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Poster 77 Oximetry monitoring as a weaning parameter of nasal ventilation in a neuromuscular disease patient
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ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Patients with organ transplantations are often appropriate candidates for rehabilitation services. At a tertiary academic center, more than 500 orthotopic cardiac transplantations have been performed. Twelve such cardiac transplant recipients were treated as inpatients on the center's rehabilitation unit. Relevant demographic data of these individuals includes: all men with an average age of 58 years (range 48 to 64); a mean length of stay of 26 days (range 10 to 63); and an average modified Barthel Index Scale Improvement from 57 at admission to 86.5 at discharge. The authors discuss medical, psychological, and social complications of these 12 patients in conjunction with those reported in the literature, and then summarize the dynamic response of a denervated transplanted heart during exercise: (1) heart rate (baseline, maximal, and postexertional); (2) Borg Rate of Perceived Exertion Scale; (3) myocardial and peripheral oxygen consumption; (4) abnormal hemodynamic responses. With an emphasis on those parameters which influence rehabilitation, practical guidelines such as precautions, goals, target heart rates and blood pressures, as well as duration and frequency of exercise are reviewed in the context of an exercise prescription.
Poster 75 "Rehabilitation of Patients with Lower Extremity Amputation following Coronary Artery Bypass Graft Surgery." William S. Marsh, MD (Walter Reed Army Medical Center, Washington, DC); Zinon M. Pappas, MD; Maria Sicilia, MD; Leon Reinstein, MD; Fowzia Taqi, MD. Lower extremity amputation is a rare complication following coronary artery bypass graft (CABG) surgery. There is only one previously reported case in the medical literature. We present three male patients ages 64, 67, and 68, with coronary artery disease and diabetes mellitus, who underwent CABG surgery with lower extremity saphenous vein grafting. Postoperatively, each man developed lower extremity complications and vascular dysfunction that required lower extremity amputation. Two of the three patients had significant premorbid lower extremity musculoskeletal dysfunction (PMLEMSD): a previous above-knee amputation, and a pre-existing right peroneal palsy. Before CABG surgery, all 3 patients had been independent in ambulation, transfers, and activities of daily living (ADLs). After CABG surgery, despite intensive inpatient rehabilitation, the 2 patients with PMLEMSD lost their independence, becoming nonambulatory and requiring assistance for ADLs and transfers. The patient without the PMLEMSD returned to independence in ambulation, transfers, and ADLs. It is concluded that patients with PMLEMSD who undergo CABG surgery will lose their independence if they develop lower extremity vasdysfunction and require lower extremity amputation. Preoperatively, for patients with PMLEMSD, consideration should be given to using alternate donor graft sites.
Poster 76 "Rehabilitation Management of Lung Transplantation Patients with Neuromuscular Complications." Leo P. Langlois, MD (Walter Reed Army Medical Center, Baltimore, MD); Robert Crook, DO; Leon Reinstein, MD; Patrice M. Becker, MD; Debra J. Carter, RN, MS. Since 1983, more than 2,000 lung transplant (LT) operations have been performed. We present 2 patients who underwent a single LT for endstage pulmonary failure and subsequently required comprehensive, inpatient rehabilitation (CIR). A 58-year-old male LT recipient had postoperative complications including respiratory arrest, acute rejection, and a right CVA with left hemiparesis. Forty-one days after surgery, he was transferred to CIR. Fifteen days later, he was discharged home requiring supervision for ambulation, activities of daily living (ADLs), and transfers. A 64-year-old male LT recipient was initially discharged home 15 days after surgery but was readmitted to the transplant center 20 days later for acute rejection. During treatment he developed proximal myopathy. After 23 days, he was transferred to CIR. He was discharged home 10 days later independent in ADLs and transfers, and ambulating with supervision. Medical management of LT patients during inpatient rehabilitation, monitoring immunosuppressive medications and their side effects, monitoring pulmonary function status, and differentiating infection from rejection, are reviewed. The unique aspects of the rehabilitation program is discussed. To our knowledge, this is the first report of rehabilitation management of LT patients with neuromuscular complications.
