Spinal Cord Injury Rehabilitation - Jane L. Wetzel

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Respiratory Evaluation of 14
Individuals with Spinal
Cord Injury
Jane L.Wetzel, PT, PhD
After reading this chapter, the reader will be able to:

• Describe how gravity, body position, and respiratory muscle actions
influence ventilation
OBJECTIVES
• Identify the primary and accessory muscles involved in ventilation

• Describe important medical information needed prior to initiating an
examination of respiratory function
• Appropriately review the level of ventilator support and safely conduct
a respiratory evaluation for an individual with spinal cord injury who is
using mechanical ventilation
• Describe the purpose of each test and measure for respiratory function
and its relevance to physical therapy for individuals with spinal injuries
• Identify how specialized testing may be useful in setting goals and
directing the plan of care for individuals with respiratory limitations
OUTLINE
NORMAL RESPIRATION: IMPLICATIONS FOR INDIVIDUALS Chest Wall Excursion
WITH SPINAL CORD INJURY Posture and Breathing Strategy
Factors Influencing Respiratory Function Muscle Examination
Ventilation and the Musculoskeletal System Cough Examination
Inspiratory Actions Auscultation
Expiratory Actions Phonation
HISTORY AND MEDICAL STATUS: IMPACT Specialized Testing of Pulmonary Function and
ON RESPIRATORY FUNCTION Respiratory Muscle Performance.
History Pulmonary Function and Respiratory Muscle Strength
Medical Status Pulmonary Function and Respiratory Muscle Endurance
PHYSICAL THERAPY EXAMINATION OF RESPIRATORY Respiratory Muscle Fatigue and Dyspnea
FUNCTION
Pulmonary Function and Cough Effectiveness
Clinical Tests and Measures
SUMMARY
Vital Signs
REVIEW QUESTIONS
Arterial Blood Gases
Breathing Pattern
1
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2 Spinal Cord Injury Rehabilitation
Normal Respiration: Implications

for Individuals With Spinal Cord Injury
Factors Influencing Respiratory Function
A
Any examination of respiratory function includes
observing the individual as he or she breathes. The
action of breathing begins with the contraction of
the muscles of inspiration acting to expand a flexible
thoracic cage. Through the action of these muscles,
intrathoracic pressure is lowered, allowing the lungs to
expand. The pressure inside the lungs becomes lower
than atmospheric pressure and air moves into the lungs.1
Expiration, during quiet breathing, occurs when the
inspiratory muscles relax; there is a passive recoiling of
the lungs and chest wall. The pressure in the thorax and
lungs is increased relative to the atmosphere, and air
moves out of the lungs. During an examination of respi-
ratory function, the therapist observes and compares
normal respiratory actions to those in the individual
with spinal cord injury (SCI) and then selects tests and
measures to describe the quality of breathing.
The therapist uses the examination findings to interpret
which factors are contributing to any respiratory dysfunc-
tion. Interpretation and sound clinical decision making
B
require an in-depth understanding of how respiratory
muscle actions, body positioning, and gravity work to- Figure 14S-1. Influence of gravity on alveolar opening and
gether. Once these factors are analyzed, the therapist knows perfusion in healthy lungs. Reprinted with permission from:
how breathing is affected when the individual with SCI Frownfelter D,Dean E, editors. Cardiovascular and Pulmonary
changes body position or presents with varying degrees of Physical Therapy, 4th edition. St. Louis, Mosby Elsevier;
muscle paralysis. The most effective interventions can then 2006. p. 79.
be offered to achieve an optimal body position.
Ventilatory demands are influenced by gravitational When the therapist observes breathing in a healthy
forces and internal elastic forces in the lungs and chest individual who is in a sitting position, lateral costal
wall. Normally, the respiratory muscles are relaxed at the expansion is easily observed, while little movement is
end of a quiet tidal volume (TV) breath, and there is no seen in the upper thoracic regions. Lateral costal expan-
air flow moving in or out of the lungs. The lungs remain sion occurs as new air is moves into the lower, more com-
partially inflated due to the opposition of two elastic pliant dependent airways during inspiration. If the same
forces: 1) the tendency of the chest wall to move or recoil individual is placed in the Trendelenberg position (with
outward from a compressed position, and 2) the tendency the head down), the lower lobes of the lung are in the
of the lungs to move inward due to their elastic recoil.1 The uppermost (least-dependent) position, and the alveoli
opposing forces create a negative force in the intrapleural there become stiff and open due to the effects of gravity.
space between the chest wall and the lungs, which creates While this position may facilitate drainage of secretions,
a partial opening of the airways even when the respiratory it increases the work of breathing. Many individuals with
muscles are relaxed. The pressure that opens the airways is SCI will need regular changes in body position. In each
also influenced by gravity. The dependent regions have new position, gravity changes the regional intrapleural
less negativity in the intrapleural space surrounding them, pressure and the distribution of alveolar opening pres-
thereby leaving the airways in a nearly closed position. sures. Positional changes may enhance or limit the indi-
However, the uppermost regions have the greatest opposi- vidual’s ability to breathe comfortably.
tion between the chest wall and the lungs, causing the A flexible chest wall preserves proper negative
intrapleural space to be more negative and thus leaving the intrapleural pressures. Additionally, the chest wall elastic
airways in a more open position relative to dependent air- forces assist the inspiratory muscles in overcoming
ways (Fig. 14S-1).2 The uppermost airways are stiff, filled resting inertia and lung recoiling tendency in early inspi-
with air, and do not accept as much new air with each new ration. This minimizes the work of breathing and is
breath. Dependent airways have a smaller amount of important when respiratory muscles are weak. Once an
opening pressure, but they are more compliant and easier individual loses mobility of the chest, it becomes more dif-
to fill with new air when the inspiratory muscles contract. ficult to initiate inspiration. The chest wall elastic forces
Chapter 14 Respiratory Evaluation of Individuals with Spinal Cord Injury 3
and gravitational influences that keep the lungs partially ventilation. Ventilation is the action of air moving from
open also help prevent atelectasis and minimize the risk the atmosphere into the lungs. It occurs when there is
of pneumonia. integrated action of both muscles and skeletal motions.
The influence of gravity and body positioning on Respiration occurs when atmospheric gases are exchanged
opening pressures will differ according to the level of between the lung and the circulation. The musculoskeletal
injury for individuals with SCI.3 Opening pressures are pump is responsible for ventilation, and the lungs and
not only influenced by passive tendency of the chest wall pulmonary circulation are responsible for respiration. The
to expand outward but also by the tonic activity of the therapist applies important musculoskeletal and kinematic
respiratory muscles, particularly the intercostal muscles.4 expertise to define the actions of the musculoskeletal
Loss of intercostal muscle activity in cervical SCI is pump as part of the evaluation of respiratory function.
thought to contribute to a decrease in outward pull of the Examination of respiration involves review of the medical
chest wall at rest, further increasing the potential for tests and is discussed later (see “History and Medical
atelectasis and respiratory complications.4,5 Individuals Status” section below).
with cervical and high thoracic SCI have decreased func- The musculoskeletal pump has a muscle component
tional residual capacity (FRC) and expiratory reserve and a skeletal component. The skeletal component, or
volume (ERV) at rest and a lower vital capacity (VC) thorax, is composed of a sternum and ribs with flexible
(Fig. 14S-2; see also the appendix in chapter 14, costal cartilage between them that allows anterior expan-
“Management of Respiratory Dysfunction”).5 The higher sion of the chest wall to occur easily. The ribs also attach
the level of injury, the greater the loss of volume.6 posteriorly to the thoracic vertebrae at the costovertebral
Compared with the supine position, VC is typically and costotransverse articulations.11 The rotational move-
greater in the sitting position for the healthy individual,7 ments of the ribs on the thoracic vertebrae are small but
yet moving from supine to sitting decreases the VC and important for permitting larger movement in the lateral
corresponds to an increase in ERV and residual volume and anterior dimensions. During inspiration, the sternum
(RV) in individuals with a higher paraplegia or cervical moves anteriorly and elevates as the chest expands in the
SCI.4, 8–10 Therefore, examination of the respiratory sys- anterior-posterior dimension (pump handle motion).12
tem in the supine position may not accurately predict The ribs move laterally and elevate as the chest expands in
ventilatory function in sitting or standing postures. the transverse dimension (bucket handle motion).12
Clinically, on inspiration there is greater anterior and
Ventilation and the Musculoskeletal lateral movement than there is motion in the posterior
System dimension. This is because only ribs 1 to 7 attach directly
to the sternum, which is attached only to the clavicles,
Chest wall mobility occurs normally when the skeletal whereas ribs 8 to 12 are attached through costal cartilage
articulations and muscles are moving freely in a coordi- or float. Thus, the thorax moves easily in the anterior
nated manner. The therapist will examine the skeletal and lateral planes.11 Thoracic expansion also occurs in a
articulations for normal range and excursion during cephalocaudal dimension as diaphragm contraction
breathing and observe the respiratory muscle actions. occurs.13 Some individuals with cervical SCI actually have
Normal range and strength is necessary for good a decrease in chest wall expansion during inspiration,
causing a negative value when measured by a circumfer-
ential tape measure.11,14-16 If the chest wall loses the flexi-
bility for movement in these dimensions, the work of
breathing increases.17
IRV
IC The muscle component of the musculoskeletal pump
VC consists of three primary muscle groups: diaphragm,
TLC TV chest wall muscles (intercostals, parasternal, and
scalenes),18–20 and abdominal muscles.11 The diaphragm is
ERV the primary muscle of ventilation and is responsible for
FRC approximately two-thirds of the change in vertical
RC RV dimension or 40% of the change in quiet TV breathing
while sitting.16,21 However, during maximal deep breath-
Figure 14S-2. Lung volumes and capacities. TLC, total lung ing (sometimes called VC breathing) in nondisabled indi-
capacity; VC, vital capacity; RV, residual volume; IC, inspiratory viduals, the diaphragm is responsible for as much as 60%
capacity; FRC, functional residual capacity; TV, tidal to 75% of the VC, which reaches approximately 5000 ml
volume; IRV, inspiratory reserve volume; ERV, expiratory in young males.13,16,22–24 The diaphragm has two halves,
reserve volume. From: Sheel AW, Reid WD, Townson AF, and each half is innervated by separate portions of the
Ayas N.: Respiratory management following spinal cord injury.
In: Eng JJ, Teasell RW, Miller WC et al, editors. Spinal Cord phrenic nerve (C3–C5). There are three parts to each
Injury Rehabilitation Evidence. Vancouver: International hemidiaphragm: sternal, crural (lumbar), and costal
Collaboration on Repair Discoveries (ICORD); 2006. (from ribs 7 to 10).18,25 All fibers converge to insert into a
central tendon. The costal portion forms the dome, and abdominal pressure, the mobile thoracic cage expands in
the crural fibers arise from the upper lumbar vertebrae multiple planes (Fig. 14S-4).11,29
up to the central tendon (Fig. 14S-3). As the diaphragm Additionally, with the descent of the diaphragm, a
contracts, the crural portion stabilizes the central tendon. negative intrathoracic pressure gradient is created that
Contraction of the dome-shaped costal fibers results in causes air to flow into the lungs.1 The negative force
flattening of the diaphragm as the contraction of the generated by the diaphragm and other muscles of inspi-
crural portion causes the central tendon to descend.21 ration can be measured and used to estimate respiratory
muscle strength. Negative inspiratory force (NIF),
Inspiratory Actions or maximal inspiratory pressure (MIP), normally
falls between −65 and −125 cm H2O with maximal
As the diaphragm contracts, it pushes down on the effort.19,30,31
abdominal contents. Normally, abdominal muscle tone External intercostal muscles (segmentally innervated
(innervated segmentally; T5–T12) stabilizes the abdomi- by the intercostal nerves; T1–T12) also assist with
nal contents.18 As intra-abdominal pressure rises, the dis- inspiratory effort by elevating the ribs in addition to
placement of the diaphragm moves the ribs laterally and providing a stabilizing influence on the thoracic
the sternum anteriorly.26–28 This action occurs only if the wall.4,21,32,33 The scalenes, considered to be primary mus-
intercostal muscles are actively stabilizing the chest wall.4 cles of inspiration along with parasternal intercostal
Once the diaphragm motion meets with the opposing muscles, assist in elevating and expanding the rib cage
Central tendon Xiphoid process
Costal
cartilage
Esophagus
Vena cava
Aorta
Quadratus
L2 lumborum
L3
Psoas major
Figure 14S-3. Anatomy of the diaphragm: transverse view of the costal and cural. Attachments with central tendon and open-
ings for esophageal and inferior venal cava. (Reproduced with permission from: Reid WD, Dechman G. Considerations
when testing and training the respiratory muscles. Physical Therapy. 1995; 75(11):971–982.)
trapezius, rhomboid major and minor, levator costarum,

latissimus dorsi, and erector spinae all function as acces-
sory muscles of ventilation.35 The origins, insertions,
and segmental innervations of these muscles, along with
the significant muscle action of each, are summarized in
Table 14S-1. The scalenes are also included among the
accessory muscles, as they may be contracting excessively
in an effort to substitute for diaphragm weakness.
Abdominal muscles can contribute to inspiration in
the presence of a weak diaphragm. The active contrac-
tion of the abdominal muscles compresses the abdomi-
nal contents, forcing the diaphragm to ascend into the
thorax. This position then improves the length-tension
relationship of the diaphragm prior to inspiration.32
This action may occur in individuals who have motor-
incomplete cervical injuries. Consideration of any residual
muscles, especially accessory muscle actions, is important
when evaluating respiratory function and selecting and
ordering equipment (see Table 14S-1).
Expiratory Actions
There are two important expiratory functions: passive
expiration during TV breathing and forced expiration for
coughing and airway clearance. Most individuals with
SCI have lost abdominal muscle function and have poor
cough function. Expiration for quiet TV breathing is
usually considered a passive process; however, this
Figure 14S-4. Respiratory muscle action on thoracic expansion. depends upon adequate lung inflation and chest wall
Diaphragm descent acts to expand thorax when opposed by ele-
vated intra-abdominal pressure. Abdominal muscle tone stability. Those individuals with SCI who have poor
restricts visceral motion to allow pressure to increase. Adapted inspiratory muscle function and decreased chest mobility
from: Massery M. Multisystem consequences of impaired also have poor quality to passive expiration. At the end of
breathing mechanics and/or postural control. In: Frownfelter inspiration, after the lungs and chest wall are expanded,
D,Dean E., editors: Cardiovascular and Pulmonary Physical the respiratory muscles relax and the passive elastic recoil
Therapy: Evidence and Practice. 4th edition. St. Louis: Mosby
Elsevier; 2006. p. 696.) returns them to their resting state. The elastic recoiling
increases intrathoracic pressure and air moves out of
the lungs.1
The capacity for passive expiration declines when a
during inspiration.18,19 The action of the scalenes in person loses the elastic lung tissue responses due to lung
addition to a number of accessory muscles of ventilation, disease or loses chest wall recoiling tendency due to
particularly the sternocleidomastoids,34 contribute propor- immobility or aging. Also, if the individual has poor
tionally more force generation when ventilatory demands inspiratory capacity secondary to weak respiratory mus-
are exaggerated, such as during running or aerobic activ- cles or contracture of the chest wall, initially the ability
ities. When the scalenes, sternocleidomastoids, and for passive expiration may also be diminished due to lim-
accessory muscles are used excessively during TV ited expansion. Active contraction of the abdominal mus-
breathing, it is usually an indication of impaired cles, internal intercostals, and some accessory muscles
respiratory status.16 The use of excessive scalene and may be observed during TV expiration in those with
accessory muscle breathing is not uncommon in persons motor-incomplete SCIs.5 This is especially true if residual
with cervical injuries to the spinal cord. inspiratory muscle function is less effective than expiratory
Accessory muscle actions appear when there is an muscle function.
increased demand (secretions or restricted airways) on the Typically, in healthy individuals the abdominal and
pulmonary system or when there is a need to substitute internal intercostals muscles are concentrically active
for a weakened or absent diaphragm. Accessory muscles during forced expiration for coughing, yelling, or during
may be required for postural or scapular stabilization or periods of excessive ventilatory demand (e.g., run-
they may be used in a reverse muscle action to expand or ning).26,36 These functions are diminished in many
elevate the rib cage.21 The sternocleidomastoid, levator persons with SCI. Maximal expiratory pressure (MEP)
scapulae, pectoralis major and minor, serratus anterior, can be measured and used to estimate the strength of
Table 14S-1
Accessory Muscles of Ventilation
Action/Significance Equipment or Therapeutic
Muscle Innervation Origin & Insertion* to Ventilation Consideration
Sternocleido- C2 O1: Sternum, manubrium Elevates the Test the strength of the cervical
mastoid O2: Clavicle-anterior sternum in the A-P extensors and upper trapezius
surface medial 1/3 dimension when to stabilize occiput (≥ 4/5?);
I:Temporal bone, mastoid the head is fixated. Consider headrest extension
process, occiput. on W/C if extensors are weak.
Keep back rest slightly reclined
to allow weight of occiput to
stabilize properly if cervical
extensors and upper trapezius
are weak.
Scalenes C3–C6 O: Superior surface of Elevates the first

