From: ssl(at)
Date: Wed, 23 Apr 1997 23:31:49 -0700 (PDT)
Subject: Respiratory problems in SCI

Enclosed is a draft of my handout "Assist Cough in SCI". This will be presented at the May 31, 1997 the program for the 7th International Post polio and independent living conference & IVUN in St Louis, Missouri. For more info- contact gini_intl(at)

"Improved Cough Using a Trained Service Dog for a Tetraplegic"

Although numerous high-tech devices are available to assist the physically disabled, many daily needs are still unmet. People with tetraplegia are unable to cough effectively. The inability to cough and clear mucus out of the lungs puts these paralyzed individuals at high risk for pneumonia. A man who has been paralyzed from the neck down for over five years has found a way to cough better and prevent serious respiratory problems. Heidi, his CCI golden retriever has been trained to press against his abdomen to help the man cough when he has increased chest congestion. His physician at the Spinal Cord Injury Unit at the VA Palo Alto Health Care System in Palo Alto, California, measured the force of the man's cough. The dog's actions were found to markedly improve the ability of the man to cough. Prior pulmonary research has shown that electrical stimulation can enhance the ability to cough in tetraplegia. The use of a trained Canine Companion could give other paralyzed individuals improved lung function while reducing costs of attendant care. Janis Thom, a registered nurse at the Spinal Cord Injury Unit, has shown that Canine Companions can be trained to assist the physically disabled in many activities of daily living. Canine Companions for Independence has been training dogs to assist people with disabilities other than blindness since 1975.

Linder SH, et al. Improved Cough Using a Trained Service Dog for a Tetraplegic , Chest 1996; 110:197S. Linder SH. Abdominal Muscle Functional Electrical Stimulation to Enhance Cough in SCI Patients(abs) The Journal of the American Paraplegia Society 1990;13:95-6. Linder SH. Functional Electrical Stimulation to Enhance Cough in Quadriplegia, Chest 1993; 103:166-69.

Lemons, VanBuren R., MD, Wagner, Franklin C. Jr., MD: Respiratory Complications After Cervical Spinal Cord Injury. Spine: Vol 19, Number 20 pp. 2315-2320, 1994.

"Respiratory complications continue to be a major cause of further morbidity and mortality in patients who have suffered cervical spinal cord injuries. Their reported incidence has varied from 36-83% with respiratory insufficiency, pneumonia, and atelectasis being the most common complications"

Jaeger, Robert J., Langbein, Edwin W., Kralj, Alojz R.: Augmenting Cough by FES in Tetraplegia: a Comparison of Results at Three Clinical Centers. Basic and Applied Myology 4 (2): 195-200, 1994.

"Continued research involving the technique described in this paper has a high probability of reducing the morbidity and mortality associated with pulmonary complications in the SCI population of today and the future."

"Coughing is a common occurrence which most people take for granted. However, the cough reflex is almost essential to life, for the cough is the means by which the passageways of the lungs are maintained of foreign matter. Thus, the loss of the ability to cough is a contributor to the pulmonary complications seen in SCI."

"All three centers showed that peak air flow rates elicited during electrically stimulated coughs were comparable to the peak flow rates produced by the manual assist technique ."

"The results at the VA Center also indicated that the technique can work in older individuals who have been injured for longer periods."

Linder, Steven H. MD, F.C.C.P.: Functional Electrical Stimulation to Enhance Cough in Quadriplegia. Chest: Vol. 103, p. 166-169, January 1993.

"Loss of abdominal and chest wall expiratory muscles reduces the ability to cough and clear secretions. In the pulmonary management of quadriplegia, secretion control is vital to prevent atelectasis and pneumonia."

"The most sensitive indicator of respiratory impairment due to neuromuscular disorders is the maximum expiratory pressure (MEP)... The CSCI patients have a MEP of less than 30 percent that of normal control subjects... Functional Electrical Stimulation (FES) of muscle partially or totally paralyzed due to upper motor neuron may be used to elicit muscle contractions."

