The Effects of Assisted Respiratory Training in Patients with TetraplegiaThe Effects of Assisted Respiratory Training in Patients with Tetraplegia ContentsContents

1 - Lung Volume Recruitment (GPB Cases)

- Respiratory muscles training - Therapeutic exercises

- Lung Volume Recruitment (GPB Cases) - Respiratory muscles training

- Therapeutic exercises

세브란스병원 재활병원 물리치료사 민 원 규 세브란스병원 재활병원 물리치료사 민 원 규

The Effects of Assisted

Respiratory Training in Patients with Tetraplegia

The Effects of Assisted

Respiratory Training in Patients with Tetraplegia

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Contents Contents

• Respiratory Interventions

– Lung Volume Recruitment (LVR) è GPB – Assisted Cough

– Inspiratory muscles training (IMT)

– Expiratory muscles training (Abd-FES, etc.)

• Therapeutic exercises

– Neck muscles strengthening : Redcord sling – Neuro-muscular reeducation : key muscles – Automatic W/C (reclined, standing etc.)

• Respiratory Interventions

– Lung Volume Recruitment (LVR) è GPB – Assisted Cough

– Inspiratory muscles training (IMT)

– Expiratory muscles training (Abd-FES, etc.)

• Therapeutic exercises

– Neck muscles strengthening : Redcord sling – Neuro-muscular reeducation : key muscles – Automatic W/C (reclined, standing etc.)

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What are signs of impending respiratory failure?

What are signs of impending respiratory failure?

v Increasing Respiratory Rate

v Decreasing FEV1 ç spirometry test v Decreased FVC ç spirometry test v Decreased inspiratory force

v Neurological level C3 or higher v “Can not count to 15 slowly”

v “VC < 1000cc”

v Increasing Respiratory Rate

v Decreasing FEV1 ç spirometry test v Decreased FVC ç spirometry test v Decreased inspiratory force

v Neurological level C3 or higher v “Can not count to 15 slowly”

v “VC < 1000cc” PM&R Board Q&A's THURSDAY, JULY 31, 2008 3

Respiratory Interventions Respiratory Interventions

• Lung Volume Recruitment (LVR)

1. Resuscitation Bag, Ambu Bag

2. Assist Cough^TM Mechanical In-exsufflator

(old name: Cough machine)

3. Glossopharyngeal Breathing

• Assisted Cough

1. Abdominal Thrust

2. Lateral Costal Compression

• Respiratory muscles training

• Lung Volume Recruitment (LVR)

1. Resuscitation Bag, Ambu Bag

2. Assist Cough^TM Mechanical In-exsufflator

(old name: Cough machine)

3. Glossopharyngeal Breathing

• Assisted Cough

1. Abdominal Thrust

2. Lateral Costal Compression

• Respiratory muscles training

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Lung Volume Recruitment (LVR) Lung Volume Recruitment (LVR)

Benefits

• Increase lung volume

• Improve cough effectiveness

• Decrease atelectasis

• Increase mechanical compliance

• Optimize thoracic range of motion (ROM)

• Increase speaking volume Benefits

• Increase lung volume

• Improve cough effectiveness

• Decrease atelectasis

• Increase mechanical compliance

• Optimize thoracic range of motion (ROM)

• Increase speaking volume

PM&R Board Q&A's THURSDAY, JULY 31, 2008

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Cough Cough

• The minimum peak cough flow (PCF) required to move secretions is 160 L/min (2.67 L/s).

• Reduced lung volumes and weak

abdominal muscles results in an inadequate cough.

• The primary cause of pulmonary infection in the SCI and NMD is the inability to cough effectives and clear the airway.

èRespiratory interventions will improve cough

(Bach JR, 1993)

• The minimum peak cough flow (PCF) required to move secretions is 160 L/min (2.67 L/s).

• Reduced lung volumes and weak

abdominal muscles results in an inadequate cough.

• The primary cause of pulmonary infection in the SCI and NMD is the inability to cough effectives and clear the airway.