C3–C8 vertebral two ribs.
transverse process.
I: 1st and 2nd ribs
Levator C3–C5 O: C1 Atlas; C2 axis and Elevates and adducts Observe head positioning for
scapulae C3 transverse scapula to act as a imbalances. Consider lateral
processes. fixator for pectoralis head support on headrest.
I:Vertebral boarder of minor.
scapula—root of spine
to superior angle.
Pectoralis C6–C8 O: Ribs 3–5, Aponeurosis Elevates ribs 3–5 Test the strength of the middle
minor of intercostal muscles. when scapulae are trapezius and rhomboids as
I: Coracoid process, stabilized. stabilizer muscles.
medial border, superior
surface.
Pectoralis C5–T1 O1: Clavicle-Anterior Draws the ribs Check strength of upper and
major surface of sternal 1/2. toward the arms lower fibers to determine
O2: Sternum—1/2 when the humerus potential to contribute to
anterior surface & ribs is fixated in ventilation.
1–7. shoulder flexion Consider full-length armrests or
and abduction lab board to support upper
I: Humerus–lateral border,
(about 30 to extremities. Arm work may
intertubercular sulcus.
60 degrees). interfere with breathing in
those with motor-incomplete
injuries. Use platform supports
on walker during ambulation.
Serratus C5–C7 O: Ribs 1–8 superior and When scapulae are Same as for pectoralis major.
anterior outer surface digitations. fixed in abduction, Check scapular stabilizers
Aponeurosis of SA can elevate the (≥4/5?). Excessive UE depression
intercostal muscles. ribs. activities may stretch the SA,
I: Scapula-Ventral surface producing scapular winging.
of entire vertebral Overstretch weakness of SA
border. may also compromise
ventilatory capacity in those
with motor-incomplete injuries.
Table 14S-1
Accessory Muscles of Ventilation—cont’d
Trapezius C3–C4 O1: Occiput-external Upper portion Check strength of upper and
protuberance and elevation of scapula middle trapezius (≥ 4/5?) in
medial 1/3 of superior and shoulder, those who rely on accessory
nuchal line. Ligamentum rotation of head, muscles to breath.
nuchae and C7 vertebral cervical and capital Consider headrest support
spinous process. extension. when trapezius is weak. Initiate
O2:T1–T6 vertebral Stabilizes the head strengthening program for
spinous processes and and neck to allow trapezius.
spurapinous ligaments. more effective
contraction of
O3:T7–T12 vertebral
sternocleido-
spinous processes.
maistoid.
I1: Clavicle-lateral 1/3
Middle/lower:
posterior surface.
Scapular adduction
Anterior acromion
stabilizes the scapula
process.
to permit effective
I2: Scapula- medial margin contraction of SA
of acromion and for inspiration.
superior lip of posterior
boarder of spine.
I3: Scapula- aponeurosis at
root of spine, tubercle
at apex of surface at
root.
Rhomboid C5 O:T2–T5 vertebral Scapular adduction, Check strength of the

major spinous processes, elevation and rhomboids as scapular
supraspinal ligament. downward rotation. stabilizers (≥ 4/5?). Initiate
I: Scapula-medial border Stabilizes scapular strengthening program for
between root of spine to improve contri- rhomboids.
and inferior angle below. bution of other
accessory muscles.
Rhomboid C5 O: C7–T1 vertebral As above

minor spinous processes and
ligamentum nuchae.
I: Scapula-root of spine,
medial border.
Latissimus C6–C8 O:T6–T12 and L1–L5 Active in forced Consider methods to permit
dorsi vertebral spinous expiration. arm support when ventilatory
processes; ribs 9–12, Assists with deep reserve is limited.
inferior angle of scapula inspiration when
and ilium-posterior 1/3 humerus is fixed.
iliac crest.
I: Humerus-
intertubercular grove
Continued
Table 14S-1
Accessory Muscles of Ventilation—cont’d
Erector spinae Spinal O: C4–L5 vertebral and Extend the spine Test strength of erector spinae
• Iliocostalis nerves spinous processes. during inspiration, for postural support when
• Longissimus segmentally I: Ribs and vertebral causing further lowering the backrest height.
• Spialis spinous processes. elevation of Inadequate back extensor
• Semispinalis the ribs. strength may compromise
See anatomy text for
• Multifidi stability for accessory muscle
details.*
use. Diaphragm mechanics and
rib mobility may be disrupted,
creating excessive kyphosis,
which decreases inspiratory
volume.
Levator T1–T12 O: C7 and T1–T11 Elevation of the ribs Watch restrictive clothing or use
costarum vertebral spinous for inspiration. of abdominal binder for individuals
processes. Assists action of with motor-incomplete injuries
I: Rib immediately below the external who may depend on external
transverse process of intercostals. intercostals and levatores
vertebrae on which costarum action for inspiration.
origin attaches.
Abdominals T5–T12 See anatomy text for Primary muscles If abdominal muscles are weak
• Rectus details* involved in forced or low tone, consider
abdominus expiration required abdominal binder to improve
• Transverus for cough function. diaphragm function.
abdominus Important role in
• Obliquus proper diaphragm
internus mechanics.
• Obliquus
Acts as an
externus
accessory muscle
to force the viscera
into the thoracic
cavity and placing a
weak diaphragm in
more optimal
length-tension for
contractions.
*Consult anatomy textbook for greater details on origin and insertion.

Sources: Hislop HJ, Montgomery J, Connelly B et al. Daniels and Worthingham’s Muscle Testing. 6th edition. Philadelphia:W.B. Saunders; 1995. Dean E.
Cardiopulmonary anatomy. In: Frownfelter D, Dean E, editors. Cardiovascular and Pulmonary Physical Therapy: Evidence and Practice. 4th edition. St. Louis: Mosby
Elsevier; 2006. Clemente, CD, editor. Gray’s Anatomy of the Human Body. 30th edition. Philadelphia: Lippincott,Williams & Wilkins; 1985.
O = origin; I = Insertion; A-P = Anterior/posterior;W/C = wheelchair; SA = serratus anterior; UE = upper extremity.
the expiratory muscles. In nondisabled individuals, MEP lungs are near the end of expiration (at FRC). This type
is typically between 85 and 240 cm H2O.19,31 Most of control is important to proper speech production.
individuals with SCI will have decreased MEP and Normally, phonation of a vowel sound may last for as
impaired cough function due to impaired abdominal long as 15 seconds.11,40 Speech production may be dis-
muscle strength.37,38 However, cough function may also turbed in individuals with high cervical lesions and with
be reduced if the inspiratory capacity is decreased.39 vocal cord paralysis.41,42 Larger inspiratory volumes assist
Eccentric control of expiration occurs by releasing the in compensating for poor expiratory capacity in those
muscles of inspiration slowly until the chest wall and with paralysis of abdominal, expiratory intercostal, and
accessory muscles.41 Some individuals with motor- and respiratory muscle performance (NIF, MIP, MEP,
incomplete injuries may have poor eccentric control but maximal voluntary ventilation [MVV]) are typically
may still be able to use concentric contraction of their compared to expected values reported in the literature
residual expiratory muscles to generate adequate flow.11 and reported as a percentage of normative values (i.e.,
percent predicted).30,44 For example, if the typical VC,
History and Medical Status: Impact for a young, 23-year-old male who is 5 feet10 inches
tall is 5000 ml, and the individual with a C6 motor-
on Respiratory Function complete tetraplegia (having similar gender, height,
History and age) demonstrates a VC of 1000 ml, the VC for
the individual with SCI is 20% of the expected or
Prior to an examination of respiratory function, the predicted value. A variety of pulmonary function and
therapist thoroughly reviews the history and present respiratory muscle measures are recorded in the med-
medical status. The process begins with a review of ical chart. The severity of respiratory dysfunction can
general demographics, including age, gender, and eth- be inferred by comparisons to norms and recorded
nicity, as well as height and weight. All of these factors using percentage of the predicted values.44 Examples of
are known to be important in prediction of normal lung respiratory function measures are listed according to
and ventilatory muscle functions.23,30,31,43,44 Measures of level of injury in Table 14-1 in chapter 14. A list of all
pulmonary impairment (VC, forced expiratory volume tests and measures of respiratory function referred to
in 1 second [FEV1], peak expiratory flow rate [PEFR]) in this chapter appears in Table 14S-2.
Table 14S-2
Examination Parameters Impacting on Respiratory Function
Clinical Measures Normal Values Clinical Significance
Blood pressure (BP) 120/80 Hg Diaphragm excursion may be limited if low

BP; possible fainting
Heart rate (HR) 50–95 b/min Low oxygenation of blood or febrile state
• Pulse Regular rhythm (pneumonia) may contribute to tachycardia
• EKG or irregular rhythms
Even R to R; normal PQRS
Respiratory rate (RR) rest 12–20 breaths/min 35 MV support needed
ABGs:
• PaO2 80–100 mm Hg PaO2 ↓ PaO2 or SaO2 Poor V/Q match
• SaO2 95–100% SaO2 (atelectasis, ↓ lung respiration)
• PaCO2 35–45 mm Hg PaCO2 ↑ PaCO2 or ETCO2 hypoventilation
• ETCO2 35–45 ETCO2 (↑ somnolence, ↓ attention span)
Temperature 98.5° F Infection if elevated; pneumonia?

(↑risk of fatigue)
Breathing pattern 2 Chest: 2 Diaphragm Inefficient breathing ↑ fatigue if abnormal

pattern (respiratory alternans, paradoxical)
Chest Wall Excursion (See Table 14S–3) ↓ CWE ↑ WOB

• Axilla/UCWE Axilla 4.75–8.5 cm Xiphoid Axillary paradoxical
• Xiphoid/MCWE Xiphoid 4.75–8.25 cm
↑ LCWE ↓ diaphragm action
• Lower/LCWE Lower No norms
Posture Erect alignment all planes ↑ kyphosis may ↓ pulmonary function
Pulmonary function Use age, gender & height to VC 10 ml/kg Ideal BW Need MV
• FVC determine percent predicted VC below 80% pred. respiratory muscle
FVC: 5000 ml (23 yr male, 6’0”) weakness present.
Continued
Table 14S-2
Examination Parameters Impacting on Respiratory Function —cont’d
Clinical Measures Normal Values Clinical Significance
• FEV1 FEV: 4000 ml (23 yr male, 6’0”) FEV 1 below 80% pred. respiratory muscle
100% predicted contractile velocity impaired;
• PEFR PEFR: 9–10 L/sec Possible flow restriction/poor cough (request
• PCFR PCFR: 6–20 L/sec medications)
300–700 L/min
Ventilatory muscle
strength
• Inspiratory MIP values: MIP 30 mm Hg
MIP 130–105 mm Hg (males) MV discontinuation is difficult
NIF
100–70 mm Hg (females)
PImax
• Expiratory MEP values: MEP declines with higher levels of injury
MEP 240–140 mm Hg (males) ↓ cough and ↑ risk of infection
PEmax
165–90 mm Hg (females)
Ventilatory muscle Percent predicted using May assist in determining intensity for
endurance normative values Ventilatory muscle training (VMT)
• MVV
• Serial MIP
• Serial MEP
• SIP
Cough function Functional if capable of Weak or nonfunction ↑ risk for

forcefully and repetitively pneumonia, respiratory complications
expelling air
Auscultation of lung fields Clear Coarse rales pneumonia

