Research Week 2 Part 3.docx

All really dependent upon the therapy that they receive. This is why it's so important to have a team that works with these patients so as to drive the process in a positive direction. Let's talk about autonomic dysreflexia. Autonomic dysreflexia is a pathological reflex that occurs in individuals t...

All really dependent upon the therapy that they receive. This is why it's so important to have a team that works with these patients so as to drive the process in a positive direction. Let's talk about autonomic dysreflexia. Autonomic dysreflexia is a pathological reflex that occurs in individuals that have some types of neurotrauma, some types of neurodegeneration. Autonomic dysreflexia can potentially be a deadly complication for a patient that has neurotrauma or neurodegeneration. Let me explain what can happen. Let me use this slide to do so. First of all, here we have an individual whose bladder is full. This individual is a spinal cord injury patient, so he or she cannot feel that the bladder is full. A full bladder like this sends a stimulus into the spinal cord. What happens in an individual that has a spinal cord injury is that a massive sympathetic response then occurs. This sympathetic response occurs below the level of injury. So there's no action potentials going up to the brain because there is an injury that does not allow those action potentials to be transmitted faithfully through to the brain. This massive sympathetic response brings about widespread vasoconstriction throughout the body. The vasculature is constricted as shown here. That causes the blood pressure to skyrocket to very, very high levels. In the major vessels, as you know, there are different types of barrel receptors, chemoreceptors that can sense the condition of the blood supply. These barrel receptors located in these major vessels will send action potentials to the brain that will inform the brain that, "Hey, this blood pressure is really, really sky high." Well, the brain very dutifully then sends impulses from the brainstem, from the cardiomotor areas, to the heart, as we talked about before. And basically tells the heart, "Please slow down." Slow down as a way of trying to decrease this hypertensive episode. And it is a potentially fatal hypertensive episode. Unfortunately, impulses from the brain being sent down to try to inhibit this massive sympathetic response go nowhere because once those action potentials reach the site of injury, they're blocked. Now, this happens in any individual that has a spinal cord injury that's at T6 or above. That is to say, thoracic segment 6 or above. So T6, T5, T4, all the way up through C1. Any of those individuals. So if you have an individual whose injury is, let's say, at T10, this would be something that you would simply not see in a T10 individual. The type of patient that typically has autonomic dysreflexia is a spinal cord injury patient at T6 or above. Well, this continues on. And as this ensues, the blood pressure can become higher and higher and higher. This requires two major interventions. Number one, a search for the problem. In this case, a bladder that has not emptied needs to be emptied. And number two, the administration of medicines per protocol designed to specifically return this patient back to normal, reducing the patient's blood pressure, and also blocking the sympathetic nervous system from continuing to have this noxious sympathetic response that goes on. That goes out to the vasculature. This set of circumstances should illustrate that the person who has a spinal cord injury has been changed in a very fundamental way. Their central nervous system does not work as it did before. Their peripheral nervous system does not work as it did before. And in fact, their entire body, their entire organism has changed dramatically. So much so that a person who has spinal cord injury is a very different kind of patient who needs to have specialized members of the medical team attending to him or her. This is why for these patients, we need nurses who are trained in neurology or the neurosciences. We need registered respiratory therapists who are trained in neurology or the neurosciences. We need doctors who specialize in neurology or the neurosciences. We need all members of the healthcare team dealing with individuals who have cervical spinal cord injury or spinal cord injury, period, to be trained in the neurosciences because we simply cannot therapeutically intervene on behalf of these individuals using what we would normally use for individuals that are neurologically intact. And we're going to see that as a theme occurring over and over and over. Now we've talked quite a bit about spinal cord injury and neurodegeneration. I would like to close by talking about two interventions. One is a therapeutic intervention and another one, a rehabilitative intervention. This slide shows basic science research with mice. And on this side of the cartoon, the upper side of the cartoon, what you see is an area that looks like it's a gaping cleft. You'll also notice that if you look on either side of this scarring area here, you have neurons that were intending to grow across the scar but stopped. There's one at the top, there's one in the middle, there's one at the bottom. And then on the right side, there are two more neurons that similarly were growing in from their side. And what we note here is, remember the microtubules? These are the microtubules that conduct the vesicles all the way out to the synapse and then conduct the vessels back from the synapse so that they