Chapter 8 - Respiratory Management in Neurological DisordersLMNR

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Laboratory Manual for Neurologic Rehabilitation
Chapter 8: Respiratory Management in Neurological Disorders
For the Instructor Guide and Worksheet Key please contact user services at userservices@mheducation.com
OUTLINE
Objectives:
The student will:
1. Assess and interpret findings of vital capacity, peak cough flow, and inspiratory/expiratory pressure tests.
2. Appropriately and effectively demonstrate techniques for managing breathlessness/dyspnea, sputum retention and ineffective cough, and
hypoventilation due to respiratory muscle weakness.
3. Identify indications, applications, and considerations for rehabilitation with noninvasive ventilation, glossopharyngeal breathing, and neck
accessory muscle breathing.
Activity 1. Introduction
A brief discussion of the cause of respiratory problems in clients with neurological disorders and diagnoses that are commonly associated with
respiratory problems. Students consider common respiratory system abnormalities in people with neurological disorders and identify the cause and
clinical manifestations of the abnormalities.
Activity 2. Respiratory Assessment
Students listen to lung sounds and are taught how to perform forced vital capacity, peak cough flow, and inspiratory/expiratory pressure
measurements.
Activity 3. Respiratory Interventions
Students practice doing multiple types of interventions to manage breathlessness/dyspnea, sputum retention and ineffective cough, and
hypoventilation due to respiratory muscle weakness.
Activity 4. Managing Respiratory Failure: Glossopharyngeal Breathing and Neck Accessory Muscle Breathing, and
Noninvasive Ventilation
Students practice the use of glossopharyngeal breathing and neck accessory muscle breathing. Students discuss the use of noninvasive ventilation.
Activity 5. Case Studies
Students answer questions on paper cases and practice interventions.
WORKSHEET
Prelab Assignment:
Read the following articles prior to coming to the lab:

