Braces

A brace device is usually recommended as the first line of defense for growing children who have a spinal curvature of 25 to 45 degrees. The mechanical objective of the brace is to hyperextend the spine and to limit forward flexion. It does not reverse the curve. Although a brace does not cure scoliosis (or even improve the condition), it has been shown to prevent the curve progression in more than 90% of patients who wear it. Bracing is not effective in congenital or neuromuscular scoliosis. The therapeutic effects of bracing are also less helpful in infantile and juvenile idiopathic scoliosis. Today a number of braces are available, including the Boston brace, Charleston bending brace, and Milwaukee brace (Figure 24-4). The type of brace is selected according to a the patient’s age, the specific characteristics of the curve, and the willingness of the patient to tolerate a specific brace.

The Boston brace (also called a thoracolumbosacral orthosis [TLSO], a low-profile brace, or an underarm brace) is composed of plastic that is custom-molded to fit the patient’s body. The Boston brace extends from below the breast to the top of the pelvic area in front, and from below the scapula to the coccyx in the back. The Boston brace is typically used for curves in the lumbar (low-back) or thoracolumbar sections of the spine. The Boston brace is worn about 23 hours a day but can be taken off to shower, swim, or engage in sports.

The Charleston bending brace (also known as a part-time brace) is worn only for 8 to 10 hours at night, when the human growth hormone (HGH) level is at its highest. The Charleston bending brace is molded to conform to the patient’s body when the patient bends toward the convexity—or outward bulge—of the curve. This brace works to overcorrect the curve while the patient is asleep. In order for the Charleston brace to be effective, the patient’s curve must be in the 20- to 40-degree range and the apex of the curve needs to be below the level of the scapula. The Charleston bending brace works on the principle that the spine should be bent to grow in the correct direction during the time of day that most growing occurs. Many studies have shown that the Charleston nighttime brace is as effective as the braces that need to be worn for 23 hours.

The Milwaukee brace (also known as a cervicothoracolumbosacral orthosis [CTLSO]) is used for high thoracic (mid-back) curves. The Milwaukee brace is a full-torso brace with a neck ring that serves as a rest for the chin and for the back of the head. It extends from the neck to the pelvis. It consists of a specially contoured plastic pelvic girdle and a neck ring that is connected by metal bars in the front and back of the brace. The metal bars work to extend the length of the torso, and the neck ring keeps the head centered over the pelvis. The Milwaukee brace is used less frequently now that more form-fitting plastic braces are available.

Surgery

In general, surgery is performed to correct unacceptable deformity and prevent further curvature. Surgery is usually recommended in patients who have curvatures of the spine greater than 40 