“Opioids in America, Part 3: The other side of the crisis - Greeley Tribune” plus 1 more
“Opioids in America, Part 3: The other side of the crisis - Greeley Tribune” plus 1 more |
| Opioids in America, Part 3: The other side of the crisis - Greeley Tribune Posted: 31 Oct 2020 04:20 PM PDT Editor's Note: This is Part 3 of a three-part series looking into the opioid epidemic across the U.S., rehabilitation options in Weld County and stories from people who have overcome or are currently fighting addiction to opioids. Like many things, there's another side to the opioid crisis. While the addiction to opioids is a problem that needs to be addressed, people who are using the drugs exclusively as prescribed — and who still truly need it from a medical perspective — have been swept up in what some have seen as government's knee-jerk reaction to the crisis. In having their ability limited to get the drugs they need in order to function, many of these patients are left suffering debilitating pain. Richard Mark VanWormer was well on his way to establishing a stellar career as a surgical first assistant at Baylor University Medical Center in Texas when in 1997 he was shot point-blank in the chest by a gang member. "I had just left surgery and just scrubbed out and was on my way home when this man walked up to me at a gas station," VanWormer recalls. "There was something shiny in his hand and he raised it up. It turned out to be a gun and he just shot me, hopped back in his car with his friend and drove off. They never saw him again." The bullet is still lodged in the mediastinum tissue of VanWormer's left lung, one millimeter over his left aorta.  VanWormer, who lives in Greeley, was left with Complex (or Chronic) Regional Pain Syndrome, CRPS, often referred to as the "suicide disease" because of the constant intense pain patients experience. The Mayo Clinic describes CRPS as "typically developing after an injury, surgery, stroke or heart attack. The pain is out of proportion to the severity of the initial injury." Some of the symptoms associated with CRPS are:
CRPS is rare, and the cause isn't clearly understood, the website explained. Many cases occur after a "forceful trauma." In VanWormer's case, his CRPS was caused by the gunshot to the chest. "The CRPS has given me severe spinal osteoporosis, which happens in the end stages of CRPS," VanWormer said. "So, I'm basically, my spine has been gnawed on by a wharf rat; it looks like it's melting. "I was 5-foot eleven two years ago and now I am five-foot one," he added.  To help control the extreme pain from CRPS, VanWormer has been prescribed opioids. Even with a prescription and several letters from his doctor, VanWormer has difficulties getting the drugs. Trips to the emergency room weren't any better, as medical staff treated him like a drug seeker, despite his visible spine condition and pain. VanWormer was taken off of opioids in 2016 after the Centers for Disease Control and Prevention (CDC) released its guidelines on prescribing opioids. "These guidelines issued by the CDC weren't mandatory," VanWormer said. "They are just being taken off by the doctors because the DEA was going in and arresting doctors for what they call over-prescribing." Patients that had been taking prescribed opioids for years were suddenly taken off the drugs and many were left not being able to function, he said. Dawn Ponsford likens the government's crackdown on opioids to that of prohibition. "It is absolutely that, it's basically the same idea. Everyone is getting punished, even if they are using the medication responsibly," she said. "It was just a knee-jerk reaction on the government's part." The 61-year-old Evans resident has Crohn's disease, Fibromyalgia, psoriatic arthritis and peripheral neuropathy. Ponsford has had five surgeries over the past 11 years to try and help her Crohn's disease and peripheral neuropathy. Like many pain patients, Ponsford's doctor suddenly stopped prescribing her pain medication out of fear of retribution from the DEA. "My doctor decided, 'I'm not going to jail for anyone,' and many people at the pain clinic were just dismissed," she explained. "So, I went through withdrawals. I didn't hit the street looking for drugs or buy them on the black market, so the idea that if you are on them long-term, you're an addict is completely false." Ponsford is currently trying to get back into a pain management clinic for help.  "I'm still struggling. My PCP and specialists have been great. They've been trying to help me get in," Ponsford said. "They all say that I need pain relief; I need pain medication. It should be part of my regimen." As part of the Don't Punish Pain Rally organization, Ponsford fights for the right to be prescribed pain medication for chronic pain as well as to put an end to the stigma of using opioids for pain. According to the Don't Punish Pain Rally National's Facebook page, the organization is protesting "to have our voices heard regarding the neglect the chronically ill community/pain patients have experienced due to the new CDC guidelines, the DEA, and the FDA's involvement." Ponsford has been with the group for three years. "The group started with like five people and it's grown to around 16,000 now across the United States," she explained. "You hear about the opioid crisis and all the horrible things going on, and that's true, but there's a flip side, and we deserve to be part of the narrative."  Tom Riggs of Fort Collins was an avid marathon runner, participating in more than 30 races including three stints at the Boston Marathon. "I absolutely loved it. I would go out and run for three or four hours just for fun," Riggs said, laughing. "We would go on vacation with my wife's parents and while they were sleeping in, I would go out and run and explore everything. When they got up, we'd get in the car and I'd take them to all these places." Despite loving running, the activity began to hurt Riggs in ways that he'd never experienced before. "I realized there was something going on, and eventually over the years I ended up having five spinal fusions and seven foot surgeries," he said. "I have titanium bits literally from my neck to my toes. I'm held together with all kinds of rods and screws and plates." Riggs also suffers from Hypermobile Ehlers-Danlos syndrome (EDS). EDS is an inherited connective tissue disorder that is caused by the defects in collagen, according to the National Institutes of Health, NIH. The disease is often characterized at having joint hypermobility, chronic muscle and bone pain, early-onset osteoarthritis, frequent joint dislocations, dysfunction of the autonomic nervous system and soft, smooth skin that may be slightly elastic and bruises easily. Because of the extreme pain he has from EDS, Riggs needs to take opioids to help him function throughout the day. "I hurt everywhere and the CDC are letting the abusers ruin this for those of us who really need it," Riggs commented. "They play the system and take advantage any way they can just for a good time or whatever. They are ruining it for people like me."  Riggs attends the Colorado Pain Clinic in Greeley for his treatments. "Basically I go in and they check that I haven't taken too many of my pills too quickly and then they refill the prescriptions," he explained. "Right now I am seeing my fourth or fifth provider." Riggs describes one provider he has worked with as "by the numbers" and wanted patients to be under the CDC guidelines for opioid prescriptions. "I told her you have to be compassionate to some of these people, me included, because if you put me under the CDC guidelines, then I am going to be miserable," Riggs said. "I won't be able to function." Riggs takes three low-dose Percocets a day help manage his pain along with several other prescribed medications. "I stay pretty much on a set schedule because I know I am going to need all of those," he explained. "If I let my pain get too bad, then the pain medication I have isn't enough to get me back to being comfortable."  Riggs admits he has a slight level of addiction to the medication, but it's not focused around getting a high from the medication, it's about relieving the pain. "If I'm not miserable, I don't think about taking them; I don't obsess over taking them," he said. "It's not something I crave, I would rather not take anything. Having to rely on opioids for pain management is a "double-edged sword," Riggs said. "They (doctors) say 'if you need more, just let us know and we will take care of you,'" Riggs adds. "But then they say, 'well you know, you don't want to be addicted so you better stop.' They make you feel terrible." Jim and Michelle Stifle of Greeley can relate to being made to feel like a criminal for using opioids. Michelle Stifle has had four left hip replacements, several knee replacements, three total joint infections, an infection in her back vertebrae, reflex sympathetic dystrophy syndrome and kidney failure.  "I take my meds, but I am taking Advil like it's candy because they don't give me enough," Michelle Stifle explained, getting emotional. "I don't have a choice. I'm either taking Advil or I am going to die." Michelle said she went to several doctors before finding one that would agree to treat her. "My doctor tells me that he's got one or two letters from the DEA letting him know they are watching. He is so afraid of losing his license or going to jail." Michelle said. "You go to Wal-Mart for your prescription and they look at you like you're a dirty criminal and they hassle you about it. Walgreens was so bad that we haven't been in there since." Every month when Michelle goes to get her meds, she's scared that the pharmacy will be out of stock of the pills or will refuse to fill the prescription. The sad truth about opioids is that it is easier to get illegal drugs on the street than to get a prescription filled, the couple said. While Michelle suffers from immense physical pain, the emotional pain affects her, Jim and their family. "It's terrible and so hard for me to watch," Jim said. "I took her to the ER at least five times. They would dope her up, she'd go to sleep and by the next morning it would wear off and she'd be in pain. She couldn't get them to listen to her." Jim takes care of the cooking and laundry to help relieve some of the stress on his wife.  "My son, he's been affected. He had to drive me to my appointments because I couldn't drive," Michelle said. "My daughter used to live here and she's been affected." And like VanWormer, Ponsford and Riggs, the Stifles don't deny that there is a problem around opioids and that illegal use and abuse of the drugs need to be controlled. However, making those who are responsibly using the medications or need the pills to just function in everyday life suffer isn't the way to go about things, they say. "We don't want addicts to get any less care, we just want the same consideration in care for chronic pain patients," Ponsford said. For more information on drug and alcohol addiction or rehabilitation programs, contact North Range Behavioral Health at www.northrange.org. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Posted: 24 Oct 2020 11:33 PM PDT 1 INTRODUCTIONDuring the COVID‐19 pandemic, emergency department (ED) personnel are facing higher caseloads, including those with special medical needs. Persons with spinal cord injuries and disorders (SCI/D) presenting to the ED with respiratory complaints require special consideration if diagnosed with COVID‐19 because they are at higher risk for rapid decompensation and progression to acute respiratory failure due to the combination of chronic respiratory muscle weakness and autonomic dysregulation, which cause neurogenic restrictive/obstructive lung disease and chronic immune dysfunction. In this review, we highlight the greater susceptibility of persons with SCI/D to death from respiratory infections, describe methods to aide in recognition of respiratory infections including COVID‐19 in persons with SCI/D, and discuss treatment strategies to better manage respiratory complications of COVID‐19 infections in this population. 2 EPIDEMIOLOGYAlmost 300,000 persons in the United States are living with SCI/D.1 The most common cause of death in this population is pneumonia and respiratory diseases. Persons with SCI/D have greater mortality from pneumonia and influenza compared to the general population with the standardized mortality ratio for pneumonia and influenza for all types of SCI/D calculated approximately 40.2, 3 Here, the standardized mortality ratio estimates the ratio between the observed number of deaths in SCI/D patients, or subgroups of SCI/D patients, compared to the expected number of deaths based on age‐ and sex‐specific rates in the general population. The finding that the ratio of observed–expected deaths (the standardized mortality ratio) far exceeds 1.0 indicates that SCI/D patients experience a manyfold higher rate of "excess deaths" from pneumonia and influenza compared to their counterparts without SCI/D. For individuals with complete tetraplegia, and therefore greater respiratory muscle paralysis and secondary respiratory compromise, the risk of death is considerably higher with standardized mortality ratio = 143.2 Compared to those with incomplete tetraplegia who ambulate, non‐ambulators with C1–C4 tetraplegia are 6 times more likely to die from pneumonia or influenza.4 Persons with complete paraplegia, preservation of full diaphragm innervation, and at least partial maintenance of accessory muscles of respiration and abdominal musculature, have a lower standardized mortality ratio of 15.2. Those who have been injured for >20 years have standardized mortality ratio = 60.2, 5 Additionally, persons with SCI/D are at higher risk of developing venous thromboembolism and pulmonary embolism, with the standardized mortality ratio