Downloaded 2021315 3:6 P Your IP is 201.234.181.53
Chapter 8: Respiratory Management in Neurological Disorders, Page
Bach JR, Bakshiyev R, Hon A. Noninvasive respiratory management for patients with spinal cord injury and neuromuscular disease. Tanaffos . 1 / 10
©2021 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility
2012;11(1):7–11. [PubMed: 25191394]
Warren VC. Glossopharyngeal and neck accessory muscle breathing in a young adult with C2 complete tetraplegia resulting in ventilator dependency.
WORKSHEET Universidad del Rosario
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Prelab Assignment:
Read the following articles prior to coming to the lab:
Bach JR, Bakshiyev R, Hon A. Noninvasive respiratory management for patients with spinal cord injury and neuromuscular disease. Tanaffos .
2012;11(1):7–11. [PubMed: 25191394]
Phys Ther . 2002;82(6):590–600. [PubMed: 12036400]
Activity 1. Introduction
Individuals with neurological conditions can have respiratory problems for a variety of reasons including reduced central drive, neuromuscular
weakness due to pathology and trauma, or respiratory infections due to immobility or aspiration. As you listen to your instructor, record the diagnoses
that are commonly associated with respiratory problems below:
1.
2.
3.
4.
5.
6.
7.
Respiratory muscle weakness due to neurological conditions is associated with insufficient ventilation, nocturnal hypoventilation, bulbar dysfunction,
and ineffective cough. As your instructor speaks, record the cause and signs and symptoms of these abnormalities in the table below.
Respiratory abnormality Cause Clinical manifestations
Insufficient ventilation
Nocturnal hypoventilation
Bulbar dysfunction
Ineffective cough
Activity 2. Respiratory Assessment
Choose a partner and observe his/her breathing pattern (normal respiratory rate for adults is 12–20 breaths/minute). Look to see that the person
exhibits normal relaxed breathing with abdominal rise followed by symmetric expansion of the ribs without accessory muscle recruitment during
inspiration and normal passive expiration. The normal inspiratory-to-expiratory time ratio is 1:2. Ask the person to cough and note the strength/force,
depth, and length, and whether it is dry or full-sounding. Perform auscultation of lung sounds with a stethoscope and systematically listen to the entire
lung space (anterior and then posterior and lateral). Record your findings:
1. Respiratory rate:
2. Breathing pattern:
Chapter 8: Respiratory Management in Neurological Disorders, Page 2 / 10
3. Cough:
4. Lung sounds:
inspiration and normal passive expiration. The normal inspiratory-to-expiratory time ratio is 1:2. Ask the person to cough and note the strength/force,
depth, and length, and whether it is dry or full-sounding. Perform auscultation of lung sounds with a stethoscope and systematically listen to the entire
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lung space (anterior and then posterior and lateral). Record your findings: Access Provided by:
1. Respiratory rate:
2. Breathing pattern:
3. Cough:
4. Lung sounds:
In addition to standard respiratory tests and measures, the respiratory assessment may include additional measures of vital capacity, peak cough flow,
and inspiratory/expiratory pressures to determine the individual's respiratory muscle strength and record progression of symptoms over time. Your
instructor will now demonstrate these clinical tests. Listen and record how to interpret each of the tests in the space provided. Your instructor may
have you practice doing these tests on a partner.
1. Vital capacity (VC) or forced vital capacity (FVC): Measures volume change at the mouth between full inspiration and complete expiration. FVC is
measured when the client is exhaling with maximal speed and effort, while VC is measured with the client exhaling slowly. Both are measured with a
conventional spirometer; the client uses a mouthpiece with a noseclip or a facemask. For FVC testing, the patient is instructed to "breathe in as
deeply as possible and then breathe out as hard and as long as possible." Repeat three trials with >1-minute rest between each. The largest value of
the three maneuvers is used.
a. Normal response:
b. Abnormal response:
2. Peak cough flow (PCF): Measure of maximal airflow generated during a cough. Measured through a mouthpiece or facemask attached to a peak
flow meter; the client is instructed to breathe in as deeply as possible and cough hard into the device. The largest value from at least three
acceptable attempts is recorded.
a. Normal response:
3. Maximal inspiratory/expiratory pressures (MIP/MEP): Used to assess respiratory muscle strength. Measurement requires maximal inspiratory or
expiratory efforts through a mouthpiece attached to a handheld pressure meter or spirometer against a partial airway occlusion. Clients are
instructed to breathe normally and, after a few normal breaths, to exhale as far as possible before inspiring against an occluded airway as strong
and as long as possible. Conversely, to measure MEP, after a few normal breaths, clients are instructed to take a deep breath before expiring as
strongly as possible. The pressure must be maintained at least 1.5 seconds so that the maximum pressure sustained for 1 second can be recorded.
The maximum value of three trials is typically recorded.
a. Normal response:
Activity 3. Respiratory Interventions
Managing Breathlessness/Dyspnea
A number of breathing retraining techniques may be used to control symptoms of breathlessness and dyspnea and improve ventilation and gas
exchange. Practice on a partner and teach the following breathing techniques:
Diaphragmatic Breathing:
Start with the client in a comfortable position (eg, lying supine with head raised 30 to 45 degrees, supported sitting). Positioning the patient with a
posterior pelvic tilt helps facilitate the use of the diaphragm.
The therapist places one hand over the client's umbilicus and the other hand on the upper chest. The client is instructed to breathe slowly and
comfortably so that the hand on the abdomen moves out with inspiration and in with exhalation and the hand on the chest remains still. The
therapist can facilitate inhalation by applying a firm quick-stretch using the hand on the abdomen at the end of the exhalation and asking the
client to "breathe into my hand." Another way to facilitate inhalation is to ask the client to "sniff" first to promote diaphragmatic contraction and
then breathe as described previously.
Once the client can perform it without cues, the therapist's hands are replaced with the client's own hands.
The exercise is progressed by having the client perform the exercise while sitting unsupported, standing, and then walking.
posterior pelvic tilt helps facilitate the use of the diaphragm.
The therapist places one hand over the client's umbilicus and the other hand on the upper chest. The client is instructed to breathe slowly and
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comfortably so that the hand on the abdomen moves out with inspiration and in with exhalation and the hand on the chest remains still. The
therapist can facilitate inhalation by applying a firm quick-stretch using the hand on the abdomen at the end of the exhalation and asking the
client to "breathe into my hand." Another way to facilitate inhalation is to ask the client to "sniff" first to promote diaphragmatic contraction and
then breathe as described previously.
Once the client can perform it without cues, the therapist's hands are replaced with the client's own hands.
The exercise is progressed by having the client perform the exercise while sitting unsupported, standing, and then walking.
Pursed-lip Breathing:
Start with the client in a comfortable position (may be a forward leaning posture in sitting if person has dyspnea).
The therapist places a hand on the client's mid abdominal muscles and instructs the client to inhale slowly through the nose.
The client is then told to exhale gently through pursed lips, avoiding excessive use of abdominal muscles. A verbal cue to facilitate performance
would be, "Let the air escape through your lips" or "Imagine you want to make the flame flicker on a candle that is being held at arm's length from
you."
The client is instructed to stop exhaling when contraction of the abdominal muscles is detected.
Relaxation Positions to Reduce Shortness of Breath:
Instruct your partner to get into these positions that help a person to relax and regain control of breathing:
Sidelying, leaning on three or four pillows, and the shoulder supported.
Sitting at the table and leaning forward onto the table with the head resting on a pillow and arms on either side of the pillow.
Sitting in a chair, leaning forward, and resting the forearms on the thighs.
Standing, leaning forward, and supporting the arms on an object near the shoulder level with the head resting on top of the forearms.
Leaning with the back against a wall with relaxed shoulder, arms hanging loosely, and neck flexed.
Managing Sputum Retention: Manual and Self-Assisted Cough Techniques
The four stages of a cough are:
1. Inspiration greater than tidal volume.
2. Closure of the glottis, which greatly increases intrathoracic pressure.
3. Contraction of the abdominal and intercostal muscles
4. Sudden opening of the glottis and forceful expulsion of inspired air that creates a shearing force that dislodges mucus adhering to airway walls.
Inspiratory muscle weakness decreases the tidal volume inspiration, which limits expiratory muscle lengthening and the volume and air flow during
expiration. Expiratory muscle weakness limits the increase in intrathoracic pressure, thereby decreasing expiratory air flow and airway compression.
Upper airway muscle weakness causes inadequate glottic closure and opening. Inadequate glottic closure results in a less effective inspiratory phase
due to leakage of inspired air and poor forceful expulsion of inspired air. Inadequate glottic opening decreases the inspiratory tidal volume and
expiratory flow.
Effective manual cough assist techniques should facilitate all of the cough stages.
Manual cough assist (MCA) techniques have been shown to increase peak cough flow. To improve cough effectiveness in people with low vital
capacities, MCA can be combined with breathstacking (person takes multiple breaths in without exhaling between breaths to reach the maximum
insufflation capacity). Find a partner and practice doing the following manual and self-assisted cough techniques. Perform them with your partner in
different positions.
Manual-Assisted Techniques (Rodrigues & Watchie, 2010)
Assist technique Position of client Description of technique