No adventitious sounds Sonorous rhonchi mucus
Wheeze restriction to airflow
MV = Mechanical ventilation; PaO2 partial pressure of oxygen in arterial blood; PaCO2 = partial pressure of carbon dioxide in arterial blood;
SaO2 = saturation of hemoglobin with O2; ETCO2 = End tidal carbon dioxide
A thorough review of factors related to the social Individuals living with chronic SCI have a greater risk of
history, employment and role functions, living environ- mortality if they are obese, continue to smoke, or have
ment (pollution or toxins), health habits (smoking or diabetes or heart disease.49,50 Education on prevention
non-smoking), and any family history of cardiovascular and management of chronic diseases needs to be included
diseases will help identify any pre-morbid factors that in the therapeutic plan.
may impact respiratory function and contribute to pro- Taking the history includes a review of prior level
longed recovery. Any smoking history and associated of functioning. It is important to establish the level of
lung disease may prolong the need for mechanical ventilatory demand required when the individual is fully
ventilation. Obesity is known to reduce lung volumes functional in all his or her roles. For example, a person
and cause alterations in respiratory muscle mechanics as who has a job that is relatively sedentary and does
well as introducing negative influence on health status.45-47 not participate in recreational sports may be able to
Excess body weight may predispose the person with a recover enough ventilation to support returning to
SCI to further elevations in partial pressure of carbon their routine, while another individual may be very
dioxide (Pa CO2) and increase the risk for sleep apnea.48 active in social and employment roles requiring more
ventilation.51 Additionally, if there are many activities mm Hg) may indicate a problem with gas exchange due
that involve arm work, this may place an added demand to a pulmonary infection. Supplemental oxygen may be
on the muscles of ventilation.52,53 Individuals with necessary, and a series of chest radiographs are usually
motor-incomplete injuries may have adequate ventila- ordered to further define the problem.
tion for general activities of daily living but may lack the Chest radiographs help determine the presence of
respiratory muscle strength and endurance required to infiltrates or the extent of atelectasis.60 Location and
sustain ventilation for activities with higher metabolic extent of pulmonary infiltrate or atelectasis will affect
demands, such as may be required to return to work preferred positioning during the physical therapy exami-
full time. nation and influence the plan of care.56 The therapist
should confirm the findings on chest radiographs
Medical Status through an auscultatory examination of lung sounds,61
which will assist in decision making for prescribing an
When gathering information from the medical team, the airway clearance program. The cause of the infiltrate will
therapist ascertains what medical and surgical pro- need to be determined and medically managed. A swal-
cedures were performed, to determine how the individ- lowing evaluation may be indicated to determine if the
ual’s respiratory status is likely to be influenced. The individual is at risk for aspiration.62 During the acute
therapist reviews a series of special tests to determine stage, a speech therapy consult is usually ordered to
how well the individual with SCI is able to use the lungs evaluate swallowing and to examine air control for those
for gas exchange. A review of the arterial blood gases, who have a tracheostomy that permits vocalization.
lung function, and observations from chest radiographs Individuals who aspirate should be identified so the
is necessary to ensure safe and effective treatment. Any risks of aspiration can be managed by the entire medical
precautions or contraindications to positioning or team.63 Aspiration into the lungs may contribute to
mobility also need to be identified before the muscu- atelectasis and scarring of lung tissues and may be pre-
loskeletal examination can begin. cipitated by obligatory supine posturing, lack of head
There are often pulmonary complications due to trau- movement, anterior cervical spine surgery, spinal shock,
ma sustained at the time of injury. It is not uncommon to and tracheotomy with poor cuff inflation.63 Swallowing
see traumatic injuries such as rib fracture, contusions to dysfunction may increase the risk for aspiration.
the lung or heart, and trauma to the diaphragm. Approximately 22.5% of individuals with cervical SCI
Traumatic injuries may result in pleural effusions, pneu- have swallowing dysfunction at the end of the acute care
mothorax, or hemopneumothorax. Chest tubes, invasive stay.64 The therapist will need to comply with any pre-
lines, or drains may be in place. The therapist needs to be cautions pertaining to oral intake (e.g., water, thin
familiar with precautions for mobilizing individuals with liquids).
these devices.54 Since chest wall trauma and autonomic Chest radiographs may also be used to examine the
dysfunction occur in many individuals with SCI, the position of the diaphragm. Normally, the right hemidi-
electrocardiogram (EKG) should be reviewed. In addi- aphragm is 1 to 2 cm higher than the left, and both
tion, respiratory anomalies can distort the chest wall hemidiaphragms sit just above the ninth rib when the
mechanics and place a strain on the heart. image is taken during deep inspiration in the supine
Early mobility is critically important to prevent throm- position.61 When there is extreme elevation in one or
boembolic disorders. The incidence of pulmonary emboli both hemidiaphragms, this may indicate paralysis.19 It is
is approximately 5% in individuals with SCI;55 however, possible to have weakness or paralysis in just one
pharmacological prophylaxis is difficult and may increase hemidiaphragm. Diaphragm activity may be inferred
the risk of bleeding.56 The therapist should review lab from double exposure roentgenograms comparing the
reports for complete blood count (white blood cells, diaphragmatic border at the end of deep inspiration (to
platelets, hematocrit, and hemoglobin) and metabolic total lung capacity, or TLC) to the position at the end of
parameters (electrolytes, arterial blood gasses [ABGs], full expiration (to RV). The diaphragmatic border
and glucose) in addition to coagulation profiles before should move three to four intercostal spaces.15,16,60 The
examining any individual with SCI.57 Presence of fever greater the change in the location of the diaphragmatic
may indicate the onset of pulmonary emboli, pneumonia, border, the more diaphragmatic excursion and ventilatory
or other infections such as sepsis that may further weaken reserve.
respiratory muscle function.58 Once the individual is medically stable, a video fluo-
Arterial blood gases are drawn and routinely recorded roscopy evaluation may be conducted to examine dynamic
in the medical chart during the acute stage. An individual diaphragmatic motion and further define swallowing func-
who has an elevated PaCO2 (50 mm Hg) and high res- tion, especially in those with multiple trauma (e.g., brain
piratory rate (RR; 30 breaths/minute) may be in need injuries).16,62 The therapist may want to be present during
of mechanical ventilation.59 Elevations in PaCO2 indicate the fluoroscopy assessment to adjust the seating system to
hypoventilation and often occur in individuals with optimize breathing and decrease the risk of aspiration.
significant respiratory muscle weakness. Low PaO2 (60 Magnetic resonance imaging, ultrasonography, computed
tomography, positron emission tomography, and radionu- rising respiratory rates lead to the need for mechanical
clide ventilation-perfusion scans are other procedures that ventilation in many.68
may be used to examine the chest wall, diaphragm, and About one-third of all those with cervical injuries
other cardiopulmonary functions.19,60 require intubation.71,72 Harrop et al.73 recently reported
Surgical instrumentation and fixation procedures that tracheostomy was necessary in more than 80% of
often determine body positioning. Examination position those with tetraplegia at C5 and above, and in less than
and the presence of body jackets or halo vests will influence 35% of those with injuries at C6 and below. According to
ventilatory mechanics. A halo vest may decrease VC Como et al.,72 of those individuals with SCI entering level
(5% predicted) in the individual who is breathing in a 1 trauma centers, continuing need for mechanical ventila-
supine position compared to breathing without a halo tion is required in 55% of those with motor-complete
vest.65 A body jacket or thoracic lumbar spinal orthosis cervical SCI upon discharge to the next level of care.
may improve breathing mechanics in the upright posi- Individuals who are less likely to survive may have
tion in those with high thoracic injuries, yet may lower advanced directives that have been issued by their power
lung capacity in those with lower thoracic injuries.66 of attorney.63 It is important that the therapist is aware of
Some individuals with motor-incomplete injuries may any “no code” orders written in the medical record.
depend on abdominal wall distension and require a relief Once the individual has been intubated, several
hole cut out of the front of the thoracic lumbar spinal important questions should be asked. Did the intubation
orthosis to permit outward movement of the abdomen result in temporary airway management or does the indi-
and better breathing mechanics.67 vidual now have a tracheostomy? Does the tracheostomy
Spasticity, particularly in the abdominal wall and inter- allow the person to speak? The examination is much
costals muscles, will also affect the mechanics of breathing, easier to conduct when good communication strategies
improving the length tension of the diaphragm in sitting and interpersonal rapport are established. The therapist
for some individuals.47,68 On the contrary, spasticity may will also need to plan for tracheal suctioning, especially if
also inhibit chest wall movement.69 Medications that are there is a history of copious secretions. Tracheal suction-
taken to reduce spasticity will also affect the muscles of ing requires thorough training in correct technique and
ventilation.70 The therapist should note the timing of these an understanding of contraindications (see Ciesla56 for
medications and any change in respiratory status. Each complete description). Individuals who are assisted by
person will need individualized assessment of the impact of mechanical ventilation are at increased risk for pneumonia
spasticity on the mechanics of breathing. with risk of occurrence increasing by 1% to 3% per day of
The therapist should review the chart for medica- intubation.68,74 Careful hand washing and observance of
tions. Some of the more common medications include universal precautions should be strictly followed.
bronchodilators (promote surfactant distribution), When a person is receiving mechanical ventilation,
anabolic steroids (oxandralone; increase muscle mass), the type of support must be determined (see Table 14-4
and methylxanthines (aminophylline, theophylline; in chapter 14). Is the individual receiving full-time or
increase diaphragmatic contractility).63 Pre-morbid lung partial mechanical ventilator support? Full support
conditions may also dictate a need for steroids (methyl- modes such as control mode ventilation (CMV) suggest
prenisolone) and anti-inflammatory agents (cromolyn severe impairment, as the machine is doing all of the
sodium) to control airway reactivity in those prone to work of breathing. Partial support modes such as syn-
asthma or in older individuals with obstructive disease. chronized intermittent mandatory ventilation (SIMV)
The individual’s participation in respiratory muscle and pressure support ventilation (PSV) allow the individual
re-education and strengthening may be assisted with the to participate in breathing, permitting active contraction
proper medication regime. of the respiratory muscles.56 Some individuals will be able
Approximately 70% of all individuals with SCI who to speak briefly during the examination.
are classified as AIS (see chapter 1, “Spinal Cord Injury: For individuals requiring mechanical ventilation, the
An Overview”) A, B, or C will have respiratory complica- mode of ventilation and orders for weaning (referred to
tions during their hospitalization.55 Therefore, daily as “ventilation discontinuation trials”) should be noted.
review of tests for pulmonary function (VC, FEV1), res- Initial physical therapy sessions should not interfere with
piratory muscle strength (NIF, MIP, or MEP), and ABGs ventilator discontinuation trials. Prior to treatment, the
will be important in order to understand current respira- therapist should determine the individual’s tolerance or
tory status and the potential for recovery. Initially, for breathing time off the ventilator. Perhaps the individual
those with higher levels of injury, there may be a mild can be briefly removed from the ventilator during a
hypoxemia (decreased PaO2) resulting from shallow rapid transfer from bed to wheelchair. It may also be important
breathing. This breathing pattern increases dead space to briefly remove the person from the ventilator to
ventilation and limits the amount of new air available to perform an accurate respiratory system examination
participate in alveolar ventilation and gas exchange. (respiratory rate, observe breathing pattern, take chest
PaCO2 becomes elevated, rising goes from a normal level expansion measures). The work of breathing will be
of 40 mm Hg to nearly 50 mm Hg. Hypercapnea and elevated during this time, and any additional therapeutic
activities could raise the metabolic demand and the need of atelectasis and pneumonia. Presence of signs and
for breathing. symptoms of fatigue may indicate the need to return the
When ventilator support is removed or the individ- individual to some form of mechanical ventilation. If an
ual changes position, an alarm may sound. There are individual has marginal respiratory status, then functional
many types of alarms that may signal during a therapy training should occur while the individual is connected to
session. However, the most commonly triggered are the ventilator or a manual resuscitation bag many be
(1) high-pressure/volume alarms that sound when there applied. The therapist may need to plan for physical
is obstruction in the airway (mucous plug, water in the assistance during bed mobility and transfers. Someone
line, coughing, movement from supine to sitting will need to support the tubing around the tracheostomy
upright, or tube occlusion in bedrail or wheelchair) and site or assist with a manual resuscitation bag during func-
(2) low-pressure/volume alarms that sound when there tional training.
is a leak in the system (tubing becomes disconnected).
Planning for suctioning prior to treatment and clearing Physical Therapy Examination
the water from the ventilator tubing can reduce the fre-
of Respiratory Function
quency of high-pressure alarms. Checking the secure
fitting of ventilator tubing and supporting it well during After the therapist is familiar with the medical history
transfers may prevent triggering of low-pressure and the medical management plan, a time may be selected
alarms. An alarm also sounds to signal a power outage. for the physical therapy examination. It is important that
Most ventilators will have a backup battery as a power the person is well rested at the time of the exam. All air-
source; however hospitals may have designated outlets way clearance and suctioning, ventilator discontinuation
that are connected directly to a backup generator.63 The trials, and meals should occur prior to the exam, with
ventilator should always be connected to a wall outlet enough time to allow the person to rest comfortably in
that defaults to a back-up generator in case of power the preferred test position. If a great deal of energy is
outage. expended to position the individual, the exam may not be
If the individual is able to breathe spontaneously, the accurate. A supine position with 10 to 15 degrees of
amount of time off support may be noted. Sometimes a elevation of the head of the bed is optimal for testing
form of noninvasive support is employed for those who ventilatory function for those with partial diaphragm
are able to breathe spontaneously but need partial venti- function.15 This allows appropriate positioning to man-
lation support to prevent fatigue or maintain the ABGs at age risk of aspiration and optimizes the mechanical
an optimal level. When an individual can breathe sponta- advantage for diaphragm contraction. Throughout the
neously, sometimes mechanical ventilation airflow can be exam, the therapist must be cognizant of the status of any
delivered by mask or nasal airway adjuncts to the mouth individual who is marginally able to breathe without
and upper nasal regions instead of through an endotra- ventilator support. Tests and measures should be priori-
cheal or tracheostomy tube. This method is considered tized and the session kept brief for those with decreased
noninvasive ventilation (NIV or NIPPV; see Table 14-4 tolerance for time off mechanical ventilation.11
in chapter 14) because there are no tubes inserted into
the trachea. Pressurized air from the ventilator may be Clinical Tests and Measures
delivered continuously at one pressure throughout the
respiratory cycle or with higher pressures during inspira- The selection of tests and measures for the person with
tion. Often continuous positive airway pressure (CPAP) SCI will vary depending on the stage of the injury (acute
at 5 to 10 cm H2O or bi-level positive airway pressure vs chronic) and the level of injury (high cervical, low
(Bi-PAP) using 10–20 cm H2O during inspiration and cervical/high thoracic, or mid- to low thoracic). The
5 to 10 cm H2O for expiration, is adequate to maintain individual with an acute high cervical injury will require
airway stability, decrease PaCO2) and prevent progressive ventilator support and tolerate few assessments in a
atelectasis.63,75,76 single therapeutic session. The person with a mid to low
Individuals may also receive noninvasive ventilation if thoracic lesion may be relatively free from problems
there is a history of sleep apnea.77,78 Presence of sleep related to poor inspiratory capacity and primarily need an
apnea may result in decreased attention span and poor examination of cough function and preventative education.
carryover for learning. Individuals with any history of Commonly used clinical examinations routinely
intubation and ventilator support are likely to have low performed by physical therapists are presented here (see
ventilatory reserve for activity even if they can breathe Table 14S-2). The clinical significance of each test is
independently full time without the ventilator. Any listed to assist the therapist in interpretation and selec-
person with a VC below 1000 mL may have difficulty tion of specific outcomes demonstrating improvements
functioning and could be at risk for declining respiratory in a variety of components contributing to overall respi-
status.68 These individuals will need to be observed care- ratory status. More detailed testing of pulmonary func-
fully for signs and symptoms of respiratory muscle tion and respiratory muscle performance, useful for
fatigue (see Table 14-3 in chapter 14) as well as onset defining baseline status for research or for more specific
documentation of outcomes of a respiratory rehabilita- individual is mechanically ventilated. If breathing is ven-

tion program, are included in subsequent sections of this tilator assisted and the individual is unable to tolerate
chapter (see the sections titled “Specialized Testing discontinuation, the therapist should record the mode of
of Pulmonary Function” and “Respiratory Muscle mechanical ventilation and the number of spontaneous
Performance”). and assisted breaths at baseline and again with any
changes in position.
Vital Signs The readiness for ventilator discontinuation is often
determined using the TV on the ventilator and the RR
The first examination session should begin with an to calculate the rapid shallow breathing index
assessment of vital signs. These include testing heart rate (RR/TV). If the rapid shallow breathing index is less
(HR), blood pressure (BP), respiratory rate (RR), and than 100 (breaths per minute/tidal volume in liters
temperature. Elevations in HR, RR, and temperature [breaths/min/L]) the individual will be likely to
may be the first signs of pneumonia or worsening of succeed in breathing without ventilator support.31,56,82,84,85
atelectasis. Increases in HR also occur in the presence of Adequate head support will be important if the person
hypoxemia or if the blood pressure is low. Blood pressure depends on accessory muscle and neck muscle breath-
and HR provide the clinician with information on the ing. The head must be stabilized in order for these
cardiac output. Cardiac output may be affected by auto- muscles to use their reverse muscle action for ventila-
nomic nervous system dysfunction, lack of muscular tion. Planning for a reclining wheelchair with a head-
support to vascular compartments, and poor diaphrag- rest extension during early mobility in the acute stage
matic excursion. The mechanics of breathing change will be important.
with positioning in upright posture, decreasing the
excursion of the diaphragm for those with high thoracic
Arterial Blood Gases
and cervical SCI. Venous return and stroke volume
are diminished. Blood pressure may also drop due to At the time of the examination, the therapist has already
orthostasis or poor lower extremity muscle support. reviewed the medical chart for ABG reports. Most indi-
There will be a compensatory rise in HR. Dizziness and viduals with SCI will not have low PaO2 unless there is a
fainting may occur.56 Any individual with an injury at the respiratory infection or infiltrate.11 However, the thera-
T5 level and higher may benefit from application of an pist can readily assess the individual’s oxygenation by
abdominal binder when beginning to sit upright. Lower taking a reading of SaO2 with a pulse oximeter. A normal
extremity pressure hose, Ace wrapping, or even placing saturation is usually between 96% and 100%.11,80 A drop
the person’s feet on the ground or footrest may assist in in SaO2 to below 90% suggests the PaO2 is below 60 mm
providing further support for cardiac output during early Hg.1 Once the SaO2 drops below 90%, supplemental
mobility assessments. oxygen may be required.59
Respiratory rate is one of the most important clinical The SaO2 may decrease with upright posturing in some
assessments that can be made. Normal RR is 12 to individuals with SCI. When this occurs, an abdominal
20 breaths per minute.18,19,79–81 Tobin et al.79 evaluated binder may be helpful for improving breathing mechan-
65 nondisabled subjects and reported a respiratory rate of ics, increasing alveolar ventilation and therefore SaO2 (see
16 2.8 breaths per minute.19,79 The RR is counted from Fig. 14-3 in chapter14). When positioned in a supine
the beginning of a TV breath to the beginning of the position at night, those who experience nocturnal
next breath, during a time when the individual is not hypoventilation and significant desaturation will likely
aware of any measurement.81 The rate is defined as have respiratory muscle strength that falls at least 30%
tachypnea if it is rapid (24 breaths per minute) and below normal.19 They may also have obstructive sleep
shallow or bradypnea if it is slow (10 breaths per apnea, which may cause hypercapnea and lower SaO2
minute).80 Elevation in RR is a sign of ventilatory pump values. The therapist should be alert to this possibility if
weakness, and potential for fatigue and failure increases early morning oximetry values are low. Low oximetry
as the rate increases. Gas exchange may also be compro- values should be reported to the medical team, as night-
mised with elevated RR due to increases in dead space time ventilator support may be necessary.
ventilation and decreases in alveolar ventilation. It is more common to see individuals with SCI develop
The RR and TV determine minute ventilation (VE) elevated PaCO2 than low PaO2. When the person has a
and the energy requirement of the respiratory muscles. PaCO2 above 50 mm Hg, he or she is underventilated and
These measures assist in estimating the work of breath- may initially have a pH below 7.35, indicating acidosis.59
ing (WOB). If the RR at rest rises above 30 breaths per Elevated PaCO2 may contribute to respiratory muscle
minute, then the need for at least part-time ventilator weakness and lead to further impairment in ventilation.86
support will be considered.56,82,83 When this occurs, the A vicious cycle develops. Usually, the therapist does not
TV frequently becomes shallow and the metabolic measure PaCO2 at the bedside. Observations of sleepi-
requirement for respiratory muscles is elevated. ness, decreased arousal, and changes in mental status
Respiratory muscle fatigue is imminent unless the are important indicators that PaCO2 is elevated. If the
individual is on ventilator support, the end tidal carbon hands on the chest wall to confirm motion.61 However,
dioxide (ETCO2) may be displayed on a monitor in the tactile cues may influence breathing strategy, even in
room. It is possible to use portable capnograph those with decreased sensation. The breathing pattern
(Microspan 8090 capnograph; Biochem International, should be reassessed when the individual is upright and
Wankesha, WI) equipment for monitoring.87 Noting the again if an abdominal binder is applied or abdominal
baseline ETCO2 and changes with upright positioning muscle spasticity appears.68,89
may help the therapist recognize when postural changes As more respiratory muscle becomes available, the
or mobility demands are excessive. individual with a mid- and low thoracic injury will have
intercostal and abdominal muscle functions. These
Breathing Pattern individuals may still display more diaphragm action than
chest movement, which would be characterized as 1-chest,
Examining the breathing pattern usually begins with the 3-diaphragm breathing pattern. Abdominal breathing
individual with a SCI in the supine position, without rarely occurs in individuals with SCI; however, it is pos-
head elevation.19,88 Breathing pattern is an observation of sible if the person has a high motor-incomplete cervical
the kinematics of breathing and is distinguished here injury. Motor-incomplete injuries may produce a variety
from respiratory pattern (tachypnea, bradypnea, hyper- of compensatory breathing patterns that may be better
ventilation, Cheyne-Stokes, biots).81 The latter involves a described without using the point system. For example,
description of the variation between breathing frequency, the individual with Brown-Sequard syndrome will have
TV, and pause characteristics. When observing the weakness on one side of the body and an asymmetrical
breathing pattern, the goal is to describe how the individ- breathing pattern.67 Those who breathe only with the
ual is getting air into the lungs. A 4-point system may be diaphragm (4-diaphragm) will have negative chest
used to describe the degree to which neck, chest, motion, which may be described more effectively as a
abdomen, and diaphragm contribute to the ventilatory paradoxical breathing pattern, rather than by using the
effort.15 Observation of breathing is done with the eyes point system. Observation of breathing pattern is recom-
on the level of the patient’s midthoracic region. A total of mended by the American Thoracic Society (ATS) for
4 points are assigned, distributing the most points to the assisting in detection of respiratory muscle fatigue.31
area that contributes the most effort. A normal breathing Paradoxical breathing patterns and respiratory alternans
pattern involves an epigastric rise (i.e., diaphragm excur- (switching between muscle groups while breathing) are
sion) followed by thoracic expansion (i.e., chest expan- two breathing strategies that may be an indication of
sion). Since these regions contribute equally from the respiratory muscle fatigue.
beginning to the end of tidal volume inspiration each
area is weighted equally with 2 points each—4 points
Chest Wall Excursion
in all. The normal pattern is described as 2-chest and
2-diaphragm to denote which muscles are responsible for Chest wall excursion (CWE) measures are another
moving air into the lungs. method used to quantify the breathing strategy and also
The individual with motor-complete low cervical describe the amount of active chest wall movement the
(C5–C8) or high thoracic (T1–T5) lesion will have a full individual can achieve. A standard soft, flexible tape
innervated diaphragm but absent or weakened abdominal measure may be used to measure the circumferential
muscles and intercostal muscles that are inadequate to change from forced expiration to maximal inspiration
oppose the action of the diaphragm. This person (referred to as VC breathing).15,90 It is also useful to
breathes using primarily the diaphragm. The resulting determine CWE during restful breathing, from the end
breathing pattern would be described using all 4 points of quiet expiration to the end of quiet inspiration
assigned to the diaphragm: 4-diaphragm (see Fig. 14-1B (referred to as TV breathing).61 Chest wall excursion
in chapter 14). Individuals with high motor-complete changes observed with VC breathing will give a better
cervical lesions (C1–C2) will recruit only neck muscles indication of the total active range of motion (ROM)
and therefore would be assigned all 4 points to the neck: available to the individual, and TV breathing measures
4-neck 14. Individuals with a motor-complete cervical will assist in the defining breathing strategy at rest.
injury between C3 and C5 begin to use some diaphragm The circumferential difference is recorded in inches or
as well as neck accessory muscles. Those with higher centimeters and will vary with changes in age, gender,
injuries (C3–C4) use more neck than diaphragm muscles body position, and site of measurement.90–95 There are
and will have a breathing pattern rating of 3-neck and three chest expansion dimensions with specific landmarks
1-diaphragm. Those with lower injuries (C4–C5) used to describe breathing pattern and chest wall move-
and more diaphragm function will be rated as 1-neck and ment.11,61 The first dimension, superior-anterior costal
3-diaphragm. Ultimately, the rating depends what the expansion, is measured at the level of the second inter-
therapist observes. Breathing pattern may vary as the costal space at the angle of Louis (angle formed at the
muscles of ventilation fatigue, increasing the neck com- junction of the manubrium and the body of the sternum)
ponent. In some cases, it may be necessary to place the and is sometimes referred to as axillary or upper chest wall
motion. The second dimension, mid-lateral costal expan- breathing but decreases CWE during VC breathing in
sion, is measured at the xiphoid process, middle chest wall. persons with cervical SCI.14 Any increase in CWE values
The third dimension is taken at a midpoint between the toward more positive numbers may suggest recovery of
xiphoid process and the umbilicus and represents lower ventilatory muscle function resulting in an improved
chest excursion or bucket handle movement.61 There is pattern or strategy for breathing. Therefore, deep
good intratester and intertester reliability (as evidenced by breathing with a VC breath may oppose chest expansion
interclass correlation coefficients [ICC] values) of xiphoid when the arms are abducted and externally rotated,
(ICC 0.92) and axillary (ICC :0.89) measures in nondis- whereas quiet TV breathing may be enhanced by using
abled individuals.92 Normative values are presented in the same position.
Table 14S-3 for clinical comparison.90–95 There are no Feldman et al.96 evaluated the relationship between
published norms for the lower chest excursion measures. the three CWE measures and measures of respiratory
Reliability of CWE measures in persons with SCI has muscle strength (MIP and MEP) in nondisabled indi-
not been established. However, Massery et al.14 reported viduals and persons with cervical SCI.96 While CWE
negative values for CWE at the upper and middle chest measures at all sites did correlate with MIP (r
with both TV and VC breathing (−0.02 to −0.39 inches) 0.62–0.89) and MEP (r 0.53–0.83) for nondisabled indi-
in seven subjects with SCI. Negative CWE values are viduals, the only correlation found in persons with cervi-
due to contraction of the diaphragm without intercostal cal spinal cord injuries was for middle CWE taken with
muscle opposition,16,32 as occurs with paradoxical breath- VC breathing and MIP (r 0.78). The small sample size
ing.11,15,16 Massery also provided a preliminary report limits the generalizability of these studies. Therefore,
noting that arm positioning in external rotation and clinical application of CWE measures using tape meas-
abduction while supine may improve CWE during TV urement techniques will require further research with
Table 14S-3
Circumferential Chest Excursions in Subjects
with Normal Pulmonary Function
Values are measured differences between inspiration and expiration; Body position, subject
characteristics and breathing maneuvers vary among studies
Author Axillary/Upper Chest Site (cm) Xiphoid/ Mid Chest Site (cm)
Carlsona ref 94 8.48 0.64 3/4 inch TV; 2–2.5 inches VCref 42
Harris et al.ref 91 7.6 1.2b 7.4 1.7

