Schilero Gregory J, Spungen Ann M, Bauman William A, Radulovic Miroslav, Lesser Marvin
Rehabilitation Research and Development Center of Excellence for the Medical Consequences of Spinal Cord Injury, The James J. Peters VA Medical Center, Bronx, NY 10468, USA.
Respir Physiol Neurobiol. 2009 May 15;166(3):129-41. doi: 10.1016/j.resp.2009.04.002. Epub 2009 Apr 9.
Injury to the cervical and upper thoracic spinal cord disrupts function of inspiratory and expiratory muscles, as reflected by reduction in spirometric and lung volume parameters and static mouth pressures. In association, subjects with tetraplegia have decreased chest wall and lung compliance, increased abdominal wall compliance, and rib cage stiffness with paradoxical chest wall movements, all of which contribute to an increase in the work of breathing. Expiratory muscle function is more compromised than inspiratory muscle function among subjects with tetraplegia and high paraplegia, which can result in ineffective cough and propensity to mucus retention and atelectasis. Subjects with tetraplegia also demonstrate heightened vagal activity with reduction in baseline airway caliber, findings attributed to loss of sympathetic innervation to the lungs. Significant increase in airway caliber following inhalation of ipratropium bromide, an anticholinergic agent, suggests that reduction in airway caliber is not due to acquired airway fibrosis stemming from repeated infections or to abnormal hysteresis secondary to chronic inability of subjects to inhale to predicted total lung capacity. Reduced baseline airway caliber possibly explains why subjects with tetraplegia exhibit airway hyperresponsiveness to methacholine and ultrasonically nebulized distilled water. While it has been well demonstrated that bilateral phrenic nerve pacing or stimulation through intramuscular diaphragmatic electrodes improves inspiratory muscle function, it remains unclear if inspiratory muscle training improves pulmonary function. Recent findings suggest that expiratory muscle training, electrical stimulation of expiratory muscles and administration of a long-acting beta(2)-agonist (salmeterol) improve physiological parameters and cough. It is unknown if baseline bronchoconstriction in tetraplegia contributes to respiratory symptoms, of if the chronic administration of a bronchodilator reduces the work of breathing and/or improves respiratory symptoms. Less is known regarding the benefits of treatment of obstructive sleep apnea, despite evidence indicating that the prevalence of this condition in persons with tetraplegia is far greater than that encountered in able-bodied individuals.
颈髓和上胸段脊髓损伤会破坏吸气和呼气肌的功能，这可通过肺量计和肺容积参数以及静态口腔压力的降低反映出来。此外，四肢瘫痪患者的胸壁和肺顺应性降低，腹壁顺应性增加，肋骨胸廓僵硬并伴有矛盾性胸壁运动，所有这些都会导致呼吸功增加。在四肢瘫痪和高位截瘫患者中，呼气肌功能比吸气肌功能受损更严重，这可能导致咳嗽无力以及黏液潴留和肺不张的倾向。四肢瘫痪患者还表现出迷走神经活动增强，基线气道口径减小，这些发现归因于肺部交感神经支配的丧失。吸入抗胆碱能药物异丙托溴铵后气道口径显著增加，这表明气道口径减小并非由于反复感染导致的获得性气道纤维化，也不是由于患者长期无法吸入至预测的肺总量而继发的异常滞后现象。基线气道口径减小可能解释了为什么四肢瘫痪患者对乙酰甲胆碱和超声雾化蒸馏水表现出气道高反应性。虽然已经充分证明双侧膈神经起搏或通过肌内膈肌电极刺激可改善吸气肌功能，但吸气肌训练是否能改善肺功能仍不清楚。最近的研究结果表明，呼气肌训练、呼气肌电刺激以及使用长效β2受体激动剂（沙美特罗）可改善生理参数和咳嗽。目前尚不清楚四肢瘫痪患者的基线支气管收缩是否会导致呼吸道症状，也不清楚长期使用支气管扩张剂是否能减少呼吸功和/或改善呼吸道症状。尽管有证据表明四肢瘫痪患者中阻塞性睡眠呼吸暂停的患病率远高于健全个体，但对于其治疗益处的了解却较少。