Manual cough assist (MCA) techniques have been shown to increase peak cough flow. To improve cough effectiveness in people Universidad del Rosario
with low vital
capacities, MCA can be combined with breathstacking (person takes multiple breaths in without exhaling between breaths to reach the maximum
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insufflation capacity). Find a partner and practice doing the following manual and self-assisted cough techniques. Perform them with your partner in
different positions.
Manual-Assisted Techniques (Rodrigues & Watchie, 2010)
Assist technique Position of client Description of technique
Costophrenic assist Supine, semi-reclining, or sidelying (if client is Therapist places hands on the lateral aspect of the client's lower ribs. At
(best for people with sidelying, this technique is applied only on one end and during expiration the therapist applies quick stretch down and in
limited bed mobility); side). on the client's chest to facilitate inspiratory muscle contraction.
a.k.a. Butterfly Instruct the client to momentarily hold his/her breath and then turn head
technique and cough. When the client coughs, the therapist applies strong pressure
through the hands in toward the central tendon of the patient's
diaphragm.
Heimlich-type assist Supine or semi-reclining, sidelying (used if there is The therapist places the palm/heel of the hand inferior to the client's
(best with clients with increased tone), sitting (therapist stands in front xiphoid process and below the client's ribs.
low neuromuscular of client or could stand in back and wrap arms The client is instructed to take a deep breath and hold it. Just as the client
tone or flaccid around client's trunk with one hand on top of initiates a cough, the therapist applies a quick push up and under the
abdominal muscles) other). diaphragm with the heel of the hand. This technique could be
uncomfortable to the client and should not be applied if person has full
stomach.
Combination of Sidelying position only. Therapist uses one hand to assist lateral compression of the lower rib
Heimlich-type assist cage (costophrenic assist), while the other hand performs a Heimlich-type
and costophrenic assist assist, pushing up and in. Practice may be needed to coordinate the two
manual strategies at the same time.
Costophrenic and Heimlich manual-assisted coughing techniques.
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Self-Assisted Cough Techniques (Rodrigues & Watchie, 2010)
Technique Population Description of technique
Prone-on- Clients with tetraplegia with good In prone on elbows the client takes in a maximal inspiration while extending the head up and back
elbows, head- head and neck control and who as far as possible.
flexion self- can attain prone on elbows Client coughs forcefully while throwing head forward and down.
assisted independently. Therapist can assist or resist (for strengthening accessory muscles) the desired movement.
cough
Long-sitting Clients with tetraplegia. In long-sitting with extended arm support, the client extends head and shoulders backward while
self-assisted taking a deep breath in and then coughs forcefully while throwing head and upper body forward
cough into a flexed position.
Long-sitting Clients with paraplegia with good Same as for the person with tetraplegia, except that client places hands on back of head in a
self-assisted control of the trunk musculature. butterfly position and quickly flexes hips to throw the body forward onto the legs during the
cough cough.
Short-sitting Clients with adequate trunk Client is sitting in wheelchair or at side of bed with one hand/wrist over the other or grasping each
self-assisted control in sitting; clients can have wrist while placing them in lap. Client extends the head and trunk backward while taking in a deep
coughs support of a backrest when breath and then flexes forward and pulls the hands up and under the diaphragm while coughing
performing this skill. forcefully.
Managing Hypoventilation: Inspiratory and Expiratory Muscle Training
For individuals with respiratory muscle weakness, strengthening exercises can be performed. Practice teaching a partner each of the following
exercises:
Diaphragmatic Strengthening Exercises:
For a person with a fair or better grade of diaphragm strength, progressive resistive exercises can be performed as follows:
Start with the client in supine.
Manually resisted inhalation: The therapist gently places the hands just below the rib cage on both sides of the client's thorax. Before the
client initiates an inspiration, the therapist gives resistance to the diaphragm by pushing gently up and in and maintains the pressure through the
inspiratory phase.
Weights for resisted inhalation: Place a weight (ie, cuff weights) over the epigastric region, without resting on the ribs which can prevent full
excursion. The amount of weight used as resistance should allow the person to breathe comfortably and without accessory muscle use for 15
minutes. Two to three sets of 10 repetitions once or twice a day is recommended. The weight can be progressed as tolerated.
For a person with a fair or better grade of diaphragm strength, progressive resistive exercises can be performed as follows:
Start with the client in supine.
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Manually resisted inhalation: The therapist gently places the hands just below the rib cage on both sides of the client's thorax. Before the