can be refurbished. Well, those microtubules were shown to you at that time because they're very, very important. They make up the cytoskeleton of the nerve cells. And in order for these nerve cells to find each other after a spinal cord injury, those neurotubules have to remain intact. They have to locate each other. They have to join with each other in order for action potentials to once again be able to propagate across a scarred area as shown on the top panel. On the bottom panel, what you see is that these microtubules now are intact. They're actually seen going across the scar tissue itself. This is from recent information that can be found in Science Journal back in 2015 that first revealed that a new type of drug known as epithelium B can in fact help microtubules to grow across a scarred area in the spinal cord of experimentally traumatized mice. Now, once again, this is basic research. But I think you can see where all of this might be going. The research continues. It is very promising. And I'm sharing it with you because I want you to realize that there are many, many laboratories around the world that are working on this problem. So it's not as if we're at some sort of a standstill. This is just one of many, many, many pharmacologic agents that are being developed for the purpose of helping people who sustained a spinal cord injury. This is unit 1.11 introducing neuro respiratory care. Neuro respiratory care is a subspecialty of respiratory therapy. You can think of this as being similar to neonatal respiratory therapy or pulmonary function testing or sleep study medicine. These are subspecialties where a respiratory therapist can specialize. Neuro respiratory care has arisen as a result of the need to provide high quality therapy for patients like patients that have spinal cord injury, ALS, traumatic brain injury, that have changes that make them very dissimilar from patients that are neurologically intact. Therefore, requiring a specialized practitioner on the part of a registered respiratory therapist. We'll define neuro respiratory care. We'll try to understand why research is a part, a central part of a neuro RTS job description. We'll explain why the chest optimization protocol is typically done before strength and endurance training, so important for a patient's recovery. We'll discuss the role that strength and endurance training play in prolonging spontaneous breathing trials. Neuro respiratory care is an allied health clinical subspecialty in respiratory therapy. It encompasses specialized therapeutics and diagnostics for all kinds of patients that have neurodegenerative problems and neuro trauma problems. Among these are the ones listed here. A brief history of neuro respiratory care at the James A. Haley Veterans Hospital. Neuro respiratory care began in earnest back in the mid 1980s. As the experience of the neuro RTS grew, it became time to move into a brand new center of excellence for spinal cord injury that was built back in 2002. Three years later, the very first national neuro respiratory care residency for registered respiratory therapists was developed. And today we have a world class institution shown at the lower right on this panel, which is where you will be coming to improve your knowledge and your skills in doing R.T. research. Veteran patients are referred to the Tampa VA from two major venues. Some veterans come from the community. When they do so, they come from all over the nation. Many of these patients have been in a motor vehicle accident or perhaps a fallen or they've been involved in some sort of an altercation. These are individuals who were service members, but have since been discharged. We also accept military referrals from around the world. Most recently, we've had veterans coming in who were victims of poly trauma, secondary to improvised explosive devices. And we'll have more to say about that later on. While at the Spinal Cord Injury Center, you're going to hear people referring to the Poly Trauma Center. Poly Trauma is a relatively new concept associated with battle associated injuries or combat associated injuries. When there's combat trauma to lots of different body areas or organ systems, we refer to that as poly trauma. It's trauma that occurs all at once. Think of a blast injury with bullets flying all over the place or shrapnel flying all over the place. Usually one or more of these traumas are life threatening. It may involve a blast injury, sometimes known as an overpressure injury, and it can involve any of the injuries that you see listed here. Let's keep in mind that when we treat these injuries or these disorders, we're really treating our fellow human beings. We're not just treating the disorder. And this is a miniature case study that I'd like to share with you. This young man was a Navy CBE reservist. He was raised in Florida, as a matter of fact, not too far from the Tampa Bay area. And so he deployed to Iraq with a construction battalion. He was injured during a mortar attack and as a result of that was airlifted stateside to a naval hospital. And then after that, he came to the Tampa Bay. This gentleman had a C3 Asia A. So, you know, from this designation, that means that his third cervical vertebra was involved. This basically means that he had about 25 percent of his ventilation still available. The fact that it's an Asia A means it's a complete injury, which is not good. Therefore, he was ventilator dependent. Unfortunately, he was also a left leg amputee, multiple shrapnel wounds, significant pain, significant spastic paralysis and a rather poor