7.1 1.3c 6.9 1.6
6.8 1.6d 8.2 1.4
6.8 1.3e 7.6 1.5
LaPier et al ref 92
4.75f 4.75
Moll and Wrightref 93 6.0 2.14g

4.82 1.29h
Burgos-Vargas et al.ref 95 5.6 1.76i
Values are measured differences between inspiration and expiration. Body position, subject characteristics, and breathing maneuvers vary among studies
a. 13 females and 6 males, aged 20–30 years, in supine position; mean standard error of the mean.
b. 30 males, aged 19–34 years, in supine position; mean standard deviation.
c. 30 females, aged 19–34 years, in supine position; mean standard deviation.
d. 30 males, aged 19–34 years, in standing position; mean standard deviation.
e. 30 females, aged 19–34 years, in standing position; mean standard deviation.
f. 20 male and female subjects, aged 20–69 years, in standing position; data reported graphically without standard deviations. Arms were elevated into
90 degrees shoulder abduction.
g. 16 males, aged 45–54 years, in standing position; mean standard deviation
h. 26 females, aged 45–54 years, in standing position, mean standard deviation
i. 157 adolescents (112 boys and 45 girls, mean age of 13 years 1.1), in standing position; mean standard deviation.
Modifications with permission from Oatis CA. Structure and function of the bones and joints of the thoracic spine. In: Oatis CA, editor. Kinesiology.
The Mechanics and Pathomechanics of Human Movement. Philadelphia: Lippincott,Williams & Wilkins; 2004. Chap 29;Table 29.2, p. 510.
adequate sample size and standardization of body posi- these regions are intact and the muscle testing to the
tioning in persons with SCI. upper trapezius (C4) and deltoid muscles (C5) indicates
For research purposes, measures of CWE and breath- normal strength (5/5 muscle test grade), then the indi-
ing pattern are determined through respiratory inductive vidual will likely have a strong and functioning diaphragm.
plethysmography, which is considered the gold standard The strength of the diaphragm can be confirmed
technique.61 The equipment is expensive and not practical through manual technique and by observing the individ-
for daily assessment by physical therapists in the clinical ual in supine position.35 The therapist places his or her
setting. Studies are needed to compare the gold standard eyes level with the individual, asks the person for a deep
with the clinical measure (using a tape measure) to deter- breath to maximum TLC, and then to hold the breath.
mine clinical error introduced with the practical The therapist will also observe the breathing pattern and
approach. In addition, research is needed to determine will see a diaphragm breathing pattern (4 points assigned
the meaning of any changes in CWE measures that may to the diaphragm). This pattern should appear in the
occur through various physical therapy interventions presence of a strong diaphragm when there is no inter-
(e.g., chest stretching, cardiovascular conditioning, costal or abdominal muscle contraction. If the epigastric
strengthening, etc). rise is full and complete, then the diaphragm muscle test-
ing grade is at least 3/5. If the individual takes heavy
Posture and Breathing Strategy resistance to the epigastric area after full inspiratory
expansion but yields to firm manual pressure, then the
Once the individual is upright, the therapist should diaphragm is graded 4/5. A 5/5 grade is given to the
examine the posture. There will be flattening of the ante- diaphragm if the individual is able to tolerate high resist-
rior chest wall in many individuals with SCI due to weak ance after full inspiratory expansion. 35,101
or paralyzed intercostal muscles.69 Additionally, the If the individual has a sensory- and muscle-testing
therapist must document any paradoxical chest wall exam that indicates the injury is above C5, the diaphragm
movement that contributes to creating a pectus excava- will likely be weak. An individual without full epigastric
tum (inward depression of the sternum into the thoracic rise, who may be using some neck muscles for breathing,
cavity). This will occur when a strong diaphragm is will have a 1-neck, 3-diaphragm breathing pattern and a
actively pulling the xiphoid region and lower ribs inward diaphragm muscle grade of 2/5.15,35 If there is predomi-
without an opposing force from the abdominal and nately neck breathing, the presence of diaphragm con-
intercostal muscles.69 Posturing in excessive thoracic traction must be determined. Trace or 1/5 diaphragmatic
kyphosis may decrease lung volumes.97 A slight anterior contraction may be palpated by placing the hands under
pelvic tilt may reduce kyphosis, pull the chin back toward the inner surface of the ribs along the sternal angle and
neutral, and improve diaphragmatic excursion when the asking the individual to sniff. The sniff maneuver has
individual is seated upright.98,99 been used since 1927 as a technique for detecting the
Individuals with motor-complete injuries having high presence of a functioning diaphragm in individuals with
paraplegia or tetraplegia will tend to have poor postural paralysis.31 Individuals with 2/5 and 1/5 diaphragm
control, an outward displacement of abdominal contents strength will likely require ventilator assistance.
while leaning with the head, and with trunk facing for- Any muscle testing or observation should occur dur-
ward. They may also be rotated and laterally lean toward ing independent breathing attempts, if possible. The
the weaker side. Selection of the proper seating system, therapist needs to have established good rapport with the
use of abdominal binder, lateral trunk supports, lumbar individual and understand the ventilator discontinuation
rolls, and head supports to allow improved trunk align- protocols in the facility prior to disconnecting the indi-
ment can be achieved after careful examination of vidual from the ventilator for this muscle examination.
posture. Optimal positioning will improve length- Once the individual is comfortable breathing briefly
tension relationships for muscles of inspiration, for without ventilator support, the therapist can examine the
vocalization, and for upper extremity function.98–100 The diaphragm. Individuals who have no intercostal muscle
individual will achieve more symmetrical breathing and function and have low muscle tone may demonstrate
more equal ventilation to all regions of the lungs if inward retractions between the intercostal spaces of the
postural alignment is addressed.98 8th, 9th, and 10th ribs. This is a sign the diaphragm is
functioning and is referred to as Litten’s sign.101
Muscle Examination
All accessory muscles may be tested for strength
Muscle and sensory testing can contribute a great deal to according to the standard procedures for muscle testing.
the understanding of respiratory muscle function in the However, the therapist must note if reverse actions are
individual with SCI. When examining the diaphragm, being used during breathing. Principles of stabilization
the physical therapist can review the segmental levels of will be important in permitting these muscles to work in
the sensory examination for sharp–dull sensation as well reverse (moving insertion toward the origin in most
as the manual muscle test grades for muscles innervated cases). The abdominal muscles should be tested if
by C3–C5 spinal nerves.15 If the sensory dermatomes in spinal mobility is permitted. When spine motions are
contraindicated, the therapist should still examine the Auscultation

presence of abdominal muscle contraction. If the cervical
The airways divide, forming 23 generations.102 Coughing
spine is cleared, an individual with a thoracic spine
can mobilize secretions from the bronchioles at the level
injury may lift the head off the bed to confirm abdominal
of the seventh generation and above. Secretions that are
muscle contraction. The therapist will also examine
located below the seventh generation in the lungs must
cough functions when examining abdominal muscle
be mobilized with other airway-clearance techniques
control.
to move the impurities or mucus up to this level in
After the therapist has performed a muscle examina-
order to be coughed out (see “Secretion Mobilization
tion, any strength grades or modified test results should
Techniques” in chapter 14). Therefore, it is important to
be documented in the medical record. The muscle-
auscultate the lobes of the lungs to detect the presence of
testing grades may assist the medical team in planning
and location of adventitious vesicular sounds to deter-
the respiratory rehabilitation program. Additional
mine if there is any mucus or atelectasis.61 Reviewing
specialized testing of pulmonary function and the respi-
chest x-rays prior to auscultation may assist in directing
ratory muscles will be necessary to obtain an accurate
the exam. Manual palpation may assist in locating fremi-
interpretation of ventilatory capacity and respiratory
tus (vibrations) within the chest wall (suggestive of mucus
status (see subsequent section entitled “Specialized
accumulation) as well as determining any regions that are
Testing of Pulmonary Function and Respiratory Muscle
expanding poorly (suggesting lung consolidation or
Performance”).
atelectasis along with weakness). Upon auscultation,
the therapist will note underventilated areas as having
Cough Examination diminished breath sounds. The presence of coarse rales
The four phases of coughing should be examined for any (crackling sounds) in dependent lobes are consistent with
individual with SCI (see “Rehabilitation Stage,” “Airway pneumonia. Rhonchi (gargling sounds) or wheezes may
Clearance,” and “Coughing” sections in chapter appear when there are airway restrictions and bron-
14).31,102,103 The exam involves simply asking the indi- chospasm, which may result from accumulation of mucus
vidual to cough. An effective cough will result in a cough or secretions. Pleural rubs or squeaks are common in
that is repeated two to six times forcefully within one individuals who have scar tissue between the chest wall
breath, using trunk flexion or intact abdominal muscles. and the pleura.104 Most individuals with high paraplegia
The exam should be performed in both supine and again or tetraplegia will have decreased breath sounds in the
in the sitting position (when medically cleared). A good regions that are not fully expanded during inspiration.
inspiratory volume will be necessary to achieve the proper
Phonation
force necessary for clearing secretions. The quality of the
cough may be classified as functional, weak-functional, or An examination of breath support for speech is easy to
nonfunctional.15,16 The cough is functional if the indi- perform and provides excellent information about the
vidual can clear all secretions using several powerful eccentric control of the diaphragm during exhalation as
expulsions within one breath without using any cough- well as the function of the vocal cords and glottis.11
assist techniques. The cough is weak-functional if there is Glottal control is not only necessary for cough function
partial clearing of secretions or clearing of the throat during but is important for learning glossopharyngeal breathing
one breath attempt. Here, a cough assist would be necessary (pumping air into the lungs with the tongue; see
to mobilize mucus and clear the airways during an infection. “Glossopharyngeal Breathing” in chapter 14) and to
The cough is classified as nonfunctional if the effort is not augment breath support for both cough and phonation.49
forceful enough to produce any expiratory airflow.15,16 Large lung volumes acquired through breath-stacking
Most individuals with thoracic injuries below T8 will strategies can compensate for expiratory muscle weak-
produce a functional cough. Individuals with an injury ness to provide adequate breath support for speech.41
between T8 and C5 will usually have a weak-functional The therapist may ask the person to say “ah, ah, ah”
cough, which can be augmented by assistive cough strate- several times in succession. A crisp staccato sound suggests
gies (see Table 14-6 in chapter14). Later, the therapist the glottis is functioning well.105 The therapist should
will examine any cough-assist strategies for effectiveness. note laryngeal functioning of the vocal cords and discuss
Typically, individuals with a motor-complete injury at C4 the quality of speech with the medical team. This will be
and above lack adequate inspiratory volume and must important for any individual who has recently had an
learn to use the glottis and tongue to increase inspiratory endotracheal intubation, a tracheostomy that is discon-
volume (see “Strategies to Augment Inspiratory Volume” tinued, or if the tracheostomy cuff is deflated (see
in chapter14). Formal measures of cough function Fig. 14-2 in chapter14). Bulbar exercises62 may be included
require determination of peak cough flow rate (PCFR), in the rehabilitation program if there are residual
normally 6 to 20 L/sec, and are discussed in the section problems with phonation or glottal control.
entitled “Specialized Testing of Pulmonary Function and The normal ratio of inspiratory-to-expiratory time in
Respiratory Muscle Performance.” the respiratory cycle is 1:1 or 1:2. However, for vocalization
the ratio increases to 1:5 or about 8 to 10 syllables per maximal inspiratory maneuvers are referred to as MIP or
breath.11 Examination of eccentric control of the PImax. Since force–length and force–velocity principles
diaphragm can be done by asking the individual to say of skeletal muscle apply to the muscles of respiration, it is
“ah” or “ooooh” continuously during exhalation after important to understand how lung volume influences the
taking a full VC breath. The nondisabled person should length–tension relationship. As lung volume changes,
have 10 to 15 seconds of phonation after releasing a there is a corresponding change in the length of the mus-
breath. This will be diminished if the VC is decreased. cles of respiration.19,32 Normally, expiratory muscles will
Many individuals with SCI will have less than three lengthen and inspiratory muscles fibers will shorten as
syllables per breath when speaking and will be easily lung volume increases, and as these changes occur the
fatigued when talking.11,41,106 MEP will increase and the MIP will decrease.108
If a person has a tracheostomy, a speaking valve may Therefore, at total lung capacity (TLC) the MEP is the
be helpful (Fig. 14S-5). This valve allows one-way inspi- highest, and at residual volume (RV) the MEP will be
ratory volume through the tracheostomy but requires air lowest, but at RV the MIP will be maximized.
to escape over the vocal cords out the mouth. The cuff These pressure measures are also influenced by the
must be deflated to allow phonation and safe use of this static recoil of the lung and chest wall.19,109 The overall
speaking adjunct.49 It will be life threatening for anyone performance of respiratory muscles is graphically depicted
to place the speaking valve over the tracheostomy site by a pressure-volume curve that proxies for the force-
when the cuff is inflated. If the individual remains on length curve typically used to describe force-generating
ventilator support with the cuff deflated, then the TV, capacity of other skeletal muscles. The force-length rela-
positive end expiratory volume, and inspiratory time will tionship of the diaphragm, as with other muscles, is such
be adjusted to compensate for air loss out the mouth dur- that the diaphragm is most effective at generating force
ing speech.49 An abdominal binder may also assist in when in its lengthened position (see Figure 14S-6a).
improving inspiratory volumes and breath support for However, because the diaphragm is inaccessible for force
phonation.107 Manual insufflation and breath-stacking measurement, forces are inferred from pressure measure-
techniques may also be evaluated as strategies to improve ments, ether the MEP (PE max) or MIP (PI max), the
vocalization once the individual no longer has a tra- pressure-volume relationship is illustrated in Figure 14S-6b.
cheostomy (see “Strategies to Augment Cough Function: Additionally, the rate of change in lung volume suggests
Inspiratory Volume and Glottal Control” in chapter 14). the velocity of respiratory muscle contraction in the
absence of lung tissue pathology.32 Therefore, tests of
Specialized Testing of Pulmonary Function forced expiratory volume in 1 second (FEV1) and peak
and Respiratory Muscle Performance cough flow rate (PCFR) will assist in determining if the
respiratory muscles can respond rapidly, which is impor-
Pulmonary Function and Respiratory Muscle Strength tant for sneezing and cough function.11 These actions
Respiratory muscle strength can be inferred from meas- require muscle power, and therefore rate dependent.
uring the pressure changes occurring during inspiratory Initially, during the acute and subacute stages after
and expiratory efforts. Maximal expiratory pressure SCI, inspiratory and expiratory muscle strength is
maneuvers are referred to as either MEP or PEmax, and inferred from measures of volume using highly sensitive
handheld spirometers that quantify vital capacity
(Fig. 14S-7a and b) or peak flow rates (Fig. 14S-8).
Alternatively, interaction between volume, pressure and
flow may be measured directly by using options within the
ventilator that can determine lung tissue compliance and
amount of negative pressure generated by any inspiratory
muscle effort.63 Negative inspiratory pressures (NIF) may
also be measured with handheld devices110 (Fig. 14S-9).
High pulmonary pressures are often unwanted during
early stages of injury, and maximal pressure testing (MIP
and MEP) may be contraindicated.63
If there is any risk for barotrauma, or if the individual
has high blood pressure, seizure disorder, or cardiac pre-
caution orders, respiratory muscle-testing procedures
and rationale should be discussed with the medical team.
Figure 14S-5. One-way valve for speech (Passy-Muir valve). A In such cases, the rapid shallow breathing index (RR/TV)
speaking valve is an attachment that fits on the tracheostomy
tube. The attachment has a one-way valve that opens to allow may be preferred or perhaps an expiratory volume or
air to pass through the tracheostomy tube. The valve closes NIF reading may be taken from a submaximal effort and
with expiration, diverting air up through the vocal cords and used to assist in determining respiratory muscle tolerance
the mouth for speech production for removal of ventilator support. Vital signs should be
120
A
100
FRC
80
Force (% max)
60 TLC
40
20 Lo
0
40 60 80 100 120
A Length (% Lo)
PEmax TLC
B
RV PImax
160 120 80 40 0 –40 –80 –120

