Chronic respiratory dysfunction and ageing

A spinal cord injury (SCI) above T12 causes changes to respiratory function and at high neurological levels of injury, significantly increases the risk of respiratory complications. Even after the acute phase, a person with SCI may have persistent respiratory dysfunction and therefore, remains highly susceptible to respiratory issues when acutely unwell or hospitalised, even for non-respiratory conditions.

One recent study with > 1000 subjects, reported that respiratory function improves following SCI, but declines below baseline by 6 years post-injury, with people who have motor complete injuries experiencing the most significant change.

More research is indicated, but presumably, residual respiratory function may decline for 2 main reasons which compound each other:

1. the chronic effects of SCI, such as postural changes and untreated sleep-disordered breathing
2. the natural ageing process, including reduced immune function and musculoskeletal changes.

When combined, this can result in complex health conditions—which are associated with premature ageing—and an increased susceptibility to respiratory complications later in life.

The summary below outlines key aspects of respiratory health decline following SCI, along with contributing risk factors.

Functional changes over time

Assessment

A comprehensive assessment should involve a multidisciplinary team, the person with SCI and their support network.

The review process determines both acute and chronic respiratory health indicators—particularly hospital admissions and reported impacts on activities of daily living (ADLs), community participation and quality of life.

Further investigation identifies specific respiratory function changes and explores contributing factors as discussed above.

Completing a current respiratory function assessment establishes a baseline, along with other relevant medical and physical assessments e.g. sleep-disordered breathing, pain, spasticity and posture.

Finally, goal setting is an important process to initiate and promote a person-centred approach, while identifying measurable health outcomes to address.

Management

A multidisciplinary team review with collaborative goal setting, will guide respiratory health recommendations and management interventions. A client-centred approach to education, as well as addressing issues related to respiratory and other health, along with lifestyle will be important.

Education

Education is an important starting point in the management of chronic health and ageing issues for a person with SCI. Introducing change may be difficult for many reasons, including limited health knowledge, diminishing supports and entrenched lifestyle habits. Hence, improving health literacy may improve understanding of complex health issues and contributing factors. It may also aid compliance with recommendations, while fostering insight into the negative consequences of inaction.

The aim of education is to promote engagement, while also building confidence and capacity in self-management and informed decision-making. It is typically a staged and repeated process, involving: the sharing of information, encouraging dialogue, checking comprehension, and exploring values and beliefs. When aligned with initial goal setting, education can support negotiation to address the following management issues.

Respiratory health management

Identified respiratory health issues may be addressed by initially trialling low-cost/simple strategies before progressing to high cost/complex strategies, which may include:

• reviewing adequacy of overall ventilation support, including review of risk for sleep-disordered breathing
• implementing lung volume augmentation
  • incorporating a balanced approached between positive pressure therapies and demand ventilation and targeted inspiratory muscle training, to avoid respiratory fatigue
• improving secretion management
• managing sleep-disordered breathing and any other respiratory diseases e.g. chronic obstructive pulmonary disease
• addressing other respiratory diseases e.g. chronic obstructive pulmonary disease
• reviewing hygiene practices
• promoting cessation of smoking/vaping and substance use
• implementing a respiratory action plan, including updating vaccinations.

Other health and supports management

Other health, including lifestyle and functioning issues may need to be addressed using evidence-based approaches, which may include:

• enhancing cardiovascular and metabolic health
• addressing weight management e.g. diet, cardiorespiratory fitness program and caloric tracking
• improving pain and spasticity management
• managing stress and mental health issues
• reviewing medications and other co-morbidities
• improving flexibility and muscle strengthening related to function, including core strength and balance
• optimising 24-hour positioning for bed, seated mobility and ADL
• problem-solving functional skills for independence and confidence, while minimising risk of injury and falls
• maintaining or increasing capacity for physical ADL, while managing fatigue
• improving home or community access
• replacing ageing equipment or introducing new equipment supports
• addressing insufficient care support
• improving linkage with and monitoring by appropriate health professional
• advocating for adequate funding.

Discharge and community planning

A person with SCI, who has had chronic respiratory dysfunction and is also ageing, may need a review of their funding, care and health professional supports for community living. This may include addressing issues related to their home environment, as well as equipment, including trialling and prescribing respiratory devices.

For more information on these considerations, refer to Discharge and community planning.