for pulmonary embolism = 45.3 Individuals with other neuromuscular diseases causing respiratory muscle weakness such as multiple sclerosis, amyotrophic lateral sclerosis, muscular dystrophies, myotonic dystrophies, spinal muscular atrophies, myasthenia, inflammatory demyelinating polyradiculoneuropathies, and spino‐cerebellar ataxias may be at higher risk of respiratory infection complications and benefit from similar management strategies. COVID‐19 has infected at least 25,248,595 persons worldwide through August 31, 2020, causing 846,877 deaths. In the United States, as of August 31, 2020, at least 5,997,622 persons have been infected with the virus and 183,068 have died from complications of COVID‐19.6 The epidemiology of COVID‐19 in persons with SCI/D is incompletely understood but appears to be similar to the general population; there have been a range of presentations from mild to severe disease.7-11 In addition to respiratory weakness, the SCI/D population has a high prevalence of hypertension, coronary artery disease, diabetes, and obesity, which are recognized to increase risk of COVID‐19 complications.12, 13 Of 25 cases of COVID‐19 infection reported thus far, one sudden death has been described in a patient with new traumatic SCI/D and mild COVID‐19, 5 cases were described as severe with Modified Early Warning Scale (MEWS) score ≥3 and <5, and the remainder were non‐severe.7-11 Recovery courses have ranged from 10 days to a few months, with older patients with high tetraplegia, tracheostomy, and severe COVID‐19 courses having the slowest recovery. In the general population, deaths from COVID‐19 are associated with the development of acute respiratory infections, sepsis, thromboembolic events, and acute respiratory failure that may be complicated by the acute respiratory distress syndrome (ARDS).12 A study of COVID‐19 case‐fatality rates in the United States in veterans with traumatic or non‐traumatic SCI/D (not including multiple sclerosis or amyotrophic lateral sclerosis) identified 140 veterans who were positive for COVID‐19 among the 17,452 veterans in the SCI/D Registry. Of these, 26 died, all within 30 days of testing positive. The case‐fatality rate of 19% for veterans with SCI/D was 2.4 times that of 7.7% in non‐SCI/D veterans. However, this rate is falsely elevated due to inability to capture COVID‐19 infections that go undetected if patients are asymptomatic or if mild symptoms are attributed to other common conditions causing fever in the SCI/D population (eg, urinary tract infections).14 3 PERTINENT PATHOPHYSIOLOGY OF SCI/D3.1 Aging with SCI/DIndividuals with SCI/D often develop respiratory complications due to age‐related alveolar changes and reductions in vital capacity superimposed on baseline neuromuscular weakness; lung and chest wall compliance changes due to respiratory muscle weakness, spasticity, or hypotonia; obesity; kyphoscoliosis; and sleep‐disordered breathing, including both central and obstructive sleep apnea. These issues increase the baseline risk of acute respiratory failure in persons with SCI/D, particularly those with underlying respiratory or cardiovascular disease, neoplastic conditions, or immune dysfunction. Consequently, respiratory infections such as COVID‐19 may increase morbidity and mortality in the SCI/D population. 3.2 Immune compromiseIndividuals with chronic SCI/D are immunocompromised for several reasons: maladaptive sympathetic—neuroendocrine adrenal reflexes,15 immune suppression with secondary immune deficiency syndrome,16 obesity‐related inflammation with reduced natural killer cell expression,17 and increased lung inflammation similar to mild asthma.18 3.3 Neurogenic respiratory muscle paralysis (restrictive lung defect)Various degrees of respiratory muscle paralysis are present in most individuals with tetraplegia and many with paraplegia due to inspiratory and expiratory muscle weakness (Table 1).19 Level and completeness of injury dictate the likelihood of restrictive and obstructive lung dysfunction.