client initiates an inspiration, the therapist gives resistance to the diaphragm by pushing gently up and in and maintains the pressure through the
inspiratory phase.
Weights for resisted inhalation: Place a weight (ie, cuff weights) over the epigastric region, without resting on the ribs which can prevent full
excursion. The amount of weight used as resistance should allow the person to breathe comfortably and without accessory muscle use for 15
minutes. Two to three sets of 10 repetitions once or twice a day is recommended. The weight can be progressed as tolerated.
With either of these methods, the quality of the contraction should be monitored. The client should not be "pushing" with abdominal muscles
against the resistance, which enhances the exhalation phase of breathing and not the inspiratory muscles. For a person with fair or less
diaphragmatic strength, the exercises can be done without resistance.
Expiratory Muscle Strengthening Exercises:
The following exercises can be used to increase expiratory muscle strength. In a seated position the client should be asked to take a deep breath in
and:
blow up balloons.
blow bubbles.
blow out as if blowing out an imaginary candle.
In addition to these strengthening exercises, evidence suggests that specific exercise training using commercially available resistive breathing devices
can be performed in individuals with neurodegenerative diseases such as multiple sclerosis and amyotrophic lateral sclerosis (ALS) to improve
ventilatory function and respiratory strength (Ferreira et al., 2016).
Inspiratory Muscle Training (IMT)
Client breathes through a device (eg, Threshold IMT device HS730; Respironics, Parsippany, New Jersey, USA) with adjustable resistance settings
(progressively narrower airways) at a normal respiratory rate (typically 15 breaths/minute).
Client usually starts using the device at 25% to 35% of measured MIP or an arbitrarily chosen low resistance that does not cause dyspnea, fatigue,
or oxygen desaturation.
Training protocols have utilized 3 sets of 15 repetitions for 10 weeks to 3 months or 10 minutes of training two to three times a day for 8 to 12
weeks. Once the client can perform the exercises comfortably at a particular setting, the resistance is increased to the next higher setting.
Expiratory Muscle Training (EMT)
Client breathes through a device (eg, Expiratory Muscle Strength Trainer (EMST) 150, Aspire Products, LCC) that provides resistance on exhalation.
Fewer studies conducted on EMT and training protocol and intensities have been similar to IMT.
Your instructor will show you a short video about pulmonary physical therapy to enhance survival in people with ALS that shows a person performing
inspiratory muscle training.
Activity 4. Managing Respiratory Failure: Glossopharyngeal Breathing (GPB), Neck Muscle Accessory Breathing,
and Noninvasive Ventilation
GPB may allow a ventilator-dependent person to breathe for up to several hours if the person becomes disconnected from the ventilator. It is also used
to improve cough efficacy to clear tracheal secretions, to increase voice volume, and to maintain chest wall mobility.
Practice doing GPB (can refer to Table 2 in the Warren article). To learn to do it think of it in three stages:
Stage 1: Make extra space in your throat, by lowering your jaw and keeping your tongue flat. At the same time you should be able to feel your
throat cartilages moving down. It may help to look in a mirror to make sure that your tongue is flat.
Stage 2: Once your throat is open (as described in stage 1) close your lips gently, so that you trap the air in your large throat cavity. Don't let your
tongue or throat cartilages move up.
Stage 3: Keep your lips shut and let the cartilages and tongue go "up," back to their normal position.
Practice doing GPB (can refer to Table 2 in the Warren article). To learn to do it think of it in three stages: Universidad del Rosario
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Stage 1: Make extra space in your throat, by lowering your jaw and keeping your tongue flat. At the same time you should be able to feel your
throat cartilages moving down. It may help to look in a mirror to make sure that your tongue is flat.
Stage 2: Once your throat is open (as described in stage 1) close your lips gently, so that you trap the air in your large throat cavity. Don't let your
tongue or throat cartilages move up.
Stage 3: Keep your lips shut and let the cartilages and tongue go "up," back to their normal position.
Once you can do these stages you can gradually speed up the gulps. During stage 3 you will be forcing each throatful of air through the vocal cords and
into the lungs. The vocal cords then close and hold the air in the lungs while you take the next gulp until your lungs are "full." It is important to note
that GPB is not swallowing air into the stomach. If you do stage 1 correctly the gulps of air will go into your lungs.
An alternative intervention to allow a person who is ventilator-dependent to breathe off of a ventilator is neck accessory muscle breathing (NAMB, refer
to the Warren article). This involves strengthening exercises to the sternocleidomastoid and scalene muscles. Practice performing manual resistive
throughout the range and isometric exercises to these muscle groups on a partner. After strengthening the muscles, the client practices using the
muscles for breathing while off of the ventilator.
