key: cord-0923081-e56m91c8
authors: Henzel, M. Kristi; Shultz, James M.; Dyson‐Hudson, Trevor A.; Svircev, Jelena N.; DiMarco, Anthony F.; Gater, David R.
title: Initial assessment and management of respiratory infections in persons with spinal cord injuries and disorders in the COVID‐19 era
date: 2020-10-24
journal: J Am Coll Emerg Physicians Open
DOI: 10.1002/emp2.12282
sha: 643d4be4b2a1c1cc81bd2de6ecd08c20502e9535
doc_id: 923081
cord_uid: e56m91c8

As the COVID‐19 pandemic unfolds, emergency department (ED) personnel will face a higher caseload, including those with special medical needs such as persons living with spinal cord injuries and disorders (SCI/D). Individuals with SCI/D who develop COVID‐19 are at higher risk for rapid decompensation and development of acute respiratory failure during respiratory infections due to the combination of chronic respiratory muscle paralysis and autonomic dysregulation causing neurogenic restrictive/obstructive lung disease and chronic immune dysfunction. Often, acute respiratory infections will lead to significant mucus production in individuals with SCI/D, and aggressive secretion management is an important component of successful medical treatment. Secretion management techniques include nebulized bronchodilators, chest percussion/drainage techniques, manually assisted coughing techniques, nasotracheal suctioning, and mechanical insufflation–exsufflation. ED professionals, including respiratory therapists, should be familiar with the significant comorbidities associated with SCI/D and the customized secretion management procedures and techniques required for optimal medical management and prevention of respiratory failure. Importantly, protocols should also be implemented to minimize potential COVID‐19 spread during aerosol‐generating procedures.

associated with SCI/D and the customized secretion management procedures and techniques required for optimal medical management and prevention of respiratory failure. Importantly, protocols should also be implemented to minimize potential COVID-19 spread during aerosol-generating procedures. 

Almost 300,000 persons in the United States are living with SCI/D. 1 The most common cause of death in this population is pneumonia and respiratory diseases. Persons with SCI/D have greater mortality from pneumonia and influenza compared to the general population with the standardized mortality ratio for pneumonia and influenza for all types of SCI/D calculated approximately 40. 2, 3 Here, the standardized mortality ratio estimates the ratio between the observed number of deaths in SCI/D patients, or subgroups of SCI/D patients, compared to the expected number of deaths based on age-and sex-specific rates in the general population. The finding that the ratio of observed-expected deaths (the standardized mortality ratio) far exceeds 1 The epidemiology of COVID-19 in persons with SCI/D is incompletely understood but appears to be similar to the general population; there have been a range of presentations from mild to severe disease. [7] [8] [9] [10] [11] In addition to respiratory weakness, the SCI/D population has a high prevalence of hypertension, coronary artery disease, diabetes, and obesity, which are recognized to increase risk of COVID-19

complications. 12 

Individuals with chronic SCI/D are immunocompromised for several reasons: maladaptive sympathetic-neuroendocrine adrenal reflexes, 15 immune suppression with secondary immune deficiency syndrome, 16 obesity-related inflammation with reduced natural killer cell expression, 17 and increased lung inflammation similar to mild asthma. 18

Various degrees of respiratory muscle paralysis are present in most individuals with tetraplegia and many with paraplegia due to inspiratory and expiratory muscle weakness (Table 1) . 19 Level and completeness of injury dictate the likelihood of restrictive and obstructive lung dysfunction.

Paralysis of a major portion of the expiratory muscles used to generate an effective cough results from SCI at or above the T6 spinal level. Weakened expiratory muscles lead to decreased peak cough flow, 20 tenacious secretions, and atelectasis. Reduced alveolar expansion decreases surfactant production, increases alveolar surface tension, and markedly increases the work of breathing.

Expiratory muscle paralysis also is associated with outward expansion of the abdominal wall resulting in shortening of the diaphragm, reducing its resting length, diminishing inspired volume, and alveolar expansion. Diaphragm resting length can be easily restored through appropriate use of an elastic abdominal binder, improving breathing efficiency when upright ( Figure 1 ). 21,22

In individuals with SCI/D above T6, para-sympathetic predominance leads to bronchiolar constriction, hyper-reactive airways, and increased mucus secretion. 23 See Figure 2 for diagnostic workups and best practices to consider 26 depending on presentation. In addition to pulmonary/critical care specialists and respiratory therapists, consultation with physical medicine and rehabilitation (PM&R) or SCI medicine specialists may be helpful to assist with interpretation of signs and symptoms in the context of SCI/D and formulation of the differential diagnosis and treatment plan.