B Pressure (em H2O)
Figure 14S-6. (A) Diaphragm contractile force and fiber length

associated with lung capacities. The relationship between con-
tractile force (as a percentage of maximum) and resting force
(% Lo) for isolated diaphragmatic fibers. Contractile force is
greatest close to the resting length (usually higher). As lung
volume is increased to total lung capacity (TLC), the
diaphragm shortens away from its Lo and loses force-generating
capacity. (B) Relationship between lung volumes and maximum
pressure-generating capacity. Pressure-volume curves for
maximum expiratory and inspiratory pressures illustrate that at Figure 14S-7. Handheld spirometers to measure vital capacity.
total lung capacity (TLC), the maximum expiratory pressure (A) Spiropet (Nihon Medical Instruments Co., LTd, Nihon
(PEmax [or MEP]) is highest, and at residual volume (RV) the Kohden America, 90 Icon Street, Foothill Ranch, California).
maximum inspiratory pressure (PImax [or MIP]) is highest. (B) Wright Peak Flow Meter (Wright Spirometer Mark 14;
From: Flaminiano LE, Celli BR. Respiratory muscle testing. Ferrasis Development and Engineering Co. Ltd., London, UK).
Clinics in Chest Medicine 2001;22(4):661–677.
documented before and after any test of respiratory mus- young, with relatively healthy lung tissue, the VC is usu-
cle performance. Initially, the individual with a SCI will ally an acceptable measure to indicate respiratory muscle
be tested in the supine position or supine with slight head status.63 Roth et al.111 reported VC to be highly correlated
elevation (15 to 30 degrees). However, when the individ- with all other measures of pulmonary function in
ual is medically stable and able to tolerate 3 to 5 hours of 52 subjects with SCI and on this basis recommended its
sitting, these tests should be repeated in the seated posi- use as a single global measure of ventilatory status in
tion. Maximal effort testing should be performed as soon those with SCI.
as the individual is medically cleared. Handheld spirometers are inexpensive and easy to use
Vital capacity measures for lung volume in liters or and carry for bedside testing of VC. The ATS has pub-
milliliters will provide information about respiratory lished guidelines for selecting accurate spirometers.43
muscle performance if the underlying lung tissue is Most commercially available spirometers meet ATS stan-
normal.88 Therefore, it is important to review all the dards, and companies publish the specifications in their
pulmonary function tests (especially FEV1, PEFR, and equipment literature.112,113 Handheld devices offer good
diffusion capacity [DLCO]) to determine the status of the correlations to gold standard methods (pneumontachog-
lung tissue and response to dynamic airflow prior to raphy) for all pulmonary function assessments (r 0.97
using a single parameter such as VC to infer respiratory for VC) with no significant differences.114 However, clin-
muscle strength.109 Because many individuals with SCI are ically there is wide variability between the gold standard
Figure 14S-8. Handheld spirometer for measuring peak expira-

tory rate (PEFR) and cough flow rate (PCFR). Assess Peak Figure 14S-9. Respiratory pressure manometer (Micro Medical
Flow Meter (Healthscan Products, Cedar Grove, NJ). Ltd., www.micromedical.co.uk).
technique and tests of VC using some handheld devices injuries may have lower lung volumes and expiratory
(mean difference 0.6 0.56 L).114 These findings suggest times and therefore do not meet ATS testing standards
that the same device should be used for repeat testing of (their expiratory time is less than 6 seconds) for VC test-
individuals. The therapist should confirm that any hand- ing. However, these authors recommended VC testing in
held device meets ATS standards.43 these individuals as essential and still reproducible; such
Pulmonary function-testing results can also be influ- individuals should not be excluded from research proto-
enced by testing technique. If possible, a standardize test- cols on this basis. During VC testing, the therapist
ing approach should be used.43 Ideally, the person being should also observe for signs of excessive muscle spasms.
tested should be seated with adequate postural support Spasticity responses in the trunk musculature do not
and remain erect throughout the expiratory maneuver. reflect volitional control and functional usefulness of the
The individual is instructed to inspire maximally to TLC respiratory muscles and their presence may be reason to
and then to exhale maximally into a mouthpiece while consider the test invalid.15 Chest trauma resulting in
sustaining the effort for at least 6 seconds. A nose clip is musculoskeletal pain may also alter VC values.
worn. Encouragement is provided by the tester during Once absolute volume measurements are recorded,
the examination, and the amount of encouragement they are compared to normal values based on age, height,
should also be standardized. There should be no leaking and gender. Self-reported height or measurements of
around the mouthpiece or nose clip, no arm support, and length are adequate when determining height for indi-
no forward or lateral trunk leaning during the expiratory viduals with SCI.115 Most individuals will have values that
maneuver. The individual is asked to repeat the test three are lower than normal predicted values for FVC and
to five times, and the volume recorded is the best value FEV1. However, the ratio of FEV1/FVC will be above
obtained from three acceptable maneuvers. The differ- 0.85, indicating restrictive pulmonary disorder.44 Values
ence between the two maneuvers with the widest varia- for VC are used to determine readiness for ventilator dis-
tion should not be more than 5% or 0.100 L, whichever continuation (success for removal from ventilator is
is larger.43 probable if VC 10 mL/kg ideal body weight) as well as
According to Kelley et al.,115 230 of 278 (83%) indi- for determining the impact of body positioning on
viduals with SCI were able to meet ATS standard for breathing mechanics.10,56
spirometry and 217 of 230 (94%) individuals had repro- Positioning differentially influences VC values. When
ducible values within the ATS standards for measures of compared to the VC values obtained in supine position,
FVC and FEV1. Some individuals with higher cervical individuals with high thoracic and cervical lesions will
have VC values that are 14 to 25 mL lower in the sitting and the difference between the two measures is the trans-
position, while those with midthoracic lesions and below diaphragmatic pressure (Pdi = Pes Pg; Fig. 14S–10).
have VC values that are 10 mL higher when seated.10 This is the best research method for evaluating the
Numerous studies have reported improved VC with lower specific force-generating capacity of the diaphragm and
levels of injury (see Table 14-1 in chapter14).3,5,9,10,116,117 for observing fatigue curves. The measurement of Pdi
Vital capacity in individuals with high cervical lesions has been used in several reports studying diaphragmatic
may be lower than 25% of normal (or predicted) and function in individuals with SCI.120,121 Measurement of
may be as high as 80% in individuals with low thoracic Pdi using this method of examination is impractical for
injuries.15,16 When VC falls below 25% predicted, gas clinical testing due to discomfort and the invasive nature
exchange may become compromised.11,12 of the test.
Individuals with high tetraplegia may have a VC When testing respiratory pressures, ideally the subject
that approaches TV and will have inadequate oxygen should be seated and posture maintained in the erect
support to muscles, leaving them prone to fatigue.11,15 position. Nose clips are not required.31 A leak port with-
Measurement of VC may be useful for monitoring in the manometer should be available to avoid including
changes in respiratory status as individuals become more
mobile and participate in therapeutic exercise and respi-
ratory muscle training.118 The VC has the potential to
increase to at least 50% of normal for individuals with
C5–C8 motor-complete injuries within 18 months after
injury.49,116 Body positioning and testing technique must
be standardized in order to use VC measures to monitor
progress in the rehabilitation program. It may be
valuable to combine CWE measures with VC or TV
breathing to assist in documenting any changes in venti-
latory strategy.11
Vital capacity reflects the weakness in both the inspi-
ratory and expiratory muscles and may also be influenced
by loss of compliance in the lungs and chest wall.31 The Pm
measure is less sensitive than measures of MIP and MEP
for detection of mild muscle weakness, such as that which
occurs with some motor-incomplete injuries.31,119
Respiratory pressure measurements also have the advan-
tage of directing testing toward measuring inspiratory
muscle function (as measured via MIP) or expiratory
muscle function (as measured via MEP) and thus are
more specific than VC measures. Therefore, the most
common procedure used to evaluate the force production Pes
of the respiratory muscles are MIP and MEP.19,85 or
As with VC testing, pressure measures are also influ- Ppl
enced by chest wall and lung mechanics and require the
same standardization procedures (positioning, encourage-
ment, and validity criteria). Measures of inspiratory or
Pg
expiratory pressures can be taken at the nose, mouth, or or
across the diaphragm (the latter requires an invasive pro- Pab
cedure).109 Clinically, the mouth pressure measures are
the most common; however, measuring pressure at the Pdi = Pab–Ppl
nose (sniff maneuver) is helpful when diaphragmatic
weakness is severe and may offer a more natural action for Figure 14S-10. Mouth pressure and transdiaphragmatic pres-
some individuals, for instance, children and adolescents.19 sure measures for determination of respiratory muscle actions.
Mouth pressure (Pm) and transdiaphragmatic pressure (Pdi).
Transdiaphragmatic pressure (Pdi) provides a direct Mouth pressure is the force exerted by the respiratory system
measure of pressure generated by the diaphragm alone (respiratory muscles, chest wall, and lungs) as measured at the
and is important for research on diaphragmatic muscle mouth. Transdiaprhagmatic pressure, the force exerted by the
function. This technique is uncomfortable for the indi- diaphragm, is the difference between esophageal pressure (Pes)
vidual because two balloons must be swallowed and or pleural pressure (Ppl) and gastric pressure, (Pg) or abdomi-
nal pressure (Pab), which is calculated by Pdi Pab – Ppl.
placed in the esophagus (Pes, an estimate of pleural pres- (Reproduced with permission from: Reid WD, Dechman G.
sure) and the gastric area (Pg, an estimate of abdominal Considerations when testing and training the respiratory mus-
pressure). The pressure from each balloon is measured cles. Physical Therapy. 1995; 75(11):971–982.)
pressure created by the buccal muscles.85 Presently, value of three maneuvers that vary less than 20% is
portable devices are available that offer metal membrane recorded.31 Rest time between maneuvers should be
or piezoelectric transducers with an accuracy of 0.5 cm 1 minute.85
H2O over a range of 200 cm H2O.109 Larger values are After respiratory pressure measurements are taken,
obtained with a tube-style mouthpiece as opposed to a the absolute values may be compared to normal values
flanged mouthpiece, even in persons with SCI.122 using age, gender, and weight to establish a percentage of
However, the ATS recommends a flanged mouthpiece predicted values.30,61,123 Normal values are now well
for clinical use when testing those with neuromuscular established and are listed in Table 14S-4.19,124 The vari-
weakness.31 The standard procedure for MIP testing ability reported in the literature relates to differences in
requires the individual to exhale fully to RV prior to measurement techniques that are now standardized;
making a maximum inspiratory maneuver. When per- however, there is more fluctuation in MIP and MEP
forming MEP testing, the person inhales fully to TLC values than in VC measures.31 Generally, a MIP of 80 cm
prior to making a maximum expiratory or Valsalva H2O or lower (more negative) suggests inspiratory mus-
maneuver.31 The individual should perform the maneu- cle weakness is unlikely.31 Conversely, individuals with
ver for at least 1.5 seconds.31 The clinician should offer MIP or NIF values that are above (less negative) 30 cm
encouragement to the individual and check that there H2O will have difficulty breathing without some ventila-
are no air leaks around the mouthpiece. The largest tor support.19,56,82,109
Table 14S-4
Normal Values for Maximum Static Airway
Pressures and Prediction Equations
Study Gender Subjects (N) Age Range MIP (cm H2O) MEP (cm H2O)
Black and Hyatt30 M 60 20–54 124 22 233 42

F 60 20–54 87 16 152 27
Cook et al.125 M 17 18–47 133 39 237 45

F 9 18–32 100 19 146 34
Leech et al.126 M 325 17–35 114 36 154 82

F 480 17–35 71 27 94 33
Rinqvist127 M 100 18–83 130 32 237 46

F 100 18–83 98 25 165 30
Rochester and Arora128 M 80 19–49 127 28 216 41

F 121 19–49 91 25 138 39
Vincken et al.129 M 46 16–79 105 25 140 38

F 60 16–79 71 23 89 24
Wilson et al.130 M 48 19–65 106 31 148 34

F 87 18–65 73 22 93 17
Prediction Equations
Black and Hyatt30 MEN (age 20–54) MIP 129 (age 0.13)
MEP 229 (age 0.08)
WOMEN (age 20–54) MIP 100 (age 0.39)
MEP 158 (age 0.18)
Continued
Table 14S-4
Normal Values for Maximum Static Airway
Pressures and Prediction Equations —cont’d
Prediction Equations
Enright et al.123 MEN ≥ 65 years MIP (weight (lbs) ( 0.131)

