When the abdominal muscles contract, the diaphragm is forced upward and coughing or forcefully blowing out air results.

The Accessory muscles are located in the neck and receive their stimulation from the spinal cord nerves in the C-1 through C-3 region. They act to elevate the rib cage and can assist in deep respiration. However, they alone are not sufficient to support deep ventilation.

For further information on the cervical, thoracic, and lumbar areas of the spinal cord, see Movement Disorders in SCI.

BREATHING AND THE RESPIRATORY SYSTEM IN SCI

     If the spinal cord injury occurs in C-3 or higher, the phrenic nerve is no longer stimulated and the diaphragm does not function. This means the individual will need mechanical assistance - a ventilator - to breathe.

     Persons with spinal cord injury at the mid-thoracic level and higher will have trouble taking a deep breath and exhaling forcefully. They have also lost the ability to forcefully cough or to cough with even normal force because of the loss of the intercostal and/or abdominal muscles. This loss of the ability to cough can lead to lung congestion and respiratory infections.

LUNG CONGESTION

Lung Congestion and Chest Cold

    You can help prevent collection of the secretions that can cause lung congestion and respiratory complications and keep the secretions thin, loose, and easy to bring up by:

• Deep breathing
• Coughing
• Turning at least every two hours while in bed
• Drinking adequate amounts of fluids
• Sitting up for short intervals (if no fever is present)
• Using postural drainage
• Using percussion

In Deep breathing, you expand the air sacs of the lungs. This expansion of the air sacs helps to keep them from becoming blocked with mucus. Deep breathe at least once an hour when you are aware. Use an incentive spirometer or other equipment to help you breathe deeply.

Coughing will expel the mucous secretions. If you cannot cough on your own, you will need help to cough. This is called an assisted cough.

Click on Postural drainage and Percussion for more information on these preventive measures.

     If you are a quadriplegic or high paraplegic, call the doctor even if you have a small amount of congestion. Don't wait until you have a fever.

PNEUMONIA

Pneumonia

Pneumonia is an infection of the lungs. The symptoms include:

• Pain (if able to feel it; pain is sometimes "referred" to shoulder in quadriplegics).
• Fever
• Shortness of breath
• Feeling of tightness in the chest
• Cough that produces secretions
• If tracheotomy is present, may have changes in secretions, such as increased amount and a change in color to green or yellow, and/or
• Weakness, fatigue, nausea, decreased appetite.

The treatment of pneumonia includes:

• Contact your physician
• Begin procedures to drain the particular area of lung involved, such as:
  • Respiratory treatments if prescribed by physician
  • Postural drainage
  • Percussion
  • Assisted coughing and/or increased suctioning if you have tracheostomy
  • Vaporizer to loosen congestion (cool mist type is preferred)

ATELECTASIS

Atelectasis

     Atelectasis may be a total or partial collapse of the air sacs (alveoli) in the lung causing a lack of air to the affected area of the lung. The symptoms include:

• Shortness of breath
• Thick secretions with change in color
• Possible pain
• Feeling of tightness in chest, and/or
• Fever

The treatment of Atelectasis includes:

• Contact your physician
• Since an airway blocked by mucus (mucous plug) may have caused the lung to collapse beyond the blockage, drainage procedures such as respiratory treatments, postural drainage, percussion, and assisted coughing should be started, and
• Deep breathing exercise may be helpful in re-expanding the lungs. An incentive spirometer may be used.

CHOKING

Choking

     It is important that you inform people with whom you spend time how to help you if you should choke.

• If you begin choking, they should ask if you can speak.
• If you can speak, they should use assisted coughing.
• If you cannot speak, they should:
  • apply four back blows (sharp blows between the shoulder blades with the palm of their hand)
  • apply four manual thrusts (assisted cough)
  • repeat four back blows and four manual thrusts until they are effective.
  • Call Emergency Medical Services if the above procedure is not effective.

RESPIRATORY TREATMENTS WITH A NEBULIZER

   If respiratory medication needs to be delivered directly to the lungs, this can be accomplished with a nebulizer, if prescribed by your physician. Indications for this treatment are:

• Tightness in chest
• Increased or thick secretions
• Pneumonia (congestion) and/or
• Atelectasis

Reasons to avoid the treatment include:

• Increased blood pressure (autonomic hyperreflexia)
• Increased pulse
• History of adverse reaction to the medication.