Suggested COVID-19 testing algorithm for persons with SCI/D presenting to ED. HCW, health care worker

Persons with SCI/D who require home care assistance may be exposed to multiple clinical or personal visitors per day. Therefore, it is critical for ED personnel to take special precautions when evaluating this population due to ease of COVID-19 transmission in the home. Initial suspicion of COVID-19 infection may be low if the patient has an atypical presentation of COVID-19 or mild COVID-19 with concurrent infection such as urinary tract infection. Figure 3 provides a suggested testing algorithm for this patient population.

The typical signs of acute respiratory failure such as dyspnea and tachypnea may not be apparent in individuals with neuromuscu- 

Many primary care and emergency clinicians are unfamiliar with both the unique physiology associated with SCI/D 31 

In general, independent respiration should be maintained as long as 

Persons with diaphragmatic and intercostal weakness due to SCI/D have reduced inspiratory force and impaired ability to activate incentive spirometry or use deep breathing alone to effectively open alveoli.

Taking successive deep breaths without exhaling in between, also known as "breath stacking," can be helpful in inflating the lungs fully, but typically takes time to learn to perform effectively. These individuals may require positive expiratory pressure devices or positiveairway pressure (PAP) treatments to prevent or reverse atelectasis, which require systems modifications to ensure safety (see Safety section). 

Nasotracheal suctioning or tracheal suctioning in individuals with tracheostomies are effective methods of removing upper airway secretions. Directional catheters have the capacity to suction both the right and left main stem bronchi and therefore may be much more effective than the use of standard catheters.

Patient positioning and percussion can be an extremely effective method of secretion clearance and should be performed by qualified personnel including respiratory therapists, physical therapists, and/or trained nurses. Specific physician orders are typically needed for these treatments to be implemented. Full prone positioning to improve lung aeration may be difficult to accomplish in person with SCI/D having joint contractures and/or limited cervical range of motion; modified proning may be required.

The use of a mechanical insufflator/exsufflator device, also known as a "cough-assist," 35 

Another method for secretion clearance is "manual assist" or "quad coughing," that uses Because individuals with SCI/D may require these aerosol generating procedures to adequately recover, rapid transition to a negativepressure room, higher level of care, or an isolated area within the emergency facilities where these procedures can be safely performed should be achieved whenever possible. In addition to the use of PPE for airborne protection, medications should be given via metered dose inhalers with spacers and at a higher dose to reach nebulizer equivalence. If nebulizers, HFNO 2 , and/or non-invasive ventilation are required, they should be administered in a negative pressure or single room with contact, droplet, and airborne precautions, which should be maintained for at least 30 minutes after completion of an aerosolgenerating procedure. [40] [41] [42] Positive expiratory pressure devices should be fitted with an antiviral filter. Those with tracheostomies who are not ventilatordependent should wear a heat and moisture exchanger and mask over their nose, mouth, and tracheostomy tube. Tracheostomy tubes should preferentially be cuffed with the cuff inflated during aerosol-generating procedures. 43 Non-invasive ventilation set-ups should be converted to a closed system with a dual lumen circuit with heat and moisture exchanger/viral filter attached to exhaust systems, and a non-vented full-face mask or helmet over nasal pillows. Mechanical insufflationexsufflation can be used with an anti-viral filter, tubing, and tracheostomy adapter attached to filter protecting the machine. Prolonged negative pressure can be maintained afterward while separating the adaptor or face mask from the patient in order to draw aerosols and droplets into the filter. The circuit tubing and filter can then be removed from the mechanical insufflation-exsufflation device and joined into a circle using the trach adapter to avoid leakage of exsufflated materials before disposal.

Many persons with SCI/D have limited mobility and may arrive in a manual or power wheelchair, and with assistive devices and medical equipment that may also be contaminated. Transfers to examination tables will often require the assistance of additional medical personnel

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