(age 1.27) 153
MEP (weight (lbs) 0.250)
(age 2.95) 347
WOMEN ≥ 65 years MIP (weight (lbs) 0.133)
(age 0.805) 96
MEP (weight (lbs) 0.344)
(age 2.12) 219
Numerous studies have reported respiratory pressure Testing respiratory muscle endurance is important for
measures in persons with SCI (see Table 14-1in chapter establishing a baseline for respiratory muscle functions
14).116,117,122,131 As a population, in comparison to healthy and for developing ventilatory muscle-training pre-
persons individuals with SCI demonstrate that MEP scription.85 Formal examination of respiratory muscle
values are more limited than MIP values, and both MIP endurance is also useful when respiratory dysfunction
and MEP become worse as the level of injury is higher is mild and difficult to quantify.109 Measurements of
(cervical vs thoracic) due to less residual respiratory mus- respiratory muscle endurance may be used to assist in
cle function.109,117 Measures of MIP and MEP may be explaining any ventilatory limitation to high-activity
useful in documenting changes in respiratory muscle states in individuals with motor-incomplete SCI who
function resulting from spontaneous recovery or the cannot return to a job with physically demanding
effects of interventions used in respiratory rehabilitation repetitive work.
programs.118,132-134 Studies have determined that at 1 year There are relatively few techniques useful for measur-
post-injury, individuals with motor-complete C5–C8 ing respiratory muscle endurance that are practical and
injuries will have an average MIP about 74 5.9 cm widely accepted in the clinical setting.19 One measure
H2O and an average MEP of 36.9 3.8 cm H2O.135 that is reported most often in the physical therapy litera-
ture is maximal voluntary ventilation (MVV). Maximum
voluntary ventilation testing involves breathing as rapidly
Pulmonary Function and Respiratory
and as deeply as possible over a 10- to 15-second period.
Muscle Endurance
The total amount of air moved is then calculated and
Respiratory muscle endurance refers to the ability to sus- reported in liters per minute. Some consider MVV testing
tain a specific muscular task over time and is different alone to be an adequate measure of respiratory muscle
from respiratory muscle fatigue.31 Fatigue is a loss of endurance.136 Technically, the measurement technique
capacity for developing force or velocity of contraction in does not invoke a prolonged challenge to the muscles of
response to a load and may be reversible by rest.18,31 Since ventilation and may not be a true test of respiratory
the respiratory muscles cannot rest completely without muscle endurance.31 Yet, MVV testing has been used
ventilatory support, it is important to notice the signs of in recent research on respiratory muscle training in per-
fatigue (see Table 14-3 in chapter 14). Individuals who sons with SCI to measure respiratory muscle endurance
are undergoing ventilator discontinuation trials or have training effects.134,137 Evaluation of respiratory muscle
marginal respiratory status are not candidates for formal endurance with an MVV assessment is very time efficient
respiratory muscle endurance testing. In these cases, the and clinically practical. There are several reports docu-
respiratory function is clearly established by measures of menting that the MVV falls below normal levels in indi-
VC, NIF, RR, and TV, and observation of breathing viduals with tetraplegia and that the MVV is inversely
pattern. correlated with level of injury.135,138 The MVV can also
For those individuals not at risk for respiratory mus- be measured over several minutes (4 to 15 minutes),
cle fatigue, assessing those individuals’ respiratory which may offer a better estimate of respiratory muscle
muscle endurance or ability to sustain a specific level of endurance than the more common MVV measurement,
respiratory muscle force over time may be considered which is taken for 12 to 15 seconds.139 When an indi-
prior to initiating a therapeutic exercise program. vidual with SCI performs the longer MVV measure, the
clinician has the opportunity to observe breathing strate- allow normocapnic hyperpnea for respiratory muscle
gies that may suggest patterns of ventilation occurring endurance training.143 Some therapists believe that venti-
during stressful activities requiring high VE. latory muscle-training prescriptions should be based
Other methods of respiratory muscle endurance test- primarily on strength measures (starting at 20% to 30%
ing involve repetitive MIP or MEP measures (12 to MIP or MEP and progressing the load).144 It is true that
18 maneuvers, each lasting 10 to 15 seconds)19,140 or strength training carries over to endurance training,
breathing with an externally applied mechanical load.61 whereas endurance training is not known to carry over to
One examination approach, recommended for establish- strength.145 Ultimately, respiratory status is monitored by
ing the initial inspiratory or expiratory training load measures of strength (MIP and MEP), but endurance
when working with individuals with SCI, involves a pro- measures can offer important information, especially if
gressive incremental resistive or threshold loading respiratory muscle performance is mild.
(TLmax) test.11,139 The test begins with inspiration
against a resistance that is 20% to 30% of the MIP or
Respiratory Muscle Fatigue and Dyspnea
MEP, and then the load is increased by 10% to 20%
every 2 to 3 minutes until exhaustion.61,85 To determine Clinically, examination of signs and symptoms of respira-
the endpoint for the test, the individual is monitored tory muscle fatigue is critically important in those with
for declines in percentage SaO2 >5% decrease from base- marginal ventilatory status. Most individuals who develop
line or falling below 90%), increased accessory muscle independence from the ventilator can readily tolerate
use, paradoxical breathing, and level of dyspnea (Borg- quiet breathing in a sitting position. However, when
modified dyspnea score (7/10).61 If there is an ETCO2 activity demands are increased, the person must increase
monitor available, then elevation in ETCO2 may also be the TV and RR to support higher VE. Spungen et al.146
used to determine a stopping point. Untrained nondis- found that self-reported symptoms of breathlessness at
abled individuals can achieve 80% to 88% of their MIP rest were significantly greater for individuals with high
during the final stage of the test.85,109 Measures of repeti- tetraplegia (≥C5) than for any other SCI group.
tive MIP, MEP, or MVV may be taken periodically to However, all individuals with tetraplegia and those with
show progress in the development of respiratory muscle high paraplegia reported breathlessness with activity.
endurance as the individual participates in respiratory Ayas et al.147 reported the frequency of self-reported
muscle endurance training. Sustainable inspiratory pres- breathlessness during activity was greater the higher the
sure (SIP) techniques have also been used to measure level of injury and highest in those with motor-complete
ventilatory muscle endurance, wherein endurance is cervical injuries. Grandes et al.106 studied dyspnea in people
recorded as the greatest pressure that can be generated with SCI during activities of daily living and found
against a given resistance and sustained over a 10-minute breathlessness during talking was the most common
period without increases in ETCO2 or changes in RR.141 activity concern for individuals using motorized wheel-
Nondisabled young individuals will have an SIP that is chairs. Other individuals with lower cervical and high
typically 68% 3% of the MIP. thoracic SCIs complained of dyspnea during dressing or
For formal research, one of the most widely accepted with mobility out in the community. Activities involving
methods for determining respiratory muscle endurance is arm work are known to interfere with ventilation in
maximal sustainable ventilation (MSV).19,109 This tech- nondisabled individuals.52 Therefore, the physical thera-
nique is complicated as the levels of CO2 must be moni- pist will need to be alert for signs and symptoms of
tored and adjustments made to maintain isocapnic breathlessness and respiratory muscle fatigue as the pro-
breathing. The method involves identifying the level of gram progresses.
ventilation (VE TV RR) that may be sustained for a Dyspnea in supine position is also considered a sign of
specified duration under isocapnic conditions. The load respiratory insufficiency in individuals with acute neuro-
is usually 50% to 90% of the individual’s MVV, and the muscular dysfunction.148 Dyspnea is not related to
duration is typically 15 minutes.19,31,61,109 Visual feedback percentage of predicted FEV1 in persons with SCI.106
from an oscilloscope is used by the individual to maintain The causes of dyspnea have been described by many and
the appropriate VE. the mechanisms are difficult to determine,18 even in those
Mueller et al.142 recently used the MSV assessment with SCI.49 Some have suggested that dyspnea is related
method and reported mean endurance times for 20%, to the increase in energy cost of breathing.88 It does
40%, and 60% MVV loading for eight individuals with appear that dyspnea may be related to the percentage of
paraplegia and six individuals with tetraplegia. As a result maximal respiratory muscle pressure developed during
of this study, they recommend ventilatory muscle loading repetitive activities in persons with neuromuscular dis-
using 60% MVV for individuals with paraplegia and 40% eases.119 Several studies have employed dyspnea measures
MVV for individuals with tetraplegia when prescribing to document improvement in perceived breathlessness
respiratory muscle training. Recently, a partial re-breathing after respiratory muscle training or conditioning pro-
system has been successfully used at home with individuals grams.132,149 Examination of dyspnea may be done with a
having chronic obstructive pulmonary disease (COPD) to variety of tools and is a good measure to include before,
during, and after functional activity assessments or con- after inspiration is called the occlusion pressure (P0.1) and
ditioning programs.150 The modified Borg dyspnea scale occurs earlier than the onset of volitional respiratory
is a commonly suggested tool for use in persons with SCI muscle responses.31 The normal P0.1 value is about 1 cm
and breathlessness.11,61 H2O. When the P0.1 value is high, this indicates elevated
Individuals with marginal ventilatory status will be at respiratory center activity, while a low value could
risk for fatigue when the ventilatory load exceeds capacity indicate any of the following: (1) a reduced respiratory
or when the capacity is so diminished that ventilatory center output, (2) a deterioration in the neural pathway
pump function cannot meet the typical metabolic to inspiratory muscles, (3) impaired electromechanical
demands (Fig. 14S-11).85,86 While RR and rapid shallow coupling, or (4) impaired pressure-generating capacity
breathing index (RR/TV) are reliable tools for predicting due to respiratory muscle fatigue or weakness. Indi-
ventilator discontinuation outcome, the ATS recom- viduals with respiratory muscle weakness who are in the
mends observation of breathing pattern for thoracoab- acute stage will have normal or slightly elevated
dominal motion for determining muscle recruitment and values.31 The test may be used in individuals with acute
function of the muscle triad (diaphragm, abdominal, and cervical SCI to assist in understanding ventilatory limita-
intercostal muscles) involved in ventilation.31 Respiratory tions in those with a multiple system issues (e.g., lung
alternans (alternating breathing strategies between vari- disorders and SCI) impacting on ventilation abilities.31
ous accessory muscle groups, chest wall muscles, and the Individuals with chronic tetraplegia (2 years post-
diaphragm) and paradoxical breathing may indicate shift- injury) who are breathing independently have an intact
ing recruitment patterns of muscles of ventilation. central neural drive; however, elevations in PaCO2 depress
In some cases electromyography (EMG) can be useful the P0.1 response relative to healthy counterparts.135,153
in identifying fatigue as well as indicating the timing and Theories explaining the blunted response of ventilatory
level of muscle activation. The risk of fatigue increases drive to hypercapnia in persons with SCI include (1)
when the inspiratory time (Ti) becomes extended as a altered chest wall mechanics, (2) respiratory muscle
portion of the total respiratory cycle (TTOT).151 Clinically, weakness, or (3) impaired chemoreceptor function.
EMG surface electrodes may be placed on the seventh, Respiratory muscle weakness does not fully explain the
eighth, and ninth intercostal spaces approximately 2.5 cm blunted response. Individuals with reduced central respi-
from the costal margin in the midclavicular line to monitor ratory drive may be prone to sleep apnea and should have
the diaphragm and or directly over the sternocleidomas- a sleep evaluation.135
toid muscles in individuals with motor-complete cervical Parameters of respiratory muscle function and poten-
lesions.31,88 The utility of surface EMG is limited in tial contributors to respiratory muscle fatigue are varied
the presence of spasticity or a motor-incomplete injury. and difficult to discern specifically, even when using the
Esophageal and needle EMG may be more reliable in numerous tests and measures described herein. When
such cases, but the invasive nature of these tools make considering the cause of breathing difficulties in those
them clinically less feasible. Many physical therapists with SCI, the therapist must consider all aspects of respi-
do have access to biofeedback units with surface EMG ratory muscle function, including the level of neural acti-
electrodes, which are useful for monitoring muscle activity vation, force-generating ability, operational length,
during some ventilatory actions. velocity of shortening, electrophysiologic properties,
New technology employing a Meteor digital spiro- pattern of recruitment, motor control (intact central
meter (Cardio-Pulmonary Technologies, Sussex, WI) drive and neural transmission), and metabolism (oxygen
and custom-prepared software for a Windows-based supply and nutritional support). The physical therapist
personal computer (FMV-660MC/W; Fujitsu Corporation, can greatly assist the medical team in understanding
Tokyo, Japan) has recently been used to calculate a the individual’s breathing problems by documenting the
breathing intolerance index [(Ti/TTOT) (TV/VC)].152 RR, dyspnea, physiologic measures (HR, BP, SaO2),
The breathing intolerance index is higher in individuals CWE, and describing breathing kinematics in various
with SCI who use mechanical ventilation support and postures and with changes in functional demands.
may be a useful measurement for identifying individuals Additional measures of VC, MIP, MEP, and MVV are
who need noninvasive ventilation or part-time ventila- easily performed by physical therapists and useful for
tion to prevent respiratory muscle fatigue.152 This meas- demonstrating program outcomes related to therapeutic
ure may be useful for monitor outcomes in those with interventions.
marginal respiratory muscle function.
Any individual having difficulty breathing without
Pulmonary Function and Cough Effectiveness
ventilator support requires an examination of central
neuromuscular drive. To evaluate respiratory drive, the Coughing is vital for clearing secretions and preventing
individual inhales a hypercapnic or hypoxic gas mixture pneumonia. Normally, cough volumes are 2.30 0.5 L154
to stimulate chemoreceptors. This is followed by occlu- and release air at peak cough flow rates (PCFR) of 6 to
sion of the airway at the onset of inspiration during TV 20 L/sec or 300 to 700 L/min.155-157 The unassisted cough
breathing. The airway pressure developed at 0.1 seconds in individuals with tetraplegia results in PCFR ranging
CAPACITY LOAD
Ventilatory
Muscle Fatigue
& Failure
• Respiratory Control • Lung Compliance/Volumes (VC, FEV1)

Drive (PO1) • Chest Wall Compliance (CWE)
Neuromuscular transmission • Pulmonary Airway Resistance (PEFR)
• Respiratory Coordination • High VE (TV x RR)
• Ventilatory Mechanics/Strength &
Endurance (MIP, MEP, MVV)
Steroids
Nutrition (glucose)
Electrolytes/minerals
Oxygen • Healthy vs Fibrosis, ARDS, Shock
• Compliant vs Stiff
• Open, Dilated vs Atelectasis + Pneumonia
• Normal DS + TLC vs DS + TLC
• TV Breathing vs VC Breathing
• Intact vs Absent • Sepsis/Fever VE
• Proper vs Dyssynchronous Sequencing
• Normal/Hypertrophied vs Weak
Figure 14S-11. A variety of factors influence respiratory function. A balance between ventilatory load and
capacity is required. If load is increased then the respiratory muscle demands are higher and fatigue is
eminent. (Modified with permission from;Vassilakopoulos T, Zakynthinos S, Roussos CH. Respiratory
muscles and weaning failure. Eur Respir J. 1996;9:2383–2400.)
from 203 to 271 L/min.157 The minimum PCFR required requires coordination of the respiratory muscles and a
to clear secretions is 2.7 L/sec or 160 L/min, but can strong glottis capable of restricting flow as intrathoracic
reach 6.5 L/sec or 390 L/min with cough-assisted pressure builds to a level that can lift and clear secretions
techniques (Heimlich, self- or caregiver-assisted or alter- during expulsion.102,156 Once assisted coughing strategies
natives) in those with neurological disorders.11,87,155,158,159 are taught (in chapter 14 see the section “Coughing” and
Typically, assisted cough provides a flow rate greater than Table 14-6), their effectiveness may be evaluated with
4.5 L/sec or 270 L/min.87 measures of PCFR using a flowmeter.
Peak cough flow rates can be measured using portable
flow meters (Assess Peak Flow Meter; Healthscan
Products, Cedar Grove, NJ). Measures of mean PCFR
taken in individuals with SCI are significantly correlated Summary
with motor level, with the lowest PCFR seen in those Normally, breathing is influenced by gravity, body posi-
with higher levels of injury (tetraplegia).38 For individu- tion, and respiratory muscle performance. Ventilation
als with cervical spinal injuries, measures of MIP and involves proper movement of muscles on a flexible tho-
MEP are significantly correlated with PCFR, with MIP racic cage. Individuals with SCI have variable respiratory
having the stronger correlation (MIP: r = 0.75 vs MEP: status, depending on changes in body position and
r 0.44).39 This suggests that inspiratory muscle func- degrees of muscle paralysis. Impairment of muscle func-
tion is critical to developing adequate cough in these tion leads to hypoventilation and impaired cough in
individuals. many individuals with SCI. The risk for life-threatening
The cough reflex remains intact; however, the fre- pneumonia and atelectasis is significant, especially in
quency of coughing may be increased in those with SCI those with high thoracic or cervical injuries. Gas
due to acquiring lower cough thresholds that develop to exchange can become compromised, leading to respira-
protect the airways when the individual is exposed to tory insufficiency. An examination of respiratory status
smoke, pollution, or infection.160,161 Cough function is will require careful review of both the ventilatory muscle
effective for airway clearance when high volumes and pump and the respiratory functions.
flow rates are achieved.102 When either the VC or the An examination of respiratory function for individu-
FEV1 fall below 60% of the predicted value, there will be als with SCI includes baseline measures of vital signs,
insufficient power behind the cough.69 The effort therefore oximetry, breathing pattern, chest wall excursion,
posture, muscle examination, coughing, auscultation, REFERENCES