The following equipment is needed for respiratory treatments with a nebulizer:

• Nebulizer
• Compressor oxygen tank (to drive nebulizer)
• Oxygen tubing
• Respiratory medication
• Normal saline (cc vials)

Following is the procedure for treatments with a nebulizer:

• Remove cup portion of the nebulizer
• Draw up prescribed amount of the mediation in the eye dropper
• Place medication in the medicine cup with 3cc normal saline
• Return cup to the nebulizer
• Place oxygen tubing on the nipple on the nebulizer and attach other end to the compressor or oxygen tank
• Turn on the compressor or tank until mist is seen coming out of the mouthpiece.
• Check pulse
• Place the mouthpiece in your mouth and take slow, deep breaths. If on a ventilator, the nebulizer can be placed in line in the ventilator circuit. To do this, remove the mouthpiece and connect the nebulizer between the dead space tubing and the exhalation valve assembly.
• During the treatment, monitor the pulse. If the pulse increases to more than 20 beats a minute, discontinue the treatment. Otherwise, continue until the medication is used up.
• Following the treatment, use postural drainage, percussion, assisted coughing and/or suctioning, as appropriate.

   Often, the effects of the treatment are most apparent 15-20 minutes later, and you may need assisted coughing or suctioning at that time.

PERCUSSION

Percussion

   Percussion can be used while you are in a postural drainage position to dislodge and mobilize secretions from the air sacs into larger airways so they can be coughed up or suctioned. This is accomplished by forcefully tapping over the affected areas of the chest. Indications for percussion are:

• Presence of thick or excessive mucus
• Inability to raise mucus with assisted cough.

Reasons to avoid percussion include:

• Chest pain
• Fractured ribs
• Irregular pulse, or
• Tendency to bleed (taking Heparin or Coumadin or if pulmonary embolus exists).

Following is the procedure for percussion:

• Lie in a postural draining position, i.e. with your chest elevated above your head, so affected area is elevated. Lie on the left side if the right side is to be percussed, or, lie on the right side if the left side is to be percussed.
• Place towel over the area to be percussed.
• Hand should be cupped, with the tip of the thumb at the side of the middle joint of the index finger. Fingers should be straight and held closed. Assistant should remove all jewelry.

  

• With hand in this cupped position, forcefully tap the rib cage over the affected area, using a smooth rhythm and keeping the arms and shoulders relaxed. (The motion is similar to playing a bongo drum).

• Percuss for 1-2 minutes. Always avoid percussing over the spinal column and the kidneys.

• Use suction or assisted cough, following each position.

ASSISTED COUGH

Assisted Cough
(Quad Cough)

   By having someone assist you in coughing, your cough will be more forceful and productive and you will be able to both prevent and treat some respiratory complications by bringing up secretions normally present in the lung. Indications for an assisted cough are:

• Weak or ineffective cough, and/or
• Excessive secretions

Reasons to avoid an assisted cough are:

• Pain
• Internal problems, such as abdominal complications, where pushing on the abdomen could cause more complications
• Chest injury ( broken ribs)
• Flail chest, where the chest has excessive mobility, usually due to paralysis of the muscles which control it.

Following is the procedure for an assisted cough:

• Place the fist of one hand, immediately below the breastbone, and the heel of the other hand on top of the breastbone. The hands need to be over the diaphragm area.

  

   

• The hand position may vary from the illustration, but the hands must be below the ribs.

• Take a breath and cough as you exhale the air. Your assistant should push inward and upwards as you cough. NOTE: If you are on a ventilator, your assistant should push during inhalation. An ambu-bag may be substituted for the ventilator for a stronger cough.

• Repeat, as necessary, with rest periods, as needed, between efforts

   Assisted coughing can be used while in bed or sitting up. Be sure the brakes of your wheelchair are locked before assisting cough.

   If lung congestion is present, assisted coughing is more effective when combined with postural drainage.

POSTURAL DRAINAGE

Postural Drainage

   To drain the middle and lower portions of your lungs, you should be positioned with your chest above your head. Possible techniques to achieve this position are:

• If a hospital bed is available, put in Trendelenburg position (head lower than feet)
• Place 3-5 wood blocks, that are 2 inches by 4 inches, in a stack that is 5 inches high, under the foot of a regular bed. Blocks should have indentations or a 1 inch rim on top so that the bed does not slip
• Stack 18-20 inches of pillow under hips.

  

   

• Place on a tilt table, with head lower than feet.

• Lower head and chest over the side of the bed.

   To drain the upper portions of your lungs, you should be in a sitting position at about a 45 degree angle.

   When you are in the proper postural drainage position, change your position per the following sequence:

• Turn side to side
• Lay on stomach
• Lay on back

Remain in each position approximately five to ten minutes. Use suction or assisted cough before changing position to insure removal of any secretions drained while in that position. Postural draining is usually taught by your physical therapist.