"Since a decrease in MEP is associated with impaired cough, this suggests that abdominal muscle FES significantly enhances cough in CSCI patients."

Jaeger, Robert J., Phd, Turba, RM, Yarkony, GM, Roth, EJ: Cough in Spinal Cord Injured Patients: Comparison of Three Methods to Produce Cough. Arch. Phys. Med. Rehabil. Vol. 74, December 1993.

"The importance of therapy cannot be overemphasized in patients who have lost cough function. Though pharmacologic agents may alter the consistency of mucus, subsequent mucokinesis requires an effective cough... Removal of secretions by cough (or other artificial means) is equally, and, at times, more important."

"In this study, efficacy of cough (as measured by peak flow rate) was measured under three conditions: volitionally with no assistance, with manual assist of a therapist, and with electrical stimulation of abdominal muscles. Coughs produced by electrical stimulation were approximately as effective as manually assisted coughs."

Jaeger, RJ., Woloszko, J., Turba, RM., Yarkony, GM., Roth, EJ: A Neuroprosthetic Cough Assist Device for use in Spinal Cord Injury. RESNA International, 1992, June 6-11.

"Given the eventual compromises that are made with respect to medical care, it is highly likely that patients do not cough with the frequency they should."

"Independence from care givers is a hallmark of effective rehabilitation in nearly every case. The long-term goal of this research is to make individuals independent of a care giver with respect to cough."

Maurer, Janet R., MD: Respiratory Issues in Quadriplegia and High Paraplegics. Pulmonary Perspectives, American College of Chest Physicians, 1994; 11(1).

"A recently reported alternative technique employs an abdominal binder with electrodes attached that can stimulate the abdominal muscles causing them to contract, tripling spontaneous expiratory pressures (Linder. Chest 1993;103:166). This technique has the advantage of self-administration."

Spinal Cord Care-Clinical Practice Guidelines. The Clinical guidelines for Respiratory management include methods to clear secretions such as assisted cough, active suction, and stimulation of the abdominal muscles. Contact The Paralyzed Veterans of America (202)USA-1300.

Pulmonary physicians and other respiratory personnel care for tetraplegics who often have chronic alveolar hypoventilation and need some form of noninvasive nocturnal ventilation. Current commercially available nasal mask headgear may be inadequate for patients with impaired hand function due to neurologic disease who require nocturnal nasal mask ventilation. "Improved Noninvasive Ventilation Headgear for Tetraplegics" discusses improvements in nasal mask headgear straps to facilitate removal.

Linder SH, Rommel J. Review of Nocturnal Nasal Mask Ventilatory Assistance in Quadriplegia, Poster American Paraplegia Society Annual Meeting Las Vegas NV Sept 1993.

Linder SH, et al. Nocturnal Oximetry During Chronic Intrathecal Baclofen Therapy, Poster American Paraplegia Society Annual Meeting Las Vegas NV September 1995.

Linder SH, et al. Improved Noninvasive Ventilation Headgear for Tetraplegics, Chest 1996; 110:75S. Other references:

Linder SH, Miner MD, Pace W. Xenon Ventilation Study Defects in Tetraplegia Jour Spin Cord Med 1996;19:285.

Guasch PA, Linder SH, Williams T, Ryan S. A Functional Classification of Respiratory Compromise in SCI SCI Nursing 1991;8:4-10.

Linder SH, Breckenridge J. Smoking Cessation in Quadriplegia , Am Rev Resp Dis 1993; 147:A805.

Linder SH, et al. Radiographic Prevalence of Tracheal Stenosis in Cervical Spinal Cord Injured Patients(abs), Am Journ Resp Crit Care Med 1997; in press.

Steven H. Linder, MD
3801 Miranda Ave
Palo Alto, CA 94304
ph(415)493-5000 x 6-4303