Spinal cord stimulation: a new method to produce an effective cough in patients with spinal cord injury.

Patients with spinal cord injury have an increased risk of developing respiratory tract infections as the result of expiratory muscle paralysis and consequent inability to cough. We have developed a method by which the expiratory muscles can be activated via lower thoracic and upper lumbar spinal cord stimulation to produce an effective cough mechanism. In a tetraplegic patient who required frequent (8.57+/-2.3 times per week [mean+/-SEM]) caregiver assistance to facilitate airway clearance and expectoration of secretions, three epidural electrodes were applied in the T9, T11, and L1 spinal cord regions. During stimulation at the T9 and L1 levels, airway pressures were 90 and 82 cm H2O, respectively. Peak expiratory flow rates were 6.4 L/s and 5.0 L/s; respectively. During combined (T9+L1) stimulation, airway pressure and expiratory flow rate increased to 132 cm H2O and 7.4 L/s, respectively. Addition of the third lead did not result in further increases in pressure generation. These values are characteristic of those observed with a normal subject. Because the patient is able to trigger the device independently, he no longer requires caregiver support for airway management. If confirmed in additional patients, spinal cord stimulation may be a useful method to restore an effective cough mechanism in patients with spinal cord injury.

[1]  S. Braun,et al.  Improving the cough in patients with spinal cord injury. , 1984, American journal of physical medicine.

[2]  R. Deyo,et al.  Spinal cord stimulation for patients with failed back surgery syndrome or complex regional pain syndrome: a systematic review of effectiveness and complications , 2004, Pain.

[3]  J. Canfield,et al.  Functional magnetic stimulation of expiratory muscles: a noninvasive and new method for restoring cough. , 1998, Journal of applied physiology.

[4]  J E Kiwerski,et al.  Factors contributing to the increased threat to life following spinal cord injury , 1993, Paraplegia.

[5]  J. R. Romaniuk,et al.  Mechanism of expiratory muscle activation during lower thoracic spinal cord stimulation. , 2002, Journal of applied physiology.

[6]  J. R. Romaniuk,et al.  Electrical activation of the expiratory muscles to restore cough. , 1995, American journal of respiratory and critical care medicine.

[7]  M. Estenne,et al.  Mechanism of active expiration in tetraplegic subjects. , 1986, The New England journal of medicine.

[8]  P. Westbrook,et al.  Pulmonary dysfunction following traumatic quadriplegia. Recognition, prevention, and treatment. , 1980, JAMA.

[9]  R. Carter.  Respiratory aspects of spinal cord injury management , 1987, Paraplegia.

[10]  E. Roth,et al.  Cough in spinal cord injured patients: comparison of three methods to produce cough. , 1993, Archives of physical medicine and rehabilitation.

[11]  G. Savić,et al.  Long-term survival in spinal cord injury: a fifty year investigation , 1998, Spinal Cord.

[12]  M. Estenne,et al.  Cough in tetraplegic subjects: an active process. , 1990, Annals of internal medicine.

[13]  T. Gal,et al.  Cough dynamics during progressive expiratory muscle weakness in healthy curarized subjects. , 1981, Journal of applied physiology: respiratory, environmental and exercise physiology.

[14]  J Moxham,et al.  Simulation of cough in man by magnetic stimulation of the thoracic nerve roots. , 1997, American journal of respiratory and critical care medicine.

[15]  Siebens Aa,et al.  COUGH FOLLOWING TRANSECTION OF SPINAL CORD AT C-6. , 1964 .

[16]  J. Mortimer,et al.  Phrenic nerve pacing in a tetraplegic patient via intramuscular diaphragm electrodes. , 2002, American journal of respiratory and critical care medicine.

[17]  M. Devivo,et al.  Recent trends in mortality and causes of death among persons with spinal cord injury. , 1999, Archives of physical medicine and rehabilitation.

[18]  A. Dimarco,et al.  Combined intercostal and diaphragm pacing to provide artificial ventilation in patients with tetraplegia. , 2005, Archives of physical medicine and rehabilitation.

[19]  J. R. Romaniuk,et al.  Pattern of expiratory muscle activation during lower thoracic spinal cord stimulation. , 1999, Journal of applied physiology.

[20]  G. Shaw,et al.  Mechanics of cough in normal subjects and in patients with obstructive respiratory disease. , 2015, The American review of respiratory disease.

[21]  J. Langlands.  The dynamics of cough in health and in chronic bronchitis. , 1967, Thorax.

[22]  S. Linder,et al.  Functional electrical stimulation to enhance cough in quadriplegia. , 1993, Chest.

[23]  J. Luce,et al.  The diagnosis and management of neuromuscular diseases causing respiratory failure. , 1991, Chest.

[24]  A. Jackson,et al.  Incidence of respiratory complications following spinal cord injury. , 1994, Archives of physical medicine and rehabilitation.

[25]  F. Biering-Sørensen,et al.  Survival and cause of death after traumatic spinal cord injury. A long-term epidemiological survey from Denmark , 1997, Spinal Cord.

[26]  I Perkash,et al.  Functional magnetic stimulation for restoring cough in patients with tetraplegia. , 1998, Archives of physical medicine and rehabilitation.

[27]  J. Bach.  Mechanical Insufflation-Exsufflation: Comparison of Peak Expiratory Flows With Manually Assisted and Unassisted Coughing Techniques , 1993 .