èRespiratory interventions will improve cough

(Bach JR, 1993)

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Lung Volume Recruitment (LVR) Lung Volume Recruitment (LVR)

Resuscitation Bag (Ambu bag) Resuscitation Bag (Ambu bag)

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Lung Volume Recruitment (LVR) Lung Volume Recruitment (LVR)

Resuscitation Bag(Ambu bag) : 폐 용적 늘리기 (심호흡, 2~3번 마시고, 숨 참고, 불기, 숨쉬기 ⁾

Resuscitation Bag(Ambu bag) : 폐 용적 늘리기 (심호흡, 2~3번 마시고, 숨 참고, 불기, 숨쉬기 ⁾

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앰부백을 이용하여

개인별 최대호흡능력 평가하기 앰부백을 이용하여

개인별 최대호흡능력 평가하기

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앰부백을 이용 폐 용적 늘리고 기침보조하기

앰부백을 이용 폐 용적 늘리고 기침보조하기

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심호흡할 때 늑골에 저항주어 늑간근 스트레칭 후 흉부마사지

심호흡할 때 늑골에 저항주어 늑간근 스트레칭 후 흉부마사지

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Lung Volume Recruitment (LVR) Lung Volume Recruitment (LVR)

Assist Cough^TM Mechanical In-Exsufflator

= Cough machine

Assist Cough^TM Mechanical In-Exsufflator

= Cough machine

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7

Lung Volume Recruitment (LVR) Lung Volume Recruitment (LVR)

CoughAssist^TM Mechanical In-Exsufflator

= Cough machine

CoughAssist^TM Mechanical In-Exsufflator

= Cough machine

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LVR with

Glossopharyngeal Breathing (GPB) LVR with

Glossopharyngeal Breathing (GPB)

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개구리 호흡이 왜 어려울까?

개구리 호흡이 왜 어려울까?

1. 솔직히 어떻게 가르쳐야 할지 잘 모름.

– 어떻게 혀를 움직이고, air를 packing해야 하는지?

– 처음엔 물리치료사인 저도 시범이 안 되는 상황에서 서로 배워가며 치료를 진행하였음.

2. 호흡기 없이 자가호흡 가능한 환자, 특히 폐활량 이 작은 여자환자, 평생 풍선을 한 번도 제대로 불어보지 못하셨다고 하시는 분들은 …?

3. FVC >800cc,

4. 개구리호흡에 대한 간절함?

1. 솔직히 어떻게 가르쳐야 할지 잘 모름.

– 어떻게 혀를 움직이고, air를 packing해야 하는지?

– 처음엔 물리치료사인 저도 시범이 안 되는 상황에서 서로 배워가며 치료를 진행하였음.

2. 호흡기 없이 자가호흡 가능한 환자, 특히 폐활량 이 작은 여자환자, 평생 풍선을 한 번도 제대로 불어보지 못하셨다고 하시는 분들은 …?

3. FVC >800cc,

4. 개구리호흡에 대한 간절함?

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LVR with GPB

What?

LVR with GPB

What?

• Client’s mouth & throat act as a pump to force air into the lungs (Dail CW, 1951; Collier et al., 1956)

• Laryngeal closure between gulps allows breath stacking (Dail CW, 1951; Collier et al., 1956)

• Known as “frog breathing”

• “1 stroke (gulp) = approximately 60ml”

(Harries & Lawes, 1957)

• “1 cycle = 6 ~ 10 gulps” (Warren, 2002)

• Client’s mouth & throat act as a pump to force air into the lungs (Dail CW, 1951; Collier et al., 1956)

• Laryngeal closure between gulps allows breath stacking (Dail CW, 1951; Collier et al., 1956)

• Known as “frog breathing”

• “1 stroke (gulp) = approximately 60ml”

(Harries & Lawes, 1957)

• “1 cycle = 6 ~ 10 gulps” (Warren, 2002) 15

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LVR with GPB

Learning Process – Stage 1

LVR with GPB

Learning Process – Stage 1

• Say the syllable “ko” “ka”

– Keep tongue close to lower teeth

– Keep jaw still

• Hint: volume is proportional to the descent of the trachea

– Place fingers on your

tracheal cartilages to feel throat movements

• Say the syllable “ko” “ka”

– Keep tongue close to lower teeth

– Keep jaw still

• Hint: volume is proportional to the descent of the trachea

– Place fingers on your

tracheal cartilages to feel

throat movements

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LVR with GPB - Regular Pace LVR with GPB - Regular Pace

until lungs are full and feel stretched until lungs are full and feel stretched

Stage 1

Open the mouth, throat, jaw

Stage 2

Then close only the lip without closing throat & jaw

Stage 3

Move the floor of the mouth up Close jaw

This pumping movement pushes air into the lungs

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CBS News 자료

CBS News 자료 맨 마지막에 spirometer를 불 때, 바늘이 몇 바퀴 돌아

가는지 세어보세요.