Paralysis of a major portion of the expiratory muscles used to generate an effective cough results from SCI at or above the T6 spinal level. Weakened expiratory muscles lead to decreased peak cough flow,20 tenacious secretions, and atelectasis. Reduced alveolar expansion decreases surfactant production, increases alveolar surface tension, and markedly increases the work of breathing. Expiratory muscle paralysis also is associated with outward expansion of the abdominal wall resulting in shortening of the diaphragm, reducing its resting length, diminishing inspired volume, and alveolar expansion. Diaphragm resting length can be easily restored through appropriate use of an elastic abdominal binder, improving breathing efficiency when upright (Figure 1).21, 22  Resting diaphragm length under normal, paralyzed, and abdominal binder conditions 3.4 Neurogenic obstructive lung diseaseIn individuals with SCI/D above T6, para‐sympathetic predominance leads to bronchiolar constriction, hyper‐reactive airways, and increased mucus secretion.23 4 DIAGNOSIS4.1 Confounding conditions in persons with SCI/DIt is important that ED personnel be aware of comorbidities in individuals with SCI/D which may thwart diagnosis of COVID‐19 when they present with potentially infectious complaints. In addition to obvious motor paralysis and sensory loss, persons with SCI/D may have thermoregulatory dysfunction with lower baseline body temperatures and blunted febrile responses, sympathetic blunting, autonomic dysreflexia, neurogenic bowel, neurogenic bladder, spasticity, and pressure injuries.24 Other conditions can make it difficult to determine the cause of symptoms. For example, poikilothermia—the inability to regulate body temperature—can lead to temperature elevations if the patient is bundled with multiple layers of fabric; and asymptomatic bacteriuria with fever was mistaken for urinary tract infection in a person with SCI/D infected with COVID‐19.7 ED staff may be unfamiliar with signs such as increased spasticity, urinary incontinence, and autonomic dysreflexia that can be surrogates for pain or infection in persons with SCI/D who may be unable to describe what is happening below their neurological level of injury.25 See Figure 2 for diagnostic workups and best practices to consider26 depending on presentation. In addition to pulmonary/critical care specialists and respiratory therapists, consultation with physical medicine and rehabilitation (PM&R) or SCI medicine specialists may be helpful to assist with interpretation of signs and symptoms in the context of SCI/D and formulation of the differential diagnosis and treatment plan.  4.2 Exposure riskPersons with SCI/D who require home care assistance may be exposed to multiple clinical or personal visitors per day. Therefore, it is critical for ED personnel to take special precautions when evaluating this population due to ease of COVID‐19 transmission in the home. Initial suspicion of COVID‐19 infection may be low if the patient has an atypical presentation of COVID‐19 or mild COVID‐19 with concurrent infection such as urinary tract infection. Figure 3 provides a suggested testing algorithm for this patient population.  Suggested COVID‐19 testing algorithm for persons with SCI/D presenting to ED. HCW, health care worker 4.3 Presentation of respiratory failureThe typical signs of acute respiratory failure such as dyspnea and tachypnea may not be apparent in individuals with neuromuscular weakness associated with SCI/D. In fact, hypotension, severe hypoxemia, hypercarbia, and altered mental status may be the only presenting signs and symptoms. Therefore, despite a relatively "stable" initial presentation, late‐onset ventilatory failure may develop without a previous ventilator dependence. For this reason, early hospitalization is recommended in the setting of acute respiratory tract infections, especially for those with high tetraplegia, SCI/D for >20 years, or age‐related comorbidities.2, 28 4.4 COVID‐19 presentation in SCI/DMuch of the published information on COVID‐19 presentation in persons with SCI/D comes from European SCI specialty and rehabilitation centers. Common presenting symptoms include prolonged fever with varying severity that does not improve with antibiotics, dry cough, fatigue/weakness, dyspnea, increased expectoration, diarrhea, and anosmia.7-11, 29 An international survey of 783 SCI/D clinicians reported the most common presenting symptom of COVID‐19 in patients with SCI/D was fever (86.2%), followed by shortness of breath (62.1%), body aches/worsening pain (20.7%), sweats (20.7%), and chest pain (13.8%). Cough was not reported in this survey. Atypical presentations reported include increased spasticity (10.3%), rigors (6.9%), or no symptoms (6.9%).30 Laboratory and radiographic findings have been similar to COVID‐19 in the general population. Multiple articles described COVID‐19 testing and diagnosis being delayed because fever was initially attributed to urinary tract infection or sepsis.7, 8, 10 A prospective case–cohort study of all SCI patients and healthcare workers in an Italian rehabilitation center found that one‐third of infected SCI patients had asymptomatic COVID‐19 infections compared to 11% of the