Respiratory Management for Traumatic Brain Injury

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Original Editor - Wendy Walker

Top Contributors - Wendy Walker, Kim Jackson, Naomi O'Reilly, Tarina van der Stockt, Rachael Lowe, Lucinda hampton, Eugenie Lamprecht, Stacy Schiurring, Simisola Ajeyalemi and Uchechukwu Chukwuemeka  

Introduction

In cases of Traumatic Brain Injury [TBI] respiratory dysfunction is the most common medical complication which occurs.

Up to one third of patients with severe TBI develop Acute Respiratory Distress Syndrome [ARDS].

There is a reciprocal relationship between lung function and brain function: the brain needs sufficient oxygen supply in order to operate, and the respiratory system needs instructions from the brain in order to operate.

Respiratory Assessment of TBI Patient

Medical Information

The respiratory physiotherapist should pay close attention to the following information when assessing a patient with TBI in the acute situation:

• arterial blood gases
• chest x-rays
• respiratory patterns
• pulmonary function testing
• peak cough flow

Past Respiratory History

This will frequently be provided by family members in cases of acute and severe TBI. The therapist should inquire about any previous respiratory conditions, as well as smoking history.

General Observation

The therapist will watch the patient and note the general respiratory pattern and posture; whether there is any cyanosis or accessory muscle use, as well as noting speech patterns if appropriate.

Respiratory Pattern Ax

This includes breathing rate, depth of breaths, symmetry of air intake/lung expansion, regularity of breaths.

Other Ax techniques

Percussion

Percussion is used to detect chest resonance. Percussion applied to the patient's chest produces audible sounds which can be interpreted by a skilled examiner to discern fluid, air or solid material within the chest cavity. Please see the Respiratory Assessment - Percussion page for further information, including a description of technique.

Auscultation

Auscultation involves using a stethoscope to listen to lung sounds. Abnormal lung sounds include wheezes, crackles, rhonchi and pleural rub. More information can be found on the Auscultation page.

Respiratory Management

In the acute stages of TBI, the aims of management in the Intensive Care Unit are to maintain oxygen delivery in order to limit secondary neurological damage. Mechanical ventilation is commonly used with 3 aims: 1. To prevent/minimise hypoxia 2. To prevent/minimise hypercapnia 3. To protect the airway from risk of aspiration. It is acknowledged that difficulties are frequently encountered when weaning these patients from mechanical ventilation. A number of recent studies have investigated the use of protective ventilation in the early stages following TBI.

During mechanical ventilation, the aim of physiotherapy is to optimise respiratory function while maintaining the neuromusculoskeletal system.

Physiotherapy interventions include:

• Positioning - to use gravity to aid sputum removal from the lungs
• Manual and ventilator hyperinflation
• Weaning from mechanical ventilation
• Non-invasive ventilation
• Percussion, vibration, suctioning - all aim to aid removal of sputum
• Respiratory muscle strengthening
• Breathing exercises and mobilisation

References

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