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Paradoxical breathing in spinal cord injury

An animated video aimed at healthcare professionals explaining the mechanism of paradoxical breathing in the spinal shock phase immediately following cervical spinal cord injury. It is a sign that is relatively rare as the incidence of cervical SCI is relatively low, and it only lasts a short time in patients who experience it. However, the consequences can be profound for the patient and so increased awareness of this sign among healthcare professionals could improve outcomes. For further reading and information: The Duke of Cornwall Spinal Treatment Centre, Salisbury UK https://www.salisbury.nhs.uk/wards-de... RISCI (Respiratory Information in Spinal Cord Injury) is formed of multidisciplinary interested parties working within Spinal Cord Injury Centres in the UK and Ireland. http://risci.org.uk Berlowitz DJ, Wadsworth B, Ross J. Respiratory problems and management in people with spinal cord injury. Breathe 2016;12:328-340 Denton M, McKinlay J. Cervical cord injury and critical care. Continuing Education in Anaesthesia 2009; 9:82-86 Transcript: We breathe using 3 groups of muscles: · The diaphragm · The intercostals · and the abdominals These muscles receive their nerve supply from the brain via the spinal cord. If someone has a spinal cord injury some or all of these muscles can be paralysed. When the diaphragm contracts it moves down and we breathe in. Its nerve supply is from C3,4 and 5 in the spinal cord in the neck. The intercostals have 2 layers that either lift or compress the rib cage when we breathe in or out. Their nerve supply is from T1 – T 11 in the spinal cord. The abdominal muscles are mainly needed for breathing only when we want to help force air out; – such as coughing or during and after strenuous exercise. Their nerve supply is from T6-T12 in the spinal cord. ---------------------------------- This person has recently suffered a spinal cord injury at the level of C5 in the neck. This means they can’t use their intercostals or abdominal muscles to breathe because they are paralysed. Their only working breathing muscle is the diaphragm. The diaphragm contracts and moves down creating negative pressure inside the chest and the person breathes in. However, in the first few days and weeks following a spinal cord injury there is a phase of spinal shock when the paralysed muscles have no tone and are ‘flaccid’ – which means they are completely slack or limp. Now the negative pressure inside the chest causes an adverse effect because the intercostals are flaccid they are not stabilising the rib cage and the chest collapses and is pulled inwards by the diaphragm action on inspiration. At the same time, the abdomen rises because the organs are being displaced by the downward movement of the diaphragm. This condition is known as paradoxical breathing because of the reverse pattern of movement seen in the chest and abdomen; it is also sometimes called ‘see saw’ breathing. It can lead to respiratory distress or even respiratory failure as the person’s work of breathing is greatly increased. Over a period of between several days to weeks following injury, spinal shock gradually resolves, and the paralysed muscles develop tone (often in the form of spasticity). The chest mechanics then improve, and paradoxical breathing reduces as does work of breathing. Outcomes will be more favourable if weaning from ventilation is delayed until this stage is reached.