healthcare workers, despite higher age and prevalence of comorbidities. Clinical courses, treatments, and outcomes were also similar with the exception that 60% of SCI patients required supplemental oxygen compared to 30% of healthcare workers. However, the majority of the SCI patients had incomplete injuries in this study and may not be representative of the entire SCI/D population.9 One asymptomatic individual with new paraplegia, incidentally diagnosed with COVID‐19, developed extensive bilateral lower extremity venous thromboembolism while on chemoprophylaxis and, later, pleuritic chest pain due to pulmonary embolism developed while receiving therapeutic anticoagulation.11 5 TREATMENTMany primary care and emergency clinicians are unfamiliar with both the unique physiology associated with SCI/D31 and the specialized respiratory interventions and techniques to treat individuals with SCI/D. The choice of treatments will depend on the person's neurological level of injury, functional status, and clinical presentation. Persons with SCI/D at or above T6 who present with infectious complaints, regardless of COVID‐19 status, should receive treatments for atelectasis prevention and treatment, because bed rest for illness can worsen baseline lung function. If hypoxemic, oxygen supplementation should be combined with nebulizers and atelectasis treatment. If increased secretions are present, then additional treatments are needed to loosen and mobilize secretions. Those with injuries below T6 may also need cough‐assist due to impairment in expiratory strength and ineffective peak cough flow. Techniques available in the ED may be limited, but ideally would include access to the methods described below (Table 2).
5.1 Hypoxemia managementIn general, independent respiration should be maintained as long as possible. Prolonged invasive ventilation can cause deconditioning of already weak respiratory muscles, extended weaning, and/or long‐term ventilatordependency in persons with SCI/D, particularly those with high tetraplegia. Provision of supplemental oxygen (O2) via low flow nasal cannula to achieve appropriate oxygen saturation should be a first‐line intervention in the setting of hypoxia. High‐flow nasal cannula O2 (HFNO2) should be considered next but requires measures to reduce risk of spreading COVID‐19 containing aerosols. Non‐invasive ventilation with face mask may be poorly tolerated if the patient is unable to adjust their mask due to upper limb paralysis. Those who are already ventilatordependent may require an increase in oxygen percentage compared to the usual. Details of when to choose which ventilation modality is outside the scope of this article; however, frailty scores based on physical function measures should not be used in persons with SCI/D or other neurological deficits to judge who qualifies for advanced care.32 5.2 Atelectasis preventionPersons with diaphragmatic and intercostal weakness due to SCI/D have reduced inspiratory force and impaired ability to activate incentive spirometry or use deep breathing alone to effectively open alveoli. Taking successive deep breaths without exhaling in between, also known as "breath stacking," can be helpful in inflating the lungs fully, but typically takes time to learn to perform effectively. These individuals may require positive expiratory pressure devices or positive‐airway pressure (PAP) treatments to prevent or reverse atelectasis, which require systems modifications to ensure safety (see Safety section). 5.3 Secretion managementFor individuals with SCI/D and significant airway secretions, aggressive pulmonary management techniques are critical for successful treatment of respiratory infections. Equally important is the early involvement of skilled personnel, including certified/registered respiratory therapists. Due to preserved vagal innervation of the bronchial tree and parasympathetic predominance, the use of a combined anticholinergic/beta‐2 adrenergic agonist agent (eg, ipratropium bromide and albuterol sulfate), can be effective in reducing bronchial tone, facilitating removal of secretions, and reducing the level of dyspnea.33 Long‐acting antimuscarinic agents (eg, tiotropium) may also be helpful in the chronic management of these patients. When persons with SCI/D and respiratory infections present with increased expectoration, nasotracheal suctioning, postural percussion, and drainage (chest physiotherapy),34 flutter valves, chest wall oscillation vests, and use of mechanical insufflation/exsufflation devices are useful mechanical methods of secretion clearance. 