Spinal cord injury can have profound effects on breathing. Some individuals must rely on a mechanical ventilator for the long term, and this need for a ventilator twenty-four hours a day can be a tremendous burden, because the ventilator must be kept available and in working order at all times.Some people have sufficient strength in their breathing muscles to manage without the ventilator for short periods of time, and other devices can sometimes be used to extend this period off the ventilator. One such device is the implantable phrenic nerve stimulator. If the phrenic nerve is undamaged, stimulating the nerve electrically causes the diaphragm to contract. By careful control of the stimulation, the diaphragm can contract with enough strength to fill the lungs with air, as in normal breathing.An electrical stimulator can sometimes be implanted in the body surgically. Its stimulation of the phrenic nerves then produces artificial breathing. This technique has several problems, however. First, it can be used only with certain types of spinal cord injury. Second, it rarely works full-time; rather, it provides part-time relief from the mechanical ventilator. Third, its effectiveness may be only temporary, slowly decreasing over several years as scarring develops around the nerve, making it resistant to stimulation. Fourth, the device may fail unexpectedly, so a mechanical ventilator must be available in case of emergency. This greatly reduces the benefit of the phrenic nerve stimulator: a primary reason for developing this device was to avoid the inconvenience of keeping a mechanical ventilator available at all times. Still, the potential benefits of artificial breathing are great, and several laboratories are working on methods to increase the effectiveness and reliability of the electrical stimulator.An additional problem with breathing after spinal cord injury is weakness of the muscles of expiration (breathing out). The key muscles of expiration are the abdominal and chest muscles, which get their nerve supply from the thoracic levels of the spinal cord. Anyone with a spinal cord lesion above T2 is likely to have some weakness of expiration, even if the diaphragm is working well. Breathing is certainly possible without expiratory muscles, but we need these muscles to exhale forcefully, to shout, and most importantly, to cough. Coughing is essential for keeping the lungs clear and preventing infection, especially pneumonia. Patients with cervical spinal cord injury are highly vulnerable to respiratory tract infections because they cannot cough.”Quad coughing” is a very effective method of clearing the lungs, but it requires another individual’s assistance. Although no method is yet available for a person with quadriplegia to cough effectively without assistance, researchers are working on several methods for independent artificial coughing. The first is a mechanical method, such as a specially made body jacket that squeezes the abdomen and chest to help generate a cough. The second method is electrical stimulation of the expiratory muscles, causing muscle contraction and forcing air out of the chest. These methods for independent artificial coughing are not yet available for clinical use.Another method for artificial coughing uses a mechanical device that has air pumps for exsufflation and insufflation. The device first blows air into the lungs (exsufflation), and then forcefully sucks it out of the lungs (insufflation) at high velocity. Some patients can learn to use this device for independent artificial coughing. Further research is needed to determine whether this is more effective at clearing the lungs than routine quad coughing.
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High blood pressure may increase the thickness of heart muscle and reduce coronary circulation.
• What is the normal blood pressure?
Blood pressure is measured with two readings, systolic and diastolic and the measurement is mm Hg.
Blood Pressure Systolic/Diastolic (mm Hg)
Normal Blood Pressure 120/80
High Normal 130-139/85-89
Stage I Hypertension 140-159/90-99
Stage II and III >160/>100
To control the blood pressure, one needs to follow certain life style modifications like diet, exercise, yoga and meditation, however in stages I – III one may need drug therapy along with lifestyle measures, depending upon the other risk factors involved. Maintenance of weight with low-fat diet and salt restriction is mandatory. Other factors that could play role in hypertension are excessive sodium, saturated fats, coffee, diet low in potassium and calcium. The studies have shown that salt restriction is important to lower the blood pressure, and for patients with hypertension lowering of dietary salt is very important.
DASH Diet (Dietary approaches to stop hypertension)
Blood pressure reduces with diet low in total fat, low saturated fat, low cholesterol, and low-fat milk and milk products, and rich in fruits and vegetables. So DASH diet includes, whole grains, fish, nuts, vegetables and fruits. DASH diet has reduced amounts of fat, red meat, sweets, refined carbohydrates, sugared beverages. It is rich in potassium, calcium, magnesium, proteins and fibre. Studies have shown that lower the sodium, lower is the blood pressure.
