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G - Independence in Breathing

Emerging Expertise with Unique Solutions The Stan Cassidy Centre for Rehabilitation, in Fredericton, New Brunswick, is a newer site of the Rick Hansen SCI Registry (joining after E-Scan data collection), and unique because it is in a different city to the hospitals that deliver acute SCI care. Their approach to respiratory management is interprofessional and evidence based. Onsite nursing, physiotherapy and physiatry are complemented with access to respiratory therapy, from industry and regional hospitals; and team members work with private industry, to conduct level three sleep studies, and to initiate non-invasive ventilation for individuals with SCI, as inpatients and outpatients. A local surgeon is trained in implantation of diaphragmatic pacing systems (two individuals have undergone a trial with the device), and mechanical insufflation-exsufflation and lung volume recruitment techniques are routine. Roadmap: Optimal Assessment and Treatment to Maximize Respiratory Function Based on the literature and the E-Scan of Canadian rehabilitation sites, there is an urgent need to: • Ensure the performance of a standardized respiratory assessment upon admission to rehabilitation, that includes pulmonary function (spirometry in supine and sitting), peak cough flow, maximum insufflation capacity and overnight oximetry, for all individuals with SCI at level L1 and above • Implement best practice interventions, including lung volume recruitment/volume augmentation techniques, cough assist techniques, CPAP or BiPAP®; and consider promising interventions to increase respiratory muscle force, including respiratory muscle training, and neuromuscular electrical stimulation • Provide specialized, inpatient SCI rehabilitation for individuals with SCI who are ventilator-dependent. FIGURE 9.0 Proposed Model of Respirator y Care Best Practice Indicators 1. Documented assessment for all individuals with SCI and a NLI above L2, by a respirologist and/or respiratory therapist, during inpatient admission, and follow-up care for those with respiratory impairment. 2. Perform routine respiratory assessments using standardized outcomes, prior to, or at the time of, rehabilitation admission. At a minimum, these include: • History of Respiratory Complications • Chest X-Ray • Pulmonary Function Test • Peak Cough Flow Physiatry Initial Assessment • Level of injury • Premorbid and co-morbid respiratory conditions Referral to respirology and/or respiratory therapy Respiratory Assessment • History, vital signs • Airway (ventilation, tracheostomy) • Pulmonary function tests (FVC, FEV1, MIP, MEP, TLC, DLCO) • Peak cough flow • Overnight oximetry • Transcutaneous CO2 • Chest x-rays Respiratory Treatment • Education • Wean from ventilation • Invasive ventilation • Non-invasive ventilation (e.g., diaphragm pacing) • Decannulation • Tracheostomy care • Suctioning • Bronchodilators • Lung volume recruitment • Mechanical insufflation-exsufflation • CPAP (Continuous Positive Airway Pressure) • Bi-level positive airway pressure Monitoring Outpatient/community respiratory follow up as required Re-assessment as required • Maximum Insufflation Capacity • Overnight Oximetry Referral to other specialities (e.g., infectious diseases) as required 3. Tertiary rehabilitation sites provide respiratory care, with specialty equipment (documented in good working order) used by appropriately trained staff. Equipment should include: • Mechanical Insufflator-Exsufflator • Manual Resuscitation Bag with Adapters • Ventilators for Invasive and Non-invasive Ventilation: CPAP; BiPAP®; Pressure-Volume Ventilators • Inspiratory Muscle Trainers 82 CAPTURING CAPACITY IN CANADIAN SCI REHABILITATION


G - Independence in Breathing
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