5.3.1 Airway suctioningNasotracheal suctioning or tracheal suctioning in individuals with tracheostomies are effective methods of removing upper airway secretions. Directional catheters have the capacity to suction both the right and left main stem bronchi and therefore may be much more effective than the use of standard catheters. 5.3.2 Postural percussion/drainagePatient positioning and percussion can be an extremely effective method of secretion clearance and should be performed by qualified personnel including respiratory therapists, physical therapists, and/or trained nurses. Specific physician orders are typically needed for these treatments to be implemented. Full prone positioning to improve lung aeration may be difficult to accomplish in person with SCI/D having joint contractures and/or limited cervical range of motion; modified proning may be required. 5.3.3 Mechanical insufflation–exsufflationThe use of a mechanical insufflator/exsufflator device, also known as a "cough‐assist,"35 has been shown to be extremely useful in patients with SCI/D (Video 1, courtesy of Kessler Foundation) for both removal of secretions and prevention and treatment of atelectasis. Mechanical insufflation–exsufflation was also shown to mobilize a larger volume of secretions than standard chest physiotherapy in adult mechanically ventilated ICU patients.36 This device delivers a positive pressure breath (+20 to +50 cmH2O), which is then switched to negative pressure (−20 to −50 cmH2O) to clear respiratory secretions. Each change from positive to negative pressure represents a cough cycle; a series of 6–10 cycles provides a full treatment. This technique is minimally invasive, can clear secretions not reachable via tracheal suction, and may reduce the need for bronchoscopy to clear mucus plugging.28, 37 Ideally, mechanical insufflation–exsufflation should be combined with one of the manually assisted cough techniques described below to optimize peak cough flow and clearance of secretions during the expiratory phase of the cough cycle. Persons with SCI who are ventilatordependent typically use mechanical insufflation‐exsufflation as part of their regular respiratory treatments and may have their own device. Mechanical insufflation–exsufflation should not be used if there is hemoptysis, pneumothorax, barotrauma, bullous emphysema, nausea, or vomiting. 5.3.4 Manually assisted coughAnother method for secretion clearance is "manual assist" or "quad coughing," that uses 1‐ or 2‐handed abdominal thrust against a closed glottis, similar to a Heimlich maneuver (Video 2, courtesy of Kessler Foundation). This can also be used in combination with the exsufflation phase of mechanical insufflation–exsufflation. This technique can be effective but is contraindicated in persons who have an inferior vena caval filter (IVCF) in place for pulmonary embolus prophylaxis, as the filter may be dislodged and migrate up or through the inferior vena cava.38 Hospital‐wide preparations for the care of individuals with SCI/D including obtaining needed equipment in advance and training respiratory and other medical staff on these techniques are necessary to provide optimal management. 6 SAFETYAlthough the above‐mentioned respiratory techniques benefit persons with SCI/D with heavy secretions and/or atelectasis, in the setting of a highly transmissible virus, an important concern in emergency care settings is the need for extreme caution during aerosol‐generating procedures including bag valve mask ventilation, oropharyngeal suctioning, endotracheal intubation, nebulizer treatment, positive expiratory pressure treatments, mechanical insufflation‐exsufflation, percussive and postural drainage therapies, HFNO2, CPAP and non‐invasive ventilation, sputum induction, bronchoscopy, and resuscitation involving emergency intubation and/or CPR, among others. Therefore, there is a high risk associated with potential of COVID‐19 aerosol or droplet spread if the individual with SCI/D who is undergoing these procedures is not in isolation and/or the health care providers are not wearing appropriate PPE.39 Because individuals with SCI/D may require these aerosol generating procedures to adequately recover, rapid transition to a negative‐pressure room, higher level of care, or an isolated area within the emergency facilities where these procedures can be safely performed should be achieved whenever possible. In addition to the use of PPE for airborne protection, medications should be given via metered dose inhalers with spacers and at a higher dose to reach nebulizer equivalence. If nebulizers, HFNO2, and/or non‐invasive ventilation are required, they should be