Arch Phys Med Rehabil Vol 76, November 1995
Poster 77 "Oximetry Monitoring as a Weaning Parameter of Nasal Ventilation in a Neuromuscular Disease Patient." Mohan S. Gulati, MD (University of Medicine and Dentistry/New Jersey Medical School, Newark, NJ); John R. Bach, MD. Neuromuscular disease inspiratory muscle weakness leads to chronic hypoventitation. Following a surgical procedure, a 56-year-old woman with a neuromuscular disorder could not be weaned from ventilatory support and a tracheostomy was performed for continuous intermittent positive pressure ventilation (IPPV). During rehabilitation, with a 780mL vital capacity (VC), she was converted to 24-hour noninvasive IPPV and the tracheostomy closed. Her VC increased to 900mL and she was weaned to nocturnal nasal IPPV during which maximum endtidal CO2 (aTCQ) levels were 26-33 tort and oxyhemoglobin saturation (Sat2) averaged 91% to 94%. On the last night of a 6-week course of nocturnal nasal IPPV her mean Sat2 was 91%. With no other treatment changes, on the following nights, mean Sat2 values were 85%, 82%, 75%, 73%, 72%, and 65%. Nocturnal ETCQ levels increased to 45 tort and a daytime Pact2 was 50 tort. At this point nasal IPPV was reinstituted. Subsequent nocturnal mean Sat2 were 76%, 78%, 84%, (4 days later) 90%, 91%, then 94%. Thereafter, nocturnal Sat2 consistently averaged 94% and ETCO2returned to low 30s. We conclude that nocturnal oximetry can be useful for gauging changes in alveolar ventilation during weaning attempts, and, like arterial blood gas sampling, it can signal impending ventilatory failure.
Poster 78 "Spinal Stimulation to Improve Circulation in the Lower Extremity." Tim DiCarlo, MD (St. Francis Medical Center, Pittsburgh, PA). Epidural spinal cord stimulation (ESCS) has been offered in the management of certain chronic pain conditions such as ischemic neuropathy. ESCS has also been evaluated in several trials in the management of nonoperable ischemia secondary to peripheral vascular disease and is the focus of this case. The patient is a 73-year-old man with a long history of peripheral vascular disease, prior left below-knee amputation, and now with burning dysesthesias, cool extremity, and dry gangrene of the right great toe. An angiogram of the pelvis and right femoral artery showed significant occlusive disease; consequently, the patient was thought not to be a candidate for bypass surgery. He is reluctant to undergo further amputation and elects to undergo epidural spinal cord stimulation. Postoperatively his subjective complaints of burning dysesthesias were markedly reduced. The color over the dorsum of the foot changed from an erythema to a more normal color; the skin temperature to touch had wanned from a previously cool extremity. Preoperative and postoperative transcutaneous oxygen measurements of his foot increased from 3mmHg to 34mmHg. A possible mechanism by which spinal cord stimulation could cause vasodilation is described by Linderothet al in animal studies and involves stimulation of sympathetic efferent fibers. Despite the overall improvement in the above findings, the patient underwent transmetatarsal amputation approximately 6 weeks later. We conclude that electrical stimulation did prove effective in reducing pain and enhancing blood flow, as measured clinically and by transcutaneous oxygen levels, but did not eliminate or delay the need for amputation in this patient. The mechanism(s) by which ESCS causes vasodilation is uncertain but may involve electrically activated sympathetic efferent fibers.