(한 바퀴=1,000cc)

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Case è 개구리 호흡의 완결판 Case è 개구리 호흡의 완결판

• 이름: 강** (M/59)

• 진단명: C2(s) ASIA-B

• Rt. C4/5 HCD진단, @@@ 병원에서 cervical

transforaminal C7 ant. epidural & DRG block Rt. side 시술 직후 tetraplegia 발생, respiratory hold 소견 보여 intubation 시행

• @@@@병원 ER 경유 NS adm.하여 ICU care 및 ventilator care 시작

• tracheostomy 시행 - 수차례 weaning을 시도, desaturation(혈액 내 산소감소) 및 BP down è fail

• Pul. rehab위해 강남세브란스 RH 강성웅 선생님 1st adm.

• 이름: 강** (M/59)

• 진단명: C2(s) ASIA-B

• Rt. C4/5 HCD진단, @@@ 병원에서 cervical

transforaminal C7 ant. epidural & DRG block Rt. side 시술 직후 tetraplegia 발생, respiratory hold 소견 보여 intubation 시행

• @@@@병원 ER 경유 NS adm.하여 ICU care 및 ventilator care 시작

• tracheostomy 시행 - 수차례 weaning을 시도, desaturation(혈액 내 산소감소) 및 BP down è fail

• Pul. rehab위해 강남세브란스 RH 강성웅 선생님 1st adm.

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C2(s) ASIA-B, Functional status C2(s) ASIA-B, Functional status

• Functional status:

Ventilator dependent state

• Initial FVC= 440cc, FEV1= 405cc

– In supine without abdominal bandage

• Ventilator setting (respiration rate)

– 18회/분è15회/분è13회/분è

12회/분

• 아주 힘들게 가까스로 1시간 자가호흡

• Functional status:

Ventilator dependent state

• Initial FVC= 440cc, FEV1= 405cc

– In supine without abdominal bandage

• Ventilator setting (respiration rate)

– 18회/분è15회/분è13회/분è

12회/분

• 아주 힘들게 가까스로 1시간 자가호흡

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혹시 옆 그림에서 혀 움직임이 이해가 되시나요?

혹시 옆 그림에서 혀 움직임이 이해가 되시나요?

혀끝을 아랫니에 붙인 상태 로, 혀의 몸통이 벌레가 기 어가듯이 뒤로 움직이는 것

을 잘 살펴보세요.

…

혀가 입천장에 붙었다가 떨 어지면서 나는 소리를 잘

들어보세요

( 빨판이 떨어지는 소리 ).

…

다음 슬라이드에서 혀의 움 직임을 준비했습니다.

혀끝을 아랫니에 붙인 상태 로, 혀의 몸통이 벌레가 기 어가듯이 뒤로 움직이는 것

을 잘 살펴보세요.

…

혀가 입천장에 붙었다가 떨 어지면서 나는 소리를 잘

들어보세요

( 빨판이 떨어지는 소리 ).

…

다음 슬라이드에서 혀의 움 직임을 준비했습니다.

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0 500 1000 1500 2000 2500 3000 3500 4000 4500 cc

치료일자

강주*, C2 FVC(cc)

GPmaxSBC(cc)

Lip closing과 tongue base movement timing을 교육, 하루

저녁 만에 스스로 터득함.

6/16 측정시 GPmaxSBC=2,990cc (1cycle=31gulps) Lip closing과 tongue base movement timing을 교육, 하루

저녁 만에 스스로 터득함.

6/16 측정시 GPmaxSBC=2,990cc (1cycle=31gulps)

1 gulp로 packing하는 air volume 의 increase

6/23 측정시 GPmaxSBC=3,280cc (1cycle = 37gulps) 1 gulp로 packing하는 air volume

의 increase

6/23 측정시 GPmaxSBC=3,280cc (1cycle = 37gulps)

6/5 Initial assessment FVC=450cc

GPmaxSBC(4gulps)=410cc 6/5 Initial assessment FVC=450cc

GPmaxSBC(4gulps)=410cc 7/1 측정시

GPmaxSBC=3,870cc (1cycle = 47gulps)

GPmaxSBC=3,870cc

(1cycle = 47gulps)

Self Breathing Time = Ventilator off time

0 50 100 150 200 250 300

Self breathing time (sum min/day)

힘들게 노력해서 얻은 1시간 힘들게 노력해서

얻은 1시간

편하게 호흡하면서 2시간 편하게 호흡하면서

2시간

편하게 호흡하면서 더 자가호흡을 할 수도 있지만, 치료 & 식사 등 스케쥴로 인해 개구리호흡으로만

호흡하는 시간을 일부러 내기가 어려워서 그냥 4시간.