TRACHEOTOMY CARE

Caring for your Tracheotomy

Preventing Water from Entering Tracheotomy - Following are some of the ways you can prevent water from entering your tracheotomy:

• Do not swim
• When showering: direct the water spray at chest level, and place the shower shield over your tracheotomy or hold a dry washcloth in your teeth.
• Keep soap and water from entering your tracheotomy when washing your face
• Use care when powders, after shave, or aerosols are directed toward your face
• Avoid contact with people with respiratory infections (colds)

Suctioning - The following equipment is needed for suctioning your tracheotomy tube.

• Sterile suction kit
• Normal saline solution
• Suction machine
• Ambu-bag

Following is the procedure for suctioning:

• Wash your hands, and then open the sterile suction kit
• Put on the sterile gloves. Keep your dominant hand "sterile" by making sure you do not touch the outside of the glove that is going on your dominant hand.
• Using your dominant "sterile" hand, attach the sterile suction catheter to the suction tubing which you will hold in your non-dominant "dirty" hand.
• Using your non-dominant "dirty" hand, attach the ambu-bag to the tracheotomy tube and give 3-5 "deep breaths".
• Remove the ambu-bag from the tracheotomy tube. With your dominant "sterile" hand, insert the suction catheter into the tracheotomy tube, keeping your non-dominant thumb off the suction port. Insert the catheter as far as it will go without using force.
• Place your non-dominant "dirty" thumb over the suction port to produce suction. Rotate the catheter between your dominant "sterile" thumb and forefinger, gradually withdrawing the catheter. As you withdraw the catheter from the tracheotomy tube, apply intermittent suction by moving your non-dominant "dirty" thumb up and down on the suction port. Do not suction for longer than 10-15 seconds.
• Flush the suction catheter with the sterile solution in the suction kit.
• Again, attach the ambu-bag to the tracheotomy tube and, using your non-dominant "dirty" hand, give 3-5 deep breaths.

   If secretions are thick, squeeze normal saline into the tracheotomy tube. With your non-dominant "dirty" hand, use the ambu-bag to give deep breaths and then repeat the suction technique. This will help "thin" secretions.

   You may suction your mouth after your tracheotomy tube has been suctioned. Never suction your mouth and then your tracheotomy.

Cleaning the Suction Catheter - Suction catheters must be cleaned after each use to keep to prevent putting bacteria into your tracheotomy when you use the catheter. The following equipment is needed to clean the suction catheter:

• Soap
• Tap water
• Cooled boiled water
• Bulb syringe
• Dry, clean towel or handi-wipe

Following is the procedure for cleaning the suction catheter:

• Wash the suction catheter with soap and water, using the bulb syringe to force soapy water and rinse water through the catheter
• Rinse catheter in boiled water
• Dry catheter with lint-free cloth or handi-wipe
• Store catheter in a dry towel or in a clean baggie (several catheters can be stored together)

   Throw catheter away if secretions cannot be removed, or if catheter becomes cloudy or cracks.

Cleaning the inner cannula - The inner, removable tube of the tracheotomy tube is the inner cannula. Secretions must be removed from the inner cannula to keep the tracheotomy tube open. Following is the procedure for cleaning the inner cannula tube:

• Wash your hands
• Gently remove the inner cannula
• Wash with mild soap and tap water; rinse very well in boiled water. If secretions are hard to remove, soak in Hydrogen Peroxide or normal saline; use a small percolator brush to clean secretions from the inside of the inner cannula
• Suction through the outer cannula
• Shake excess moisture from the inner cannula, removing lint.
• Grasp the collar of the outer cannula and insert inner cannula; lock in place
• Wash skin around the tracheotomy with soap and water; rinse well with tap water and dry with a clean cloth
• If there are secretions around the tracheotomy tube, apply folded 4" x 4" dressing

Tracheotomy with Dressing

    The inner cannula needs to be cleaned at least once a day (cleaning every 8 hours is best). Skin around the tracheotomy can also be cleaned at the same time. Do not leave a regular inner cannula out more than 10-15 minutes while cleaning. Inner cannula can be stored in a clean jar with a lid.

Cleaning connecting tubes on suction machine - These tubes must be cleaned to prevent too many bacteria from getting into the suction equipment. Clean daily with soap and water; rinse well with hot water.

Cleaning drainage bottle - The drainage bottle must be emptied once a day. Clean it with soapy water and rinse it well with hot water.