Poster 79 "Recruitment Patterns of Abdominal Muscles During Inspiratory Resistance Breathing." Eileen H. Breslin, RN, DNSc (University of California Davis Medical Center/Center for Nursing Research, Sacramento, CA); Viviane Ugalde, MD; H. William Bonekat, DO; Sandra A. Walsh, BS; Sylvia J. Horasek, BA; Michael Cronin, RT, DMS. Inspiratory resistance breathing (IRB) training is frequently used to improve respiratory muscle function. However, muscles recruited during IRB at commonly used resistance training loads of 40% and 60% maximum inspiratory pressure (MIP) have not been reported. The purpose of this study was to determine the EMG recruitment patterns of four expiratory muscles (Transverse Abdominis [TA], Internal Oblique [IO], External Oblique [EO], and Rectus Abdominis IRA]) during tidal breathing and with breathing loads of 40% and 60% MIP. EMG activity
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Patients with organ transplantations are often appropriate candidates for rehabilitation services. At a tertiary academic center, more than 500 orthotopic cardiac transplantations have been performed. Twelve such cardiac transplant recipients were treated as inpatients on the center's rehabilitation unit. Relevant demographic data of these individuals includes: all men with an average age of 58 years (range 48 to 64); a mean length of stay of 26 days (range 10 to 63); and an average modified Barthel Index Scale Improvement from 57 at admission to 86.5 at discharge. The authors discuss medical, psychological, and social complications of these 12 patients in conjunction with those reported in the literature, and then summarize the dynamic response of a denervated transplanted heart during exercise: (1) heart rate (baseline, maximal, and postexertional); (2) Borg Rate of Perceived Exertion Scale; (3) myocardial and peripheral oxygen consumption; (4) abnormal hemodynamic responses. With an emphasis on those parameters which influence rehabilitation, practical guidelines such as precautions, goals, target heart rates and blood pressures, as well as duration and frequency of exercise are reviewed in the context of an exercise prescription.
Poster 75 "Rehabilitation of Patients with Lower Extremity Amputation following Coronary Artery Bypass Graft Surgery." William S. Marsh, MD (Walter Reed Army Medical Center, Washington, DC); Zinon M. Pappas, MD; Maria Sicilia, MD; Leon Reinstein, MD; Fowzia Taqi, MD. Lower extremity amputation is a rare complication following coronary artery bypass graft (CABG) surgery. There is only one previously reported case in the medical literature. We present three male patients ages 64, 67, and 68, with coronary artery disease and diabetes mellitus, who underwent CABG surgery with lower extremity saphenous vein grafting. Postoperatively, each man developed lower extremity complications and vascular dysfunction that required lower extremity amputation. Two of the three patients had significant premorbid lower extremity musculoskeletal dysfunction (PMLEMSD): a previous above-knee amputation, and a pre-existing right peroneal palsy. Before CABG surgery, all 3 patients had been independent in ambulation, transfers, and activities of daily living (ADLs). After CABG surgery, despite intensive inpatient rehabilitation, the 2 patients with PMLEMSD lost their independence, becoming nonambulatory and requiring assistance for ADLs and transfers. The patient without the PMLEMSD returned to independence in ambulation, transfers, and ADLs. It is concluded that patients with PMLEMSD who undergo CABG surgery will lose their independence if they develop lower extremity vasdysfunction and require lower extremity amputation. Preoperatively, for patients with PMLEMSD, consideration should be given to using alternate donor graft sites.
Poster 76 "Rehabilitation Management of Lung Transplantation Patients with Neuromuscular Complications." Leo P. Langlois, MD (Walter Reed Army Medical Center, Baltimore, MD); Robert Crook, DO; Leon Reinstein, MD; Patrice M. Becker, MD; Debra J. Carter, RN, MS. Since 1983, more than 2,000 lung transplant (LT) operations have been performed. We present 2 patients who underwent a single LT for endstage pulmonary failure and subsequently required comprehensive, inpatient rehabilitation (CIR). A 58-year-old male LT recipient had postoperative complications including respiratory arrest, acute rejection, and a right CVA with left hemiparesis. Forty-one days after surgery, he was transferred to CIR. Fifteen days later, he was discharged home requiring supervision for ambulation, activities of daily living (ADLs), and transfers. A 64-year-old male LT recipient was initially discharged home 15 days after surgery but was readmitted to the transplant center 20 days later for acute rejection. During treatment he developed proximal myopathy. After 23 days, he was transferred to CIR. He was discharged home 10 days later independent in ADLs and transfers, and ambulating with supervision. Medical management of LT patients during inpatient rehabilitation, monitoring immunosuppressive medications and their side effects, monitoring pulmonary function status, and differentiating infection from rejection, are reviewed. The unique aspects of the rehabilitation program is discussed. To our knowledge, this is the first report of rehabilitation management of LT patients with neuromuscular complications.