prognosis. In spite of all of that, this gentleman's determination and the wonderful support he had from his family allowed him to wean from the mechanical ventilator. He was discharged home. He receives nocturnal ventilation so that when he goes to bed at night, he sleeps on the mechanical ventilator and gets assistance from the mechanical ventilator. He continues to receive at home the chest optimization protocol that was started for him twice a day in PRN while he was in the SCI Center. And before we go any further, let's introduce you to the Neuro RRT. What is it that the Neuro RRT does? Well, first of all, the major thing is that Neuro RRT is a case manager that performs neuro respiratory rehabilitation. This individual manages vent weaning per protocol. And it's per protocol because obviously we want the best available scientific evidence to be brought to bear on the patient's problem. This individual, of course, uses new scientific findings, helps to design evidence based protocol, implements evidence based protocols, performs non-invasive cardiac monitoring, which you'll be doing with the NM3 monitor. He helps plan for patient's discharge. He participates in telemonitoring, participates in clinical research, needless to say, performs non-invasive ventilation. Can on occasion visit patients at home for therapy and also for diagnostics. Manages diaphragmatic pacing. We'll have more to say about that later on. And finally, very importantly, teaches the patient, the family, the clinical staff, the caregivers about neuro respiratory care and what neuro respiratory care can do for patients. Thinking about the future a little bit, think about the prospect of having an ARTP in the future whose focus is neuro respiratory care. Well, the Neuro RRT serves on the transdisciplinary team, which is ultimately involved in designing and implementing the protocols that will help our patients to get better. And the way that these protocols are brought into existence is by searching the scientific literature for the best available scientific evidence that can be found. The team then ranks the findings in order of the strength of those findings. And we'll have much more to say about that later on. It incorporates those findings into a protocol. It implements the protocol. It analyzes the protocol. And it tries to make sure that when it's time to change the protocol, that those changes are implemented in a timely fashion. Obviously, safety is at the very center. And the ability to really project what it is that is important to the patient and the patient's family are paramount. These are the four elements of the chest optimization protocol, or as it is sometimes referred to as the COP. First, chest optimization consists of positioning the patient in from Dellenberg, usually about 10 to 15 degrees, sometimes a little bit less, sometimes a little more. Secondly, speed of mobilization. Speed of mobilization uses such things as mechanical in exhalation, may use the chest vest percussor, may also use suctioning, may also use bed-based thoracic vibration. Mechanical hyperinflation is part of the protocol and has been part of the protocol for many, many years. There is a very substantial literature base dealing with the need for larger tidal volumes for patients who have spinal cord injury. And this is appropriate for patients who have spinal cord injury. This is not the case with patients who do not have spinal cord injury. So you will see in later units that large tidal volumes are used. This is in no way meant to infer that these large tidal volumes are appropriate for all patients. It is appropriate for spinal cord injury patients, but not necessarily for any other patient subpopulation. Airway bronchodilation is also an important element. As you know, we've previously discussed the problem with parasympathetic predominance, hence the need for airway bronchodilation. Why this protocol? Well, because we can decrease atelectasis, mucus plugging, and pneumonia. And those are the big three complications that occur over and over again with patients that have spinal cord injury, individuals that have ALS, individuals that have traumatic brain injury, individuals that have neurotrauma or neurodegeneration and find themselves on mechanical ventilator will often have problems associated with atelectasis, mucus plugging, and pneumonia. We can increase the duration of spontaneous breathing trials when we use chest optimization. That's the big reason for using that specific protocol. We can also improve numerous cardiopulmonary variables. And we know that to be the case because we've done so in the past. And we've done so by using the NM3 monitor that you'll be using. We can also, very importantly, help to decrease the mortality. And we know that being able to remove patients from mechanical ventilation as soon as possible is very, very closely correlated with their ability to survive over the long term. Well, let's see how chest optimization fits into the daily regimen. Daily chest optimization really forms the foundation of the medical pyramid or the therapeutic pyramid that is used to conceptualize the therapy that's implemented for patients that have cervical spinal cord injury. In addition to that, there are sessions where daily resistance and endurance training is delivered to these patients. And finally, all of that is done in an attempt to try to improve the length of the spontaneous breathing trials. So that's what everyone on the team is working toward. And that's why it is at the pinnacle of this pyramid. Being able to position patients in