Activity 5. Case Studies
Divide into groups of three to four students and work through these case studies together.
Case 1: Mrs. P who has amyotrophic lateral sclerosis is noted to sound like she has fluid in her throat when talking. When asked to cough she does not
produce any secretions. She has reduced breath sounds in her lower lobes. In addition, she requires a breath every four or five words and cannot
complete one sentence in one breath. Her peak cough flow is 150 L/minute.
1. What muscle groups are likely weak? (upper airway, inspiratory and/or expiratory muscles)?
2. What would be the most likely findings for her on a maximal inspiratory/expiratory pressure (MIP/MEP) test?
3. What does her peak cough flow reading mean regarding her function?
4. What interventions would be recommended for her? Practice these with your partner.
Case 2: Mr. Y who has been diagnosed with Guillain-Barré syndrome is noted to have activation of his neck musculature during breathing, his ribs do
not expand when he inhales, and he c/o being very tired all day long. When his oxygen saturation is monitored, it is noted that he has readings of 92%,
89%, and 90% at three times during the day. His FVC while sitting is <60% predicted.
1. What muscle groups are likely weak? (inspiratory or expiratory muscles)?
2. What physical therapy treatment would be recommended for him based on his examination results? Practice these with your partner. Document
what benefits you expect for him with these therapies.
3. Would he be a possible candidate for noninvasive ventilation? If so would he likely use it 24 hours a day or when would he use it?
4. What benefits might you see in therapy if Mr. Y uses noninvasive ventilation?
Case 3: Mr. B sustained a complete C2 spinal cord injury with resultant tetraplegia and is on a mechanical ventilator.
1. Would he be expected to regain the ability to breathe on his own at all?
2. What should you teach him to do if his ventilator ever stops working?
"Take Home"
Therapists need to be able to conduct an assessment of the respiratory system in individuals with neurological disorders and recognize when
there are "red flags" that need medical attention.
Therapists need to be aware of common respiratory problems associated with clients with neurological disorders such as
breathlessness/dyspnea, sputum retention and ineffective cough, and hypoventilation and have interventions to manage these problems.
Therapists should evaluate and monitor clients with progressive respiratory weakness using FVC, peak cough flow, and MIP and MEP measures if
possible and educate about benefits of NIV if appropriate.
In clients with high tetraplegia, therapists can teach clients to use GPB and/or neck accessory muscle breathing in the event that they are
Therapists need to be able to conduct an assessment of the respiratory system in individuals with neurological disorders and recognize when
there are "red flags" that need medical attention.
Access Provided by:
Therapists need to be aware of common respiratory problems associated with clients with neurological disorders such as
breathlessness/dyspnea, sputum retention and ineffective cough, and hypoventilation and have interventions to manage these problems.
Therapists should evaluate and monitor clients with progressive respiratory weakness using FVC, peak cough flow, and MIP and MEP measures if
possible and educate about benefits of NIV if appropriate.
In clients with high tetraplegia, therapists can teach clients to use GPB and/or neck accessory muscle breathing in the event that they are
disconnected from the ventilator.
Bibliography
Aboussouan LS. Mechanisms of exercise limitation and pulmonary rehabilitation for patients with neuromuscular disease. Chron Resp Dis .
2009;6(4):231–249.
Bach JR, Bakshiyev R, Hon A. Noninvasive respiratory management for patients with spinal cord injury and neuromuscular disease. Tanaffos .
2012;11(1):7–11. [PubMed: 25191394]
Ferreira GD, Costa A, Plentz R, Coronel C, Sbruzzi G. Respiratory training improved ventilator function and respiratory muscle strength in patients
with multiple sclerosis and lateral amyotrophic sclerosis: systematic review and meta-analysis. Physiotherapy . 2016;102(3):221–228. [PubMed:
27026167]
Macpherson CE, Bassile CC. Pulmonary physical therapy techniques to enhance survival in amyotrophic lateral sclerosis: a systematic review. J Neurol
Phys Ther . 2016;40(3):165–175. [PubMed: 27164308]
Massery M, Schneider F. Respiratory Management of the Patient with Quadriplegia . [DVD] Chicago: MOVCO Media Productions, Inc.; 1999, reformatted
in 2005.
Rodrigues J, Watchie J. Cardiovascular and pulmonary physical therapy treatment. In: Watchie J, ed. Cardiovascular and Pulmonary Physical
Therapy . 2nd ed. St. Louis, MO: Saunders; 2010:324–328.
Phys Ther . 2002;82(6):590–600. [PubMed: 12036400]
SKILL CHECK
You started treating a 50-year-old male with a diagnosis of amyotrophic lateral sclerosis two years ago. He is having difficulty with removing secretions,
which has caused him anxiety. You determine that his peak cough flow is 250 liters and that he could benefit from assisted cough techniques. Teach a
Heimlich-type manual-assisted cough technique to a family member with the client in a seated position. Demonstrate the technique to the client.
*To satisfactorily complete the competency, the students must perform with 80% accuracy in all areas. Safety must be appropriate 100% of the time.
SKILL CHECK KEY