Arch Phys Med Rehabil Vol 76, November 1995
Poster 77 "Oximetry Monitoring as a Weaning Parameter of Nasal Ventilation in a Neuromuscular Disease Patient." Mohan S. Gulati, MD (University of Medicine and Dentistry/New Jersey Medical School, Newark, NJ); John R. Bach, MD. Neuromuscular disease inspiratory muscle weakness leads to chronic hypoventitation. Following a surgical procedure, a 56-year-old woman with a neuromuscular disorder could not be weaned from ventilatory support and a tracheostomy was performed for continuous intermittent positive pressure ventilation (IPPV). During rehabilitation, with a 780mL vital capacity (VC), she was converted to 24-hour noninvasive IPPV and the tracheostomy closed. Her VC increased to 900mL and she was weaned to nocturnal nasal IPPV during which maximum endtidal CO2 (aTCQ) levels were 26-33 tort and oxyhemoglobin saturation (Sat2) averaged 91% to 94%. On the last night of a 6-week course of nocturnal nasal IPPV her mean Sat2 was 91%. With no other treatment changes, on the following nights, mean Sat2 values were 85%, 82%, 75%, 73%, 72%, and 65%. Nocturnal ETCQ levels increased to 45 tort and a daytime Pact2 was 50 tort. At this point nasal IPPV was reinstituted. Subsequent nocturnal mean Sat2 were 76%, 78%, 84%, (4 days later) 90%, 91%, then 94%. Thereafter, nocturnal Sat2 consistently averaged 94% and ETCO2returned to low 30s. We conclude that nocturnal oximetry can be useful for gauging changes in alveolar ventilation during weaning attempts, and, like arterial blood gas sampling, it can signal impending ventilatory failure.
Poster 78 "Spinal Stimulation to Improve Circulation in the Lower Extremity." Tim DiCarlo, MD (St. Francis Medical Center, Pittsburgh, PA). Epidural spinal cord stimulation (ESCS) has been offered in the management of certain chronic pain conditions such as ischemic neuropathy. ESCS has also been evaluated in several trials in the management of nonoperable ischemia secondary to peripheral vascular disease and is the focus of this case. The patient is a 73-year-old man with a long history of peripheral vascular disease, prior left below-knee amputation, and now with burning dysesthesias, cool extremity, and dry gangrene of the right great toe. An angiogram of the pelvis and right femoral artery showed significant occlusive disease; consequently, the patient was thought not to be a candidate for bypass surgery. He is reluctant to undergo further amputation and elects to undergo epidural spinal cord stimulation. Postoperatively his subjective complaints of burning dysesthesias were markedly reduced. The color over the dorsum of the foot changed from an erythema to a more normal color; the skin temperature to touch had wanned from a previously cool extremity. Preoperative and postoperative transcutaneous oxygen measurements of his foot increased from 3mmHg to 34mmHg. A possible mechanism by which spinal cord stimulation could cause vasodilation is described by Linderothet al in animal studies and involves stimulation of sympathetic efferent fibers. Despite the overall improvement in the above findings, the patient underwent transmetatarsal amputation approximately 6 weeks later. We conclude that electrical stimulation did prove effective in reducing pain and enhancing blood flow, as measured clinically and by transcutaneous oxygen levels, but did not eliminate or delay the need for amputation in this patient. The mechanism(s) by which ESCS causes vasodilation is uncertain but may involve electrically activated sympathetic efferent fibers.
Poster 79 "Recruitment Patterns of Abdominal Muscles During Inspiratory Resistance Breathing." Eileen H. Breslin, RN, DNSc (University of California Davis Medical Center/Center for Nursing Research, Sacramento, CA); Viviane Ugalde, MD; H. William Bonekat, DO; Sandra A. Walsh, BS; Sylvia J. Horasek, BA; Michael Cronin, RT, DMS. Inspiratory resistance breathing (IRB) training is frequently used to improve respiratory muscle function. However, muscles recruited during IRB at commonly used resistance training loads of 40% and 60% maximum inspiratory pressure (MIP) have not been reported. The purpose of this study was to determine the EMG recruitment patterns of four expiratory muscles (Transverse Abdominis [TA], Internal Oblique [IO], External Oblique [EO], and Rectus Abdominis IRA]) during tidal breathing and with breathing loads of 40% and 60% MIP. EMG activity