and phonation. Many of these measures are easily per-
formed in the clinic and offer important information to 1. Widmaier EP, Raff H, Strang KT. Vander’s Human
direct the management of respiratory care. Specialized Physiology. The Mechanisms of Body Function. 10th edition.
testing of pulmonary function (VC, FEV1 and PEFR) New York: McGraw Hill; 2006.
2. Dean E. Body positioning. In: Frownfelter D, Dean E,
and respiratory muscle performance (MIP, MEP, and
editors. Cardiovascular and Pulmonary Physical Therapy:
MVV) may also be performed. These measures may be Evidence and Practice. 4th edition. St. Louis: Mosby
applied to documenting all the dimensions of respiratory Elsevier; 2006. pp. 307–324.
muscle function and the impact of therapeutic exercise 3. Chen CF, Lien IN, Wu MC. Respiratory function in
or adaptations. By including a comprehensive examina- patients with spinal cord injuries: Effects of posture.
tion of respiratory function, the therapist is able to offer Paraplegia. 1990;28(2):81-86.
sound clinical decision making. Strategies to facilitate 4. De Troyer A, Heilporn A. Respiratory mechanics in quad-
and recover respiratory function are optimized. riplegia. The respiratory function of the intercostal mus-
Additionally, individuals who are at risk for respiratory cles. Am Rev Respir Dis. 1980;122:591–600.
insufficiency can be identified and their overall out- 5. Anke A, Aksnes AK, Stanghelle JK et al. Lung volumes in
come improved. tetraplegic patients according to cervical spinal cord injury
level. Scand J Rehabil Med. 1993;25(2):73–77.
6. Linn WS, Adkins RH, Gong H, Jr. et al. Pulmonary func-
tion in chronic spinal cord injury: A cross-sectional survey
of 222 southern California adult outpatients. Arch Phys Med
REVIEW QUESTIONS Rehabil. 2000;81(6):757–763.
7. Vilke GM, Chan TC, Neuman T et al. Spirometry in nor-
mal subjects in sitting, prone, and supine positions. Respir
1. Describe how gravity and body position influence Care. 2000;45(4):407–410.
breathing in the nondisabled person. What position 8. Craig AB. Effects of position on expiratory reserve volume
is recommended for examination of an individual of the lungs. J Appl Physiol. 1960;15:59–61.
with a motor-complete C6 spinal injury? Which 9. Estenne M, DeTroyer A. Mechanism of the postural
position would be most stressful for an individual dependence of vital capacity in tetraplegic subjects. Am Rev
with a motor motor-complete T10 spinal injury Respir Dis. 1987;135:367–371.
(assume medical issues are resolved). 10. Baydur A, Adkins RH, Milic-Emili J. Lung mechanics
2. Identify the primary and accessory muscles involved in individuals with spinal cord injury: Effects of injury
level and posture. J Appl Physiol. 2001;90(2):405–411.
in ventilation. What muscle actions and patterns of
11. Massery M, Cahalin L. Physical therapy associated with
breathing are dominant for individuals with high cer-
ventilatory pump dysfunction and failure. In: DeTurk W,
vical injuries (C2–C4)? What muscle actions and pat- Cahalin LP, editors. Cardiovascular and Pulmonary Physical
terns of breathing are dominant for individuals with Therapy: An Evidence-Based Approach. New York: McGraw
motor-complete injuries at C5–T4? Hill; 2004. pp. 593–646.
3. List at least three important medical management 12. Cherniack R, Cherniack L. Respiration in Health and
issues that may impact on respiratory function in Disease. 3rd edition. Philadelphia: W.B. Saunders; 1983.
individuals with SCI? 13. Verschakelen JA, Deschepper K, Demedts M. Relationship
4. What information will tell the therapist about degree of between axial motion and volume displacement of the
pulmonary impairment and overall respiratory status? diaphragm during VC maneuvers. J Appl Physiol.
5. At what level of injury will the individual with a SCI 1992;72(4): 1536–1540.
14. Massery MP, Dreyer HE, Bjornson AS et al. Chest wall
be likely to need some ventilation support, even at
excursion and tidal volume change during passive position-
the end of the acute stage?
ing in cervical spinal cord injury. Cardiopulmonary Phys Ther
6. Name the types of alarms that may sound from the J. 1997;8(4):27. (Abstr.)
ventilator, and tell what the physical therapist should 15. Wetzel JL, Lunsford BR, Peterson MJ et al. Respiratory
do to prevent or minimize this occurrence. rehabilitation of the patient with a spinal cord injury. In:
7. Where are the landmarks for taking measures of Irwin S, Techlin JS, editors. Cardiopulmonary Physical
chest wall expansion? Therapy. 3rd edition. St. Louis: Mosby; 1995. pp. 579–603.
8. How can you quantify eccentric control of the 16. Alvarez SE, Peterson M, Lunsford BR. Respiratory treat-
diaphragm? ment of the adult patient with spinal cord injury. Physical
9. Which specialized test would you use to document Therapy. 1981;61(12):1737–1745.
respiratory muscle endurance? 17. Harty HR, Corfield DR, Schwartzstein RM et al. External
thoracic restriction, respiratory sensation, and ventilation
10. Which specialized test would you use to document
during exercise in men. J Appl Physiol. 1999;86(4):1142–1150.
respiratory muscle strength?
18. Reid D, Dechman G. Considerations when testing and
11. Which specialized test would you use to document training the respiratory muscles. Physical Therapy.
cough function? What is the normal value for PCFR, 1995;75:971–982.
and what is the range for PCFR reported for those 19. Flaminiano LE, Celli BR. Respiratory muscle testing. Clin
with tetraplegia? Chest Med. 2001;22(4):661–677.
20. DeTroyer A, Estenne M. Coordination between rib cage palsies during anterior cervical spine surgery. Spine. 2000;
muscles and diaphragm during quiet breathing in humans. 25(22):2906–2912.
J Appl Physiol. 1984;57:899–906. 43. American Thoracic Society. Standardization of spirometry,
21. Dean E. Cardiopulmonary anatomy. In: Frownfelter D, 1994 update. Am J Respir Crit Care Med. 1995;152:
Dean E, editors. Cardiovascular and Pulmonary Physical 1107–1136.
Therapy: Evidence and Practice. 4th edition. St. Louis: Mosby 44. American Throacic Society. Lung function testing:
Elsevier; 2006. pp. 53–72. Selection of reference values and interpretive strategies.
22. Carter RE. Medical management of pulmonary complica- Am Rev of Respir Dis. 1991;144:1202–1218.
tions of spinal cord injury. Adv Neurol. 1979;22:261–269. 45. DeLorey DS, Wyrick BL, Babb TG. Mild-to-moderate
23. Morris JF, Koski A, Johnson LC. Spirometric standards for obesity: Implications for respiratory mechanics at rest and
healthy nonsmoking adults. Am Rev Respir Dis. 1971;103: during exercise in young men. Int J Obes. 2005;29(9):
57–67. 1039–1047.
24. Bergofsky EH. Mechanism for respiratory insufficiency 46. Varon J, Marik P. Management of the obese critically ill
after cervical cord injury: A source of alveolar hypoventila- patient. Crit Care Clin. 2001;17(1):187–200.
tion. Ann Intern Med. 1964;61:435–447. 47. Menter RR, Bach J, Brown DJ et al. A review of the respi-
25. Loring SH, DeTroyer A. Actions of the respiratory mus- ratory management of a patient with high level tetraplegia.
cles. In: Roussos CH, Macklem PT, editors. The Thorax. Spinal Cord. 1997;35:805–808.
New York: Marcel Dekker Inc.; 1985. pp 327–349. 48. Burns SP, Kapur V, Yin KS et al. Factors associated with
26. Grimby G, Goldman M, Mead J. Respiratory muscle sleep apnea in men with spinal cord injury: A population-
action inferred from rib cage and abdominal V-P partition- based case-control study. Spinal Cord. 2001;39(1):15–22.
ing. J Appl Physiol. 1976;41:739. 49. Brown R, DiMarco AF, Hoit JD et al. Respiratory dysfunc-
27. Goldman G, Mead J. Mechanical interaction between the tion and management in spinal cord injury. Respir Care.
diaphragm and the rib cage. J Appl Physiol. 1973;35:197. 2006;51(8):853–867.
28. Goldman M, Grimby G, Mead J. Mechanical work of 50. Garshick E, Kelley A, Cohen SA et al. A prospective assess-
breathing derived from rib cage and abdominal V-P parti- ment of mortality in chronic spinal cord injury. Spinal Cord.
tioning. J Appl Physiol. 1976;41:752. 2005;43(7):408–416.
29. Roussos C, Macklem PT. The respiratory muscles. N Engl 51. Uijl SG, Houtman S, Folgering HT et al. Training of the
J Med. 1982;307:786–797. respiratory muscles in individuals with tetraplegia. Spinal
30. Black LF, Hyatt RE. Maximal respiratory pressures: Cord. 1999;37(8):575–579.
Normal values and relationship to age and sex. Am Rev 52. Cerny FJ, Ucer C. Arm work interferes with normal venti-
Respir Dis. 1969;99:696 –702. lation. Appl Ergonomics. 2004;35(5):411–415.
31. ATS/ETS. ATS/ETS Statement on Respiratory Muscle 53. Sutbeyaz ST, Koseoglu BF, Gokkaya NK. The combined
Testing. Am J Resp Crit Care Med. 2002;166(4):518–624. effects of controlled breathing techniques and ventilatory
32. Derenne J, Macklem PT, Roussos CH. The respiratory and upper extremity muscle exercise on cardiopulmonary
muscles: Mechanics, control, and pathophysiology. Part I. responses in patients with spinal cord injury. Int J Rehabil
Am Rev Respir Dis. 1978;118:119–133. Res. 2005;28(3):273–276.
33. Taylor A. Contribution of intercostal muscles to the effort 54. Ciesla ND, Murdock KR. Lines, tubes, catheters, and
of respiration in man. J Physiol. 1960;151:390. physiologic monitoring in the ICU. Cardiopulmonary Phys
34. Campbell EJM. The role of scalene and sternocleidomas- Ther J. 2000;11(1):16–25.
toid in breathing in normal subjects. J Anat. 55. Jackson AB, Groomes TE. Incidence of respiratory com-
1955;89:378–386. plications following spinal cord injury. Arch Phys Med
35. Hislop HJ, Montgomery J, Connelly B et al. Daniels and Rehabil. 1994;75(3):270–275.
Worthingham’s Muscle Testing. 6th edition. Philadelphia: 56. Ciesla N. Physical therapy associated with respiratory fail-
W.B. Saunders; 1995. ure. In: DeTurk WE, Cahalin LP, editors. Cardiovascular
36. Aliverti A, Cala SJ, Duranti R et al. Human respiratory and Pulmonary Physical Therapy: An Evidence-Based
muscle actions and control during exercise. J Appl Physiol. Approach. New York: McGraw Hill; 2004. pp. 541–592.
1997;83:1256–1269. 57. Hergenroeder AL. Implementation of a competency-based
37. Braun SR, Giovannoni R, O’Connor JR. Improving cough assessment of interpretation of laboratory values. Acute
in patients with spinal cord injury. Am J Physical Med. Care Perspectives. 2006;15(1):7–15.
1984;63:1–10. 58. Poponick JM, Jacobs I, Supinski G et al. Effect of upper
38. Wang AY, Jaeger RJ, Yarkony GM et al. Cough in spinal respiratory tract infection in patients with neuromuscular
cord injured patients: The relationship between motor level disease. Am J Respir Crit Care Med. 1997;156(2 Pt1):659–664.
and peak expiratory flow. Spinal Cord. 1997;35(5): 299–302. 59. Shapiro BA. Evaluation of blood gas monitors:
39. Kang SW, Shin JC, Park CI et al. Relationship between Performance criteria, clinical impact, and cost/benefit. Crit
inspiratory muscle strength and cough capacity in cervical Care Med. 1994;22(4):546–548.
spinal cord injured patients. Spinal Cord. 2006;44(4): 242–248. 60. Knott P. Imaging of the chest. In: Frownfelter D, Dean E,
40. Deem JF, Nukker L. Manual of Voice Therapy. 2nd edition. editors. Cardiovascular and Pulmonary Physical Therapy.
Austin, TX: ProEd; 2000. Evidence and Practice. 4th edition. St. Louis: Mosby
41. Hoit JD, Banzett RB, Brown R, Loring SH. Speech Elsevier; 2006. pp. 163–168.
breathing in individuals with cervical spinal cord injury. J 61. Cahalin LP. Pulmonary evaluation. In: DeTurk WE,
Speech & Hear Res. 1990;33(4):798–807. Cahalin LP, editors. Cardiovascular and Pulmonary Physical
42. Apfelbaum RI, Kriskovich MD, Haller JR. On the inci- Therapy. An Evidence-Based Approach. New York: McGraw
dence, cause, and prevention of recurrent laryngeal nerve Hill; 2004. pp. 221–269.
62. Zablotny C. Evaluation and management of swallowing 80. Eason JM. Cardiopulmonary Assessment. Cardiopulmonary
dysfunction. In: Montgomery J, editor. Clinics in Physical Phys Ther J. 1999;10(4):135–142.
Therapy. Physical Therapy for Traumatic Brain Injury. 81. Schmitz TJ. Vital signs. In: O’Sullivan SB, Schmitz TJ,
New York: Churchill Livingstone; 1995. pp. 99–115. editors. Physical Rehabilitation: Assessment and Treatment.
63. Consortium for Spinal Cord Medicine. Respiratory man- 4th edition. Philadelphia: F. A. Davis; 2001. pp. 77–100.
agement following spinal cord injury: A clinical practice 82. Gerold K. Physical therapists’ guide to the principles of
guideline for health-care professionals. J Spinal Cord Med. mechanical ventilation. Cardiopulmonary Phys Ther J.
2005;28(3):259–293. 1992;3: 8–13.
64. Kirshblum S, Johnston MV, Brown J et al. Predictors of 83. MacIntyre NR, Cook DJ, Guyatt GH, editors. Evidence-
dysphagia after spinal cord injury. Arch Phys Med Rehabil. based guidelines for weaning and discontinuing ventilatory
1999;80(9):1101–1105. support: A collective task force facilitated by the American
65. Maeda CJ, Baydur A, Waters RL et al. The effect of the College of Chest Physicians; the American Association for
halovest and body position on pulmonary function in quad- Respiratory Care; and the American College of Critical
riplegia. J Spinal Disorders. 1990;3(1):47–51. Care Medicine. Chest. 2001;120(6):375S–395S.
66. Noble-Jamieson CM, Heckmatt JZ, Dubowitz V et al. 84. Yang KL, Tobin MJ. A prospective study of indexes pre-
Effects of posture and spinal bracing on respiratory function dicting the outcome of trials of weaning from mechanical
in neuromuscular disease. Arch Dis Child. 1986;61(2):178–181. ventilation. N Engl J Med. 1991;324:1445–1450.
67. Massery M. Multisystem consequences of impaired breath- 85. Clanton TL, Diaz PT. Clinical assessment of the respirato-
ing mechanics and/or postural control. In: Frownfelter D, ry muscles. Physical Therapy. 1995;75:983–995.
Dean E, editors. Cardiovascular and Pulmonary Physical 86. Vassilakopoulos T, Zakynthinos S, Roussos CH.
Therapy: Evidence and Practice. 4th edition. St. Louis: Mosby Respiratory muscles and weaning failure. Eur Respir J.
Elsevier; 2006. pp. 695–717. 1996;9:2383–2400.
68. Ball PA. Critical care of spinal cord injury. Spine. 87. Tzeng AC, Bach JR. Prevention of pulmonary morbidity
2001;26(24 Suppl):S27–30. for patients with neuromuscular disease. Chest.
69. Massery M. The patient with neuromuscular or muscu- 2000;118(5):1390–1397.
loskeletal dysfunction. In: Frownfelter D, Dean E, editors. 88. Derenne J, Macklem PT, Roussos CH. The respiratory
Principles and Practice of Cardiopulmonary Physical Therapy. muscles: Mechanics, control, and pathophysiology. Part
3rd edition. St. Louis: Mosby Yearbook, Inc.; 1996. III. Am Rev Respir Dis. 1978;118:581–601.
pp. 679–702. 89. Threethambal P, Vareshree AL, Shivani M et al.
70. Dean E, Frownfelter D. Individuals with chronic second- Thoracolumbar corsets alter breathing pattern in normal
ary cardiopulmonary dysfunction. In: Dean E, Frownfelter individuals. Int J Rehabil Res. 2005;28(1):81–85.
D, editors. Cardiovascular and Pulmonary Physical Therapy. 90. Oatis CA. Structure and function of the bones and joints of
Evidence and Practice. 4th edition. St. Louis: Mosby the thoracic spine. In: Oatis CA, editor. Kinesiology. The
Elsevier; 2006. pp. 569–593. Mechanics and Pathomechanics of Human Movement.
71. Gardner BP, Watt JW, Krishnan KR. The artificial ventila- Philadelphia: Lippincott, Williams & Wilkins; 2004.
tion of acute spinal cord damaged patients: A retrospective pp. 488–514.
study of forty-four patients. Paraplegia. 1986;24(4): 208–220. 91. Harris J, Johansen J, Pedersen S et al. Site of measurement
72. Como JJ, Sutton ER, McCunn M et al. Characterizing the and subject position affect chest excursion measurements.
need for mechanical ventilation following cervical spinal Cardiopulmonary Phys Ther J. 1997;8(4):12–17.
cord injury with neurologic deficit. J Trauma. 2005;59(4): 92. LaPier TK, Cook A, Droege K et al. Intertester and intrat-
912–916. ester reliability of chest excursion measurements in subjects
73. Harrop JS, Sharan AD, Scheid EH, Jr. et al. Tracheostomy without impairment. Cardiopulmonary Phys Ther J. 2000;
placement in patients with complete cervical spinal cord 11(3):95–98.
injuries: American Spinal Injury Association Grade A. J 93. Moll JM, Wright V. An objective clinical study of chest
Neurosurg. 2004;100 Suppl 1:20–23. expansion. Ann Rheum Dis. 1972;31:1–8.
74. Fagon J, Chastre J, Hance AJ et al. Nosocomial pneumonia 94. Carlson B. Normal chest expansion. Physical Therapy.
in ventilated patients: A cohort study evaluating attributable 1973;53:10–14.
mortality and hospital stay. Am J Med. 1993;94: 281–288. 95. Burgos–Vargas R, Castelazo-Duarte G, Orozco JA et al.
75. Bach JR. Alternative methods of ventilatory support for the Chest expansion in healthy adolescents and patients with
patient with ventilatory failure due to spinal cord injury. J the seronegative enthesopathy and arthropathy syndrome
Am Paraplegia Soc. 1991;14(4):158–174. or juvenile ankylosing spondylitis. J Rheumatol. 1993;20:
76. Bach JR, Alba AS. Noninvasive options for ventilatory sup- 1957–1960.
port of the traumatic high level quadriplegic patient. Chest. 96. Feldman D, Ouellette M, Villamez A et al. The relation-
1990;98(3):613–619. ship of ventilatory muscle strength to chest wall excursion
77. Burns SP, Rad MY, Bryant S et al. Long-term sleep apnea in normal subjects and persons with cervical spinal cord
in persons with spinal cord injury. Am J Phys Med Rehabil. injury. Cardiopulmonary Phys Ther J. 1998;9(4):20. (Abstr.)
2005;84(8):620–626. 97. Mellin G, Harjula R. Lung function in relation to thoracic
78. McEvoy RD, Mykytyn I, Sajkov D et al. Sleep apnea in spine mobility and kyphosis. Am Rev Respir Dis.
patients with quadriplegia. Thorax. 1995;50(6):613–619. 1987;19:89–92.
79. Tobin MJ, Mador MJ, Guenther SM et al. Variability of 98. Frownfelter D, Massery M. Facilitating ventilation patterns
resting respiratory drive and timing in healthy subjects. and breathing strategies. In: Frownfelter D, Dean E, editors.
J Appl Physiol. 1988;65(1):309–317. Cardiovascular and Pulmonary Physical Therapy. Evidence and
Practice. 4th edition. New York: Mosby Elsevier; 2006. 118. Cruzado D, Jones MJ, Segebart S et al. Resistive inspira-
pp. 377–403. tory muscle training improves inspiratory muscle
99. Frownfelter D, Massery M. Body mechanics—The art of strength in subjects with cervical spinal cord injury.
positioning and moving patients. In: Frownfelter D, Dean E, Neurol Rep. 2002;26(1):3–7.
editors. Cardiovascular and Pulmonary Physical Therapy. 119. Black LF, Hyatt RE. Maximal static respiratory pressures
Evidence and Practice. 4th edition. St. Louis: Mosby in generalised neuromuscular disease. Am Rev Respir Dis.
Elsevier; 2006. pp. 749–758. 1971;103:641–650.
100. Crosbie W, Myles S. An investigation into the effect of 120. Gross D, Grassino A, Scott G et al. Respiratory muscle
postural modification on some aspects of normal pul- fatigue in quadriplegic patients. Clinical Research.
monary function. Physiotherapy. 1985;7:311–314. 1977;25:713A.
101. Dail CW. Muscle breathing patterns. Med Arts & Sci. 121. Gross D, Ladd HW, Riley EJ et al. The effect of training
1956;10(Second Quarter):64. on strength and endurance of the diaphragm in quadri-
102. Frownfelter D, Massery M. Facilitating airway clearance plegia. Am J Phys Med. 1980;68(1):27–35.
with coughing techniques. In: Frownfelter D, Dean E, 122. Tully K, Koke K, Garshick E et al. Maximal expiratory
editors. Cardiovascular and Pulmonary Physical Therapy. pressures in spinal cord injury using two mouthpieces.
Evidence and Practice. 4th edition. St. Louis: Mosby Chest. 1997;112(1):113–116.
Elsevier; 2006. pp. 363–376. 123. Enright PL, Kronmal RA, Manolio TA et al. Respiratory
103. Bouros D, Siafakas N, Green M. Cough: Physiology muscle strength in the elderly. Correlates and reference
and pathophysiological considerations. In: Roussos CH, values. Cardiovascular health study research group. Am J
editor. The Thorax. New York: Marcel Dekker; 1995: Resp Crit Care Med. 1994;149:430–438.
1335–1354. 124. Fishman A, Elias J, Fishman J. Fishman’s Pulmonary
104. Wilkins RL, Hodgkin JE, Lopez B. Lung Sounds. St. Louis: Diseases and Disorders. 3rd edition. New York: McGraw
Mosby; 1988. Hill; 1998.
105. Warren VC. Glossopharyngeal and neck accessory muscle 125. Cook CD, Mead J, Orzalesi MM. Static volume-pressure
breathing in a young adult with C2 complete tetraplegia characteristics of the respiratory system during maximal
resulting in ventilator dependency. Physical Therapy. efforts. J Appl Physiol. 1964;19:1016–1022.
2002;82(6):590–600. 126. Leech JA, Ghezzo H, Stevens D et al. Respiratory pres-
106. Grandas NF, Jain NB, Denckla JB et al. Dyspnea during sures and function in young adults. American Review of
daily activities in chronic spinal cord injury. Arch Phys Respiratory Disease. 1983;128:17–23.
Med Rehabil. 2005;86(8):1631–1635. 127. Rinqvist, T. The ventilatory capacity in healthy adults: an
107. Hoit JD, Banzett RB, Brown R. Binding the abdomen can analysis of causal factors with special reference to the res-
improve speech in men with phrenic nerve pacers. Am piratory forces. Scand Journal of Clinical Laboratory
J Speech Lang Pathol. 2002;11(1):71–76. Investigation. 1966;18(Suppl):1–111.
108. Rahn H, Otis AB, Chadwick LE et al. The pressure-vol- 128. Rochester D, Arora NS. Respiratory muscle failure. The
ume diagram of the thorax and lung. Am J Physiol. Medical Clinics of North America. 1983;67:573–598.
1946;146:161. 129. Vincken W, Ghezzo H, Cosio MG. Maximal static respi-
109. Troosters T, Gosselink R, Decramer M. Respiratory mus- ratory pressures in adults: normal values and their rela-
cle assessment. Eur Respir Mon. 2005;31:51–71. tionship to determinants of respiratory function. Bulletin
110. Hamnegard CH, Wraggs S, Kyroussis D et al. Portable of European Physiopathology of Respiration. 1987;23:435–439.
measurement of maximum mouth pressures. Eur Respir 130. Wilson DO, Cooke NT, Edwards RHT et al. Predicted
J. 1994;7:398–401. normal values for maximal respiratory pressures in cau-
111. Roth EJ, Nussbaum SB, Berkowitz M et al. Pulmonary casian adults and children. Thorax. 1984;39:535–538.
function testing in spinal cord injury: Correlation with 131. Gounden P. Static respiratory pressures in patients with
vital capacity. Paraplegia. 1995;33(8):454–457. post-traumatic tetraplegia. Spinal Cord. 1997;35(1):43–47.
112. Gardner RM, Hankinson JL, West BJ. Evaluation of 132. Rutchik A, Weissman AR, Almenoff PL et al. Resistive
commercially available spirometers. Am Rev Resp Dis. inspiratory muscle training in subjects with chronic cervi-
1980;121(1):73–82. cal spinal cord injury. Arch Phys Med Rehabil. 1998;
113. Nelson SB, Gardner RM, Crapo RO et al. Performance 79(3):293–297.
evaluation of contemporary spirometers. Chest. 133. McCool FD, Tzelepis GE. Inspiratory muscle training in
1990;97(2):288–297. the patient with neuromuscular disease. Physical Therapy.
114. Rebuck DA, Hanania NA, D’Urzo AD et al. The accuracy of 1995;75:1006–1114.
a handheld portable spirometer. Chest. 1996;109(1):152–157. 134. Derrickson J, Ciesla ND, Simpson N et al. A comparison
115. Kelley A, Garshick E, Gross ER et al. Spirometry testing of two breathing exercise programs for patients with
standards in spinal cord injury. Chest. 2003;123(3): quadriplegia. Physical Therapy. 1992;72:763–769.
725–730. 135. Lin KH, Wu HD, Chang CW et al. Ventilatory and
116. McMichan JC, Michel L, Westbrook PR. Pulmonary dys- mouth occlusion pressure responses to hypercapnia in
function following traumatic quadriplegia. Recognition, chronic tetraplegia. Arch Phys Med Rehabil. 1998;79(7):
prevention, and treatment. JAMA. 1980;243(6):528–531. 795–799.
117. Roth EJ, Lu A, Primack S et al. Ventilatory function in 136. Aldrich TK, Arora NS, Rochester DF. The influence of
cervical and high thoracic spinal cord injury. Relationship airway obstruction and respiratory muscle strength on
to level of injury and tone. Am J Phys Med Rehabil. maximal voluntary ventilation in lung disease. Am Rev
1997;76(4):262–267. Respir Dis. 1982;126:195–199.
137. Wang TG, Wang YH, Tang FT et al. Resistive inspiratory 149. Wien MF, Garshick E, Tun CG et al. Breathlessness and
muscle training in sleep-disordered breathing of traumatic exercise in spinal cord injury. J Spinal Cord Med.
tetraplegia. Arch Phys Med Rehabil. 2002;83(4): 491–496. 1999;22(4):297–302.
138. Almenoff PL, Spungen AM, Lesser M et al. Pulmonary 150. Frownfelter D, Ryan J. Dyspnea: Measurement and eval-
function survey in spinal cord injury: Influences of smok- uation. Cardiopulmonary Phys Ther J. 2000;11(1):7–15.
ing and level and completeness of injury. Lung. 1995; 151. Bellemare F, Grassino A. Effect of pressure and timing of
173(5):297–306. contraction on human diaphragm fatigue. J Appl Physiol.
139. Sheel AW, Reid WD, Townson AF et al. Respiratory man- 1982;53(5):1190–1195.
agement following spinal cord injury. In: Eng JJ, Teasell RW, 152. Koga T, Watanabe K, Sano M et al. Breathing intolerance
Miller WC et al, editors. Spinal Cord Injury Rehabilitation index. Am J Phys Med Rehabil. 2006;85(1):24–30.
Evidence. Vancouver: International Collaboration on Repair 153. Manning HL, Brown R, Scharf SM et al. Ventilatory and
Discoveries (ICORD); 2006. pp. 8.1–8.30. P0.1 response to hypercapnia in quadriplegia. Resp Physiol.
140. McKenzie DK, Gandevia SC. Influence of muscle length 1992;89:97–112.
on human inspiratory and limb muscle endurance. Respir 154. Leith DE. Cough. In: Brain JD, Proctor D, Reid L,
Physiol. 1987;67:171–182. editors. Lung Biology in Health and Disease: Respiratory
141. Nickerson BG, Keens TG. Measuring ventilatory muscle Defense Mechanisms. Vol 2. New York: Marcel Dekker;
endurance in humans as sustainable inspiratory pressure. 1977. pp. 545–592.
J Appl Physiol. 1982;52(3):768–772. 155. Bach JR. Mechanical insufflation-exsufflation: Comparison
142. Mueller G, Perret C, Spengler CM. Optimal intensity for of peak expiratory flows with manually assisted and unas-
respiratory muscle endurance training in patients with sisted coughing techniques. Chest. 1993;104:1553–1562.
spinal cord injury. J Rehabil Med. 2006;38(6):381–386. 156. Kang SW, Bach JR. Maximum insufflation capacity. Chest.
143. Gosselink R. Controlled breathing and dyspnea in 2000;118:61–65.
patients with chronic obstructive pulmonary disease 157. Agency of Healthcare Research and Quality. Treatment
(COPD). J Rehab Res Dev. 2003;40(5):S25–34. of Pulmonary Disease Following Cervical Spinal Cord
144. Fry DK, Pfalzer LA, Chokshi AR et al. Randomized con- Injury. Summary Evidence Report/Technology Assessment:
trol trial of effects of a 10-week inspiratory muscle training Number 27; AHRQ Publication No. 01-E013; June
program on measures of pulmonary function in persons 2001. Available at: http://www.ahrq.gov/clinic/epcsum/
with multiple sclerosis. J Neurol Physical Therapy. spinalsum.htm
2007;31(4):162–172. 158. Bach JR, Saporito L. Criteria for extubation and tra-
145. Kisner C, Colby LA. Resistive Exercise for Impaired cheostomy tube removal for patients with ventilatory fail-
Muscle Performance. In: Kisner C, Colby LA, editors. ure: a different approach to weaning. Chest. 1996;110:
Therapeutic Exercise: Foundations and Techniques. 5th edi- 1566–1571.
tion. Philadelphia: F.A. Davis; 2007. 159. Kirby NA, Barnerias MJ, Siebens AA. An evaluation of
146. Spungen AM, Grimm DR, Lesser M et al. Self-reported assisted cough in quadriparetic patients. Arch Phys Med
prevalence of pulmonary symptoms in subjects with Rehabil. 1966;46:705–710.
spinal cord injury. Spinal Cord. 1997;35(10):652–657. 160. Lin KH, Lai YL, Wu HD et al. Cough threshold in peo-
147. Ayas NT, Garshick E, Lieberman SL et al. Breathlessness ple with spinal cord injury. Physical Therapy.
in spinal cord injury depends on injury level. J Spinal Cord 1999;79(11):1026–1031.
Med. 1999;22(2):97–101. 161. Dicpinigaitis PV, Grimm DR, Lesser M. Cough reflex
148. Rabinstein AA, Wijdicks EF. Warning signs of imminent sensitivity in subjects with cervical spinal cord injury. Am
respiratory failure in neurological patients. Semin Neurol. J Respir Crit Care Med. 1999;159(5 Pt 1):1660–1662.
2003;23(1):97–104.