편하게 호흡하면서 더 자가호흡을 할 수도 있지만, 치료 & 식사 등 스케쥴로 인해 개구리호흡으로만

호흡하는 시간을 일부러 내기가 어려워서 그냥 4시간.

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§The patient had no movement of his diaphragm, yet was able to increase his vital capacity from 250cc to 600cc with the use of GPB. (Warren, 2002)

§The patient had no movement of his diaphragm, yet was able to increase his vital capacity from 250cc to 600cc with the use of GPB. (Warren, 2002)

처음 2주

교육 및 GPB 방법 터득기간?

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6살 8개월 tracheomized, (ventilator dependent state) 10, 11, 12, 13, 20살è22살에 측정

즉, 16년간 follow up 6살 8개월 tracheomized, (ventilator dependent state) 10, 11, 12, 13, 20살è22살에 측정

즉, 16년간 follow up

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Respiratory Interventions Respiratory Interventions

Respiratory muscles training – Inspiratory muscle training (IMT) – Expiratory muscle training (Abd-FES) Respiratory muscles training

– Inspiratory muscle training (IMT) – Expiratory muscle training (Abd-FES)

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유발폐활량측정기

(호흡근 강화훈련하기, 1세트 5~7회 추천)

유발폐활량측정기

(호흡근 강화훈련하기, 1세트 5~7회 추천)

Inspiratory muscle training (IMT) Inspiratory muscle training (IMT)

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Inspiratory muscle training (IMT) Inspiratory muscle training (IMT)

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Inspiratory muscle training (IMT) Inspiratory muscle training (IMT)

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Expiratory muscle training (Abd-FES) Expiratory muscle training (Abd-FES)

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Pulmonary function

Experimental group Control group

Pre-test change Post-test change FU-test Pre-test change Post-test change FU-test

MIC(cc) 1764.0±494.7 166.0±131.4 1930.0±519.0^*** 46.0±254.2 1976.0±612.8 2313.0±420.6 418.0±498.2 2730.0±421.8^*** 66.0±44.0^† 2793.0±392.5^***

FVC(cc) 1388.0±422.0 131.5±112.4 1519.5±383.5^*** 31.0±35.0^† 1550.5±399.0^*** 1951.0±381.1 379.0±332.2 2333.0±418.5^*** 46.0±59.5^††† 2372.0±421.2

FEV1(cc) 1071.0±401.2 30.5±143.3 1101.5±351.3 50.0±82.2 1151.5±390.0^*** 1735.0±429.8 269.0±243.7 1999.0±398.3^** 21.0±45.6^††† 2027.0±376.5 FEV1/FVC(%) 76.7±13.9 30.5±143.3 72.3±12.6 1.6±3.3 73.9±13.6 88.1±4.47 -2.3±3.2 85.8±3.4 -0.6±1.9 85.1±3.2

FVC/MIC(%) 79.9±16.7 -0.1±8.37 79.8±10.8 0.1±7.9 79.9±9.0 85.2±9.3 0.6±6.7 85.7±6.0 -0.5±1.8 85.2±6.0 APCF 180.0±56.2 37.5±40.8 217.5±62.9^*** 14.0±14.1 231.5±63.2^*** 224.0±91.7 59.0±60.1 279.0±72.8^* 6.0±16.6^† 284.0±70.5 UPCF 129.0±62.6 22.0±32.7 151.0±58.3^** 13.5±14.3 164.5±61.8^*** 190.0±89.3 58.0±64.3 245.0±66.5^* 3.0±17.7^† 248.0±59.6

MIC: Maximum insufflation capacity; FVC: forced vital capacity; FEV1: forced exhaled volume in 1 second

APCF: Assisted Peak Cough Flow; UPCF: Unassisted Peak Cough Flow

Expiratory muscle training (Abd-FES) Expiratory muscle training (Abd-FES)

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