administered in a negative pressure or single room with contact, droplet, and airborne precautions, which should be maintained for at least 30 minutes after completion of an aerosol‐generating procedure.40-42 Positive expiratory pressure devices should be fitted with an anti‐viral filter. Those with tracheostomies who are not ventilatordependent should wear a heat and moisture exchanger and mask over their nose, mouth, and tracheostomy tube. Tracheostomy tubes should preferentially be cuffed with the cuff inflated during aerosol‐generating procedures.43 Non‐invasive ventilation set‐ups should be converted to a closed system with a dual lumen circuit with heat and moisture exchanger/viral filter attached to exhaust systems, and a non‐vented full‐face mask or helmet over nasal pillows. Mechanical insufflation–exsufflation can be used with an anti‐viral filter, tubing, and tracheostomy adapter attached to filter protecting the machine. Prolonged negative pressure can be maintained afterward while separating the adaptor or face mask from the patient in order to draw aerosols and droplets into the filter. The circuit tubing and filter can then be removed from the mechanical insufflation–exsufflation device and joined into a circle using the trach adapter to avoid leakage of exsufflated materials before disposal. 7 LOGISTICAL CONCERNSMany persons with SCI/D have limited mobility and may arrive in a manual or power wheelchair, and with assistive devices and medical equipment that may also be contaminated. Transfers to examination tables will often require the assistance of additional medical personnel or special equipment, such as lifts. Personal protective equipment (PPE) and airborne precautions must be employed, as well as ensuring patient‐handling equipment is sanitized before admission and upon discharge. It should also be noted that these individuals are also at high risk of pressure injuries, venous thromboembolism, and pulmonary embolism at baseline. Some may already be ventilator‐ or non‐invasive ventilation‐dependent. Additional staff may be required to address unique care needs of patients with SCI/D, such as turning and repositioning, management of neurogenic bowel and bladder, feeding, drinking, and respiratory care during their time in an ED.31 8 DISPOSITIONEven in mild to moderate‐severe cases, due to the high acuity of nursing care required for activities of daily living, neurogenic bowel care, and turning for pressure redistribution, or in the case of pre‐morbid ventilator dependence, the safest location for a person with SCI/D and COVID‐19 may be an intensive care unit or step‐down unit with a higher nurse‐to‐patient ratio than is available on a med‐surg floor. This is particularly true for those who may need specialized air mattresses and frequent turning for pressure injury prevention. Goals of care should be discussed with the patient and family as early as possible to ensure patients' desires are respected particularly as they relate to intubation and code status is appropriate; this may guide disposition. For those appropriate to discharge home (regardless of COVID‐19 diagnosis), social work should be involved to ensure adequate home care is in place. Medical follow‐up post ED visit should ideally occur via telemedicine with home tele‐monitoring when possible to permit patients to remain isolated. Supplemental O2 and monitoring devices such as oximeters should be supplied when needed. For those who are clinically suitable for and agreeable to vaccination, influenza and pneumonia vaccines should be administered prior to discharge.44 9 CONCLUSIONSIn summary, the majority of individuals who become infected with COVID‐19 will develop only mild symptoms. However, individuals with SCI/D are at much higher risk of complications of respiratory infections including the more rapid onset of respiratory failure and death due to respiratory muscle paralysis, other chronic respiratory or cardiac conditions, and chronic immune dysfunction. When necessary, aggressive secretion management techniques and a low threshold for transfer to a higher level of care are warranted. The secretion management techniques described above will likely be required for individuals with high thoracic or cervical SCI/D. It cannot be emphasized enough that the proper personnel including PM&R/SCI medicine, pulmonary/critical care physicians, and respiratory therapists be involved early in the care of individuals with SCI/D to provide optimal respiratory care for all respiratory infections to reduce an otherwise high morbidity and mortality.
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