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qxd 3/31/09 10:05 AM Page 1

After reading this chapter, the reader will be able to:

• Identify the primary and accessory muscles involved in ventilation

2 Spinal Cord Injury Rehabilitation

Normal Respiration: Implications

Chapter 14 Respiratory Evaluation of Individuals with Spinal Cord Injury 3

4 Spinal Cord Injury Rehabilitation

Central tendon Xiphoid process

Chapter 14 Respiratory Evaluation of Individuals with Spinal Cord Injury 5

trapezius, rhomboid major and minor, levator costarum,

6 Spinal Cord Injury Rehabilitation

Scalenes C3–C6 O: Superior surface of Elevates the first

Chapter 14 Respiratory Evaluation of Individuals with Spinal Cord Injury 7

Rhomboid C5 O:T2–T5 vertebral Scapular adduction, Check strength of the

Rhomboid C5 O: C7–T1 vertebral As above

8 Spinal Cord Injury Rehabilitation

*Consult anatomy textbook for greater details on origin and insertion.

Chapter 14 Respiratory Evaluation of Individuals with Spinal Cord Injury 9

Blood pressure (BP) 120/80 Hg Diaphragm excursion may be limited if low

Respiratory rate (RR) rest 12–20 breaths/min 35 MV support needed

Temperature 98.5° F Infection if elevated; pneumonia?

Breathing pattern 2 Chest: 2 Diaphragm Inefficient breathing ↑ fatigue if abnormal

Chest Wall Excursion (See Table 14S–3) ↓ CWE ↑ WOB

Posture Erect alignment all planes ↑ kyphosis may ↓ pulmonary function

10 Spinal Cord Injury Rehabilitation

Cough function Functional if capable of Weak or nonfunction ↑ risk for

Auscultation of lung fields Clear Coarse rales pneumonia

Chapter 14 Respiratory Evaluation of Individuals with Spinal Cord Injury 11

12 Spinal Cord Injury Rehabilitation

Chapter 14 Respiratory Evaluation of Individuals with Spinal Cord Injury 13

14 Spinal Cord Injury Rehabilitation

documentation of outcomes of a respiratory rehabilita- individual is mechanically ventilated. If breathing is ven-

Chapter 14 Respiratory Evaluation of Individuals with Spinal Cord Injury 15

16 Spinal Cord Injury Rehabilitation

Harris et al.ref 91 7.6  1.2b 7.4  1.7

Moll and Wrightref 93 6.0  2.14g

Burgos-Vargas et al.ref 95 5.6  1.76i

Chapter 14 Respiratory Evaluation of Individuals with Spinal Cord Injury 17

18 Spinal Cord Injury Rehabilitation

contraindicated, the therapist should still examine the Auscultation

Chapter 14 Respiratory Evaluation of Individuals with Spinal Cord Injury 19

20 Spinal Cord Injury Rehabilitation

160 120 80 40 0 –40 –80 –120

Figure 14S-6. (A) Diaphragm contractile force and fiber length

Chapter 14 Respiratory Evaluation of Individuals with Spinal Cord Injury 21

Figure 14S-8. Handheld spirometer for measuring peak expira-

22 Spinal Cord Injury Rehabilitation

Chapter 14 Respiratory Evaluation of Individuals with Spinal Cord Injury 23

Black and Hyatt30 M 60 20–54 124  22 233  42

Cook et al.125 M 17 18–47 133  39 237  45

Leech et al.126 M 325 17–35 114  36 154  82

Rinqvist127 M 100 18–83 130  32 237  46

Rochester and Arora128 M 80 19–49 127  28 216  41

Vincken et al.129 M 46 16–79 105  25 140  38

Wilson et al.130 M 48 19–65 106  31 148  34

24 Spinal Cord Injury Rehabilitation

Enright et al.123 MEN ≥ 65 years MIP (weight (lbs) ( 0.131) 

Chapter 14 Respiratory Evaluation of Individuals with Spinal Cord Injury 25

26 Spinal Cord Injury Rehabilitation

Chapter 14 Respiratory Evaluation of Individuals with Spinal Cord Injury 27

• Respiratory Control • Lung Compliance/Volumes (VC, FEV1)

28 Spinal Cord Injury Rehabilitation

posture, muscle examination, coughing, auscultation, REFERENCES

Harris et al.ref 91 7.6 1.2b 7.4 1.7

Moll and Wrightref 93 6.0 2.14g

Burgos-Vargas et al.ref 95 5.6 1.76i

Black and Hyatt30 M 60 20–54 124 22 233 42

Cook et al.125 M 17 18–47 133 39 237 45

Leech et al.126 M 325 17–35 114 36 154 82

Rinqvist127 M 100 18–83 130 32 237 46

Rochester and Arora128 M 80 19–49 127 28 216 41

Vincken et al.129 M 46 16–79 105 25 140 38

Wilson et al.130 M 48 19–65 106 31 148 34

Enright et al.123 MEN ≥ 65 years MIP (weight (lbs) ( 0.131)