Trendelenburg, sometimes known as T-Berg, is very important because that results in the expansion of basilar alveoli. We know that because we see increases in the alveolar minute volume as measured by the NM3 monitor. We also see improved delivery of bronchodilators to the basilar alveoli. We see increased surfactant production, which stabilizes those alveoli. And very importantly, we see an increase in cardiac output in patients that have neurologic compromise. This improves blood flow to the exercising muscles and helps them be able to do the resistance and the endurance that is part of the protocol. Mechanical in-ex ciflation is part of the chest optimization protocol. It can be used with or without individuals that have a trach tube. Typically, when we provide the inspiratory phase, it will be done 40 to 60 centimeters of water pressure. The expiratory phase will similarly be negative 40 to negative 60 centimeters of water pressure. And this intervention is really for individuals who have a vital capacity lower than 1,500 cc or a peak cough flow of less than 270 liters per minute. And typically, this is done on manual mode. It doesn't always have to be done on manual mode, but it is a preferred method to start the protocol with. Occasionally, an individual will develop a problem with atelectasis or consolidation or mucous plugging. And when that happens, we will put that side of involvement up. Here you can see an individual's chest X-ray. You can see a radiopaque region right along the left border of the heart. You can see that same region here on an MRI. And so what's done is that side of involvement is placed in an upward position like this or in a non-dependent position. And in some instances, not only will the individual assume this configuration, but we'll also place this individual in Trundlenburg, all in an effort to try to remove that obstruction, if at all possible, without the need for a bronchoscopic intervention. Chest-vest percussion is done with neurological patients because they cannot cough adequately. The chest-vest percussor is typically used with the patient in Trundlenburg, not in Fowler's position. And the reason for that is because we want to be able to remove the secretions and have the secretions move cephalad or toward the head so that the secretions can be abstracted by suctioning the patient or by using the mechanical anexoflator. I referred to earlier to bed-based thoracic vibration. This is typically done with a hill-rump bed. The patient will be placed in Trundlenburg, and we then provide the individual with high-intensity thoracic vibration, meaning vibration just at the thorax. You may have seen this used before. What's key here is to have the patient in Trundlenburg so that the secretions do move cephalad. Lung hyperinflation done with a mechanical ventilator is very important, and I want to caution you here again because this is for individuals that have cervical spinal cord injury. This is not for all patients. They are typically placed on the assist control mode, and their tidal volume is 15 milliliters per kilogram of body weight, maintaining a peak inspiratory pressure of less than or equal to 40 centimeters of water pressure and maintaining a plateau pressure of less than 30 centimeters of water pressure. Sometimes the tidal volume will actually be increased a little bit more as a result of the small-volume nebulizer that is often administered along with the hyperinflation. Thoracodilation is crucial for these individuals. As you will recall, these individuals have parasympathetic predominance, so combination therapy is often provided per protocol. Atravent as well as albuterol unit doses are utilized, and the small-volume nebulizer is powered at 8 liters per minute and placed on the dry side of the Fischer-Pacal humidifier with the humidifier turned off so that a large plume of bronchodilator can be provided to the patient each and every breath. We've talked a lot about different facets of the chest optimization protocol. Let's turn our attention to how we measure the different physiologic variables. We tend to use volumetric capnography, and this is the same volumetric capnography that you'll be using in the spinal cord injury center with our ALS patients. The volumetric capnograph monitoring capability allows one to monitor all kinds of physiologic variables, and there are hundreds of them that can be monitored. However, we have chosen to focus on just a few, and among these are static chest compliance, alveolar tidal volume, rapid shallow breathing index or frequency to tidal volume ratio, the carbon dioxide elimination, cardiac output, and airway resistance. And again, these are just a very small number of variables that can be measured. So now what I'd like to do is share with you some preliminary information regarding 20 mechanically ventilated spinal cord injury patients that were studied over the course of one year. These individuals were individuals who were receiving chest optimization protocol, and what we wanted to do was we wanted to find out from our patients if, in fact, the chest optimization protocol was helpful to them or not. A fairly simple, straightforward question that we wanted to answer using volumetric capnography. Finally, let's look at our two-hour spontaneous breathing trial. We would like for these patients to be able to do a two-hour spontaneous breathing trial. Remember, these are individuals who are all spinal cord injury patients. They have been given the chest optimization profile in Trendelenburg over the course of several months, and when they get