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Cardiovascular diseases account for an appreciable proportion of total morbidity and mortality in adults throughout the world. Nutritional factors play an important and parallel role in the etiology and management along with some environmental factors like physical exercise, cigarette smoking, tobacco chewing and type of personality. Other factors associated, of course, are family history, overweight, hypertension, diabetes and stress of life.
Incidence of obesity, diabetes and CVD is increasing and at present obesity is present in 14% of rural population and 27% of urban population, as urban population is more prosperous and sedentary, along with refined food eating patterns. Hypertension (high blood pressure) is 5% in rural population and 5-15% in urban population. Diabetes is 7-12% and heart disease is 6-10% and all these conditions are interrelated.
Risk Factors
1. Family history
People who already have the disease in their family are more prone to getting heart disease.
2. Obesity
Obesity or excessive weight is the primary cause of most of the illnesses, it has a major role to play in heart disease. Obese people or overweight people are more prone to heart disease. There is no clear definition of desirable or ideal body weight, however, a simple way of finding out is the ratio of weight and height termed body mass index (BMI); weight in kg and height in m2
People who have their BMI between 23 and 25 are called overweight and all those who have their BMI>25 are called obese. Normal BMI being between 18.5 and 23.
More than the general accumulation, distribution of fat around the abdomen is considered more harmful than the fat on the hips, therefore waist/hip ratio (WHR) is a better predictor of chronic diseases. Normal WHR is 0.85 for female and 0.90 for males, waist has be measured at the naval point and hips at the maximum level.
3. Hypertension or high blood pressure
Is also a risk factor. Coronary heart disease (CHD) has a striking relationship with systolic and diastolic blood pressure and reduction of weight and alcohol can lower blood pressure.
4. Diabetes
Diabetics are more prone to CVD as compared to non-diabetics, therefore, it is important for all diabetics to keep their sugar under good control so that they can delay or prevent getting coronary artery disease.
5. Age
Age is also a factor and men >45 years and women >55 years are more prone to getting a coronary disease.
6. Smoking and tobacco
Cigarette smoking and tobacco chewing are both bad. Tobacco is injurious to heart and health in all forms, whether in chewable or non-chewable such as cigarette or cigars. Coronary artery disease has been seen in 80% of the smokers. Inhaling nicotine, carbon monoxide and various other pollutants narrow the coronary arteries, thus reducing the blood flow to the heart muscle.
7. Lack of physical activity
Sedentary and unexercised people are more prone to CVD. Physical activity or exercise is a recommendation.
8. Blood lipids or fats in the blood
• The risk is more when
Plasma total cholesterol > 200 mg/dl
Plasma HDL cholesterol < 35/dl
Plasma LDL cholesterol > 135 mg/dl
With CVD
• Plasma TG > 150 mg/dl
• Total cholesterol: HDL ratio > 5
• Elevated homocysteine levels
These are the levels beyond which the risk factor increases.
9. What is blood cholesterol?
High cholesterol is a serious problem for heart disease. The higher the blood cholesterol, the greater is the risk of getting the heart disease. Blood cholesterol has different fractions; one is called low density lipoprotein (LDL), the bad cholesterol and the other is called the higher density lipoprotein (HDL), the good cholesterol. LDL gets deposited in the arteries, therefore more the LDL in the blood, greater is the risk of heart disease. On the other hand, HDL the good cholesterol helps us to get rid of the bad cholesterol, so higher the HDL better it is. Similarly, we also have triglycerides (TG) in the blood, which is also a risk factor just like cholesterol.
Factors you can control Factors you cannot control
1. Cigarette smoking Age (55 years for men and 45 years for women)
2. High blood cholesterol Family history of early heart disease (heart attack or
especially LDL sudden death)
3. Low HDL Heredity.
4. High blood pressure
5. Diabetes
6. Obesity/overweight
7. Physical activity.
10. Dyslipidaemia
Elevated serum cholesterol and triglycerides are the strongest risk factors of CVD. When the person has blood lipid levels more than the mentioned limit, it is termed dyslipidaemia.
The cholesterol lowering will reduce the major risk of coronary event. Treatment of dyslipidaemia is mandatory for primary and secondary prevention of CVD.
11. Hypertriglyceridaemia
High triglycerides in the blood are termed hypertriglyceridaemia.
12. Apolipoprotein (A)
The factor in combination with low levels of HDL and elevated triglycerides results in the formation of small dense LDL, which increases the risk of CVD.
13. Elevated homocysteine
Having high homocysteine in blood is also a risk factor for CVD.
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