which has caused him anxiety. You determine that his peak cough flow is 250 L and that he could benefit from assisted cough techniques. You taught
through demonstration a manual-assisted cough technique to a family member and a self-assisted cough technique to the client.
Manual-Assisted Cough Technique(s) to Teach Family:
Assist
Position of client Description of technique
technique
Heimlich- Sitting (therapist stands in front of client or could stand The therapist places the palm/heel of the hand inferior to the client's xiphoid
Chapter 8: Respiratory Management in Neurological Disorders,
type assist in back and wrap arms around client's trunk with one process and below the client's lower ribs.
Page 9 / 10
hand on top of other). The client is instructed to take a deep breath and hold it. Just as the client is
instructed to cough, the therapist applies a quick push up and in under the
which has caused him anxiety. You determine that his peak cough flow is 250 L and that he could benefit from assisted cough techniques. You taught
through demonstration a manual-assisted cough technique to a family member and a self-assisted cough technique to the client. Access Provided by:
Manual-Assisted Cough Technique(s) to Teach Family:
Assist
Position of client Description of technique
technique
Heimlich- Sitting (therapist stands in front of client or could stand The therapist places the palm/heel of the hand inferior to the client's xiphoid
type assist in back and wrap arms around client's trunk with one process and below the client's lower ribs.
hand on top of other). The client is instructed to take a deep breath and hold it. Just as the client is
instructed to cough, the therapist applies a quick push up and in under the
diaphragm with the heel of the hand.
Performance is graded as pass/fail using the following criteria:
1. Performs assistive cough technique safely and effectively.
2. Uses clear and understandable verbal cues/directions.
3. Uses good body mechanics.
*To satisfactorily complete the competency, the students must perform with 80% accuracy in all areas. Safety must be appropriate 100% of the time.

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Laboratory Manual for Neurologic Rehabilitation

Chapter 8: Respiratory Management in Neurological Disorders

The student will:

Activity 2. Respiratory Assessment

Activity 3. Respiratory Interventions

Activity 5. Case Studies

Students answer questions on paper cases and practice interventions.

Read the following articles prior to coming to the lab:

Read the following articles prior to coming to the lab:

Respiratory abnormality Cause Clinical manifestations

Activity 2. Respiratory Assessment

Activity 3. Respiratory Interventions

Relaxation Positions to Reduce Shortness of Breath:

Sidelying, leaning on three or four pillows, and the shoulder supported.

Managing Sputum Retention: Manual and Self-Assisted Cough Techniques

The four stages of a cough are:

1. Inspiration greater than tidal volume.

2. Closure of the glottis, which greatly increases intrathoracic pressure.

3. Contraction of the abdominal and intercostal muscles

Assist technique Position of client Description of technique

Manual-Assisted Techniques (Rodrigues & Watchie, 2010)

Assist technique Position of client Description of technique

Costophrenic and Heimlich manual-assisted coughing techniques.

Self-Assisted Cough Techniques (Rodrigues & Watchie, 2010)

Technique Population Description of technique

Managing Hypoventilation: Inspiratory and Expiratory Muscle Training

Diaphragmatic Strengthening Exercises:

Start with the client in supine.

Expiratory Muscle Strengthening Exercises:

blow out as if blowing out an imaginary candle.

Inspiratory Muscle Training (IMT)

Expiratory Muscle Training (EMT)

Activity 5. Case Studies

1. What muscle groups are likely weak? (inspiratory or expiratory muscles)?

1. Would he be expected to regain the ability to breathe on his own at all?

SKILL CHECK KEY

Manual-Assisted Cough Technique(s) to Teach Family:

Manual-Assisted Cough Technique(s) to Teach Family:

Performance is graded as pass/fail using the following criteria:

1. Performs assistive cough technique safely and effectively.

2. Uses clear and understandable verbal cues/directions.

3. Uses good body mechanics.

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