to the point where they're able to do their spontaneous breathing trial, they're going to do that on a GEN gas injection nebulizer as shown in the upper left. And what we want to know is, for these individuals, does it really matter whether we do chest optimization with them in Trendelenburg? Does that improve their ability to do a two-hour spontaneous breathing trial? And the precondition before the chest optimization is shown in blue, the blue bars. The postcondition is shown in yellow. And even if you don't do the mathematics, you can kind of just eyeball this, and you can see that there's a rather sizable difference between the blue bars, the precondition, and the yellow bars, the postcondition. When we do the statistical analysis, once again, what we find is that the probability is less than 0.0001. In other words, we have a statistically significant difference. We find that there is a 68% increase in the ability of these patients to do a spontaneous breathing trial just because they were given chest optimization in Trendelenburg. Once again, this is a way of confirming that the protocol that is based on the best available scientific evidence that we have been able to find is in fact working. It is taking our patients in the positive direction that we want them to go. So it enables us to have a very high degree of confidence that what we are doing is in fact working. I want you to realize that we know what we know because we have measured the performance of the patients. We have also measured the performance of our protocol. Welcome to Module 2. This is Unit 2.1. We're going to look at what an RT case study consists of. And the question you should have in mind throughout this entire presentation is, if I were doing a case study, what would I need to emphasize in a case study? So to do that, we're going to define a case study. We're going to realize that telling a case study is really telling a unique medical story. We'll introduce some new concepts and we'll hopefully tie them to some established concepts. And again, what we want to do is we want to find out the answer to the question, what will the clinician audience get in return for their time and effort that they spend on studying my case study? First of all, what is a case study? Well, in the grand scheme of things, we refer to a case study as an observational study because we are observing a single patient's medical case. That's different from the kind of study where we use a statistical analysis because we have a group of patients, it's an experimental group, and we have another group of patients, it's a control group, and we're trying to compare the experimental group against the control group, and we need to come up with a p-value to tell us if we have a statistically significant difference or not. In a case study, we will not have a control group, we will not have an experimental group, there will be no p-value. As a matter of fact, in a case study, we often refer to the case study as an N-of-1 study or an N-equal-to-1 study. It's usually an unusual medical case, it doesn't happen very often, and it's presented to help the medical team learn about a new diagnostic procedure, a new therapeutic intervention, a new pathology, a new protocol, a new monitoring method, something that's new and instructive and worthy of the medical team's attention. Now, if we had several case studies together, we could refer to all of those together as a case series, and we'll have occasion to study that another time. Is institutional review board approval? Well, that's a great question. The answer is, will this individual need to give you his or her consent because you're going to be using his or her information? If the answer is yes, then you will most definitely need to get IRB approval, institutional review board approval, first before you proceed with the collection process. So let's delve right into a case study. This case study happens to have been presented a few years ago at a summit conference in Jacksonville, and it's entitled "Intensive Neuro-Respiratory Rehabilitation Following Olfactory Sheathing Cell Implantation in Ventilator and Pacer-Dependent Veteran." Well, this is the case study of a 30-year-old Hispanic male who is a special forces operative. And in 2008, this gentleman was wounded in combat. You can see here the vehicle that he was in. As a matter of fact, at the time, there was a driver in the driver's side. There was an Afghanistani interpreter on the passenger side, and he was manning the .50 caliber machine gun that's in the top turret of this vehicle. And at that time, they came under a barrage of gunfire as they were proceeding into a valley where they were going to meet with a tribal chieftain. This service member sustained an injury as a result of a bullet wound that occurred along the path shown here, this red line where it says "path of bullet" is the approximate angle at which the bullet came in. And the reason for that is because this gentleman turned around to reload his gun, and when that happened, the bullet came through and crashed through the posterior aspect of cervical vertebrae number three, destroying a significant portion of the posterior aspect of the spinal cord. So that this individual became a C3 Asia A. As you can see, it's a high-level injury. It's a complete injury. And as a result of this, this individual was attended to immediately. As the battle was continuing, they performed an emergency tracheotomy because they realized that he was unable to ventilate, and he was taken back to the staging areas for further medical intervention.