Respiratory Care - Dr. Finder

Dr. Jonathan Finder made the following presentation at the 7th Annual Parent Project Muscular Dystrophy Conference (June 22-24, 2001).

 

This outline is reprinted with Dr. Finder’s permission.

Respiratory Care in Muscular Dystrophy

Jonathan D. Finder, M.D., Pediatric Pulmonologist

University of Pittsburgh School of Medicine

Children’s Hospital of Pittsburgh

Respiratory Issues...

·       Ultimately the most important issues!

·       Do not have to be life shortening

o      I never use the phrase “end stage”

·       Predictable in their course

·       Critical to anticipate

Be aware of new technologies

Four Respiratory Stages in MD

I. Initially: Normal respiratory function

II. Normal breathing, but weak cough

III. Normal breathing during daytime, but inadequate breathing asleep

IV. Inadequate breathing awake and asleep

Stage I: Normal Respiratory Function

·       No special needs

·       A good idea to

o      Get fully immunized against influenza annually, and

o      Receive Prevnar against pneumonia

·       Annual screening

o      Pulmonary Function Tests (PFT’s) for boys over age 6

Stage II: Weakened Cough

·       May not know until you get a cold

·       Predictable with semi-annual PFT’s

·       Main risk is pneumonia

Cough

·       Two Kinds of Respiratory Muscles

o      Inspiration

o      Expiration

·       Inhaling (inspiration)

o      Breathing-in requires muscle force, like stretching a spring

o      Uses diaphragm and intercostal muscles

·       Exhaling (expiration)

o      Generally, breathing-out is passive, like the recoil of a spring

·       Coughing (forceful expiration)

o      Uses abdominal muscles to increase pressure

How Do We Cough?

1. Take a deep breath (diaphragm/intercostals)

2. Close the voice box

3. Squeeze the abdominal muscles to increase pressure inside the chest

4. Open the voice box

5. Air rushes out at a high velocity, carrying with it mucus and debris

Why MD Patients Get Pneumonia

·       Inability to take a deep breath

o      Weak diaphragm/intercostals

·       Inability to generate good expiratory flow rate to expel mucus

o      Weak abdominal muscles

·       Retention of secretions

o      “Lunch for bugs” (rich medium for bacterial growth)

·       So a cold can lead to pneumonia

Weakened Cough: What Can YOU Do?

·       A lot, it turns out!

·       Manually assisted cough:

o      Abdominal thrust following deep breath (or breath assisted with ambu bag or other device)

o      Fair at best

·       Mechanically assisted cough:

o      The Emerson Cough Assist™ (In-Exsufflator, Cofflator)

o      A fantastic device

o      A gift to the MD community

Emerson Cough Assist™

 

Click on photo for more information.

 

The Key: PREVENTION!

·       Assisted cough (Cough Assist™) with colds

o      ABSOLUTELY CRITICAL!

o      The best way of preventing pneumonia

o      Most reliable means

·       Immunizations

o      Influenza

o      Prevnar

·       Percussion and drainage

o      Only useful if you can get those secretions out!

·       Nebulized medications when prescribed

·       Prompt medical attention and respiratory support with colds and lower respiratory infections

Stage III: Inadequate Breathing in Sleep

·       Symptoms may be subtle:

o      Fatigue

o      Lack of restful sleep

o      Morning headache

·       Easy to detect with overnight, in-home study with pulse-oximeter

·       May require follow-up study in hospital

·       Most common solution is BiPAP – Bi-level Positive Airway Pressure

BiPAP – Bi-level Positive Airway Pressure

·       BiPAP can support breathing in sleep

·       Nasal mask or face mask is used (non-invasive)

·       Uncomfortable to use continuously, so

·       Not a good option for 24-hour support

Stage IV: Inadequate Breathing All The Time

·       This stage often occurs following a severe infection like pneumonia

·       Respiratory insufficiency can be shown with PFT’s

·       No longer is tracheostomy mandated at this stage

Non-invasive Breathing Support

·       Portable ventilator with a mouthpiece attached (like a microphone) to wheelchair has been successful for daytime or 24-hour support

·       Pulmonetic LTV 950

o      Weighs only 12 lbs with 1-hour internal battery

o      3-hour and 9-hour external batteries available

Pulmonetic LTV series

 

 

 

 

Click on photo for more information.

Mouth Piece Ventilators

·       A standard ventilator, wheelchair-mounted

·       Great for folks who

o      Need some help during the day, but

o      Can breathe without help some of the time

·       Non-invasive

·       Take a deep breath every minute or two

·       Tremendous improvement in

o      Energy level

o      Quality of life

Invasive Support of Breathing

·       Consider when a person

o      Cannot breathe sufficiently, and

o      Cannot use mouthpiece vent

·       Tracheostomy—a big decision!

·       Ventilator can be attached to wheelchair

o      Goal is mobility!

o      Lightweight vent is key to this

·       Trache can

o      Facilitate suctioning

o      Can be used with Cough Assist™ (In-Exsufflator, Cofflator)

In summary:

·       Key to good health is anticipating respiratory needs

·       Don’t wait until a crisis occurs!

·       Take an interventional approach

·       Get the technology you need to stay away from the hospital!

·       Identify a respiratory care professional interested in the care of MD patients

 

The breathing animation is used by permission of Michael Grant White of www.breathing.com.


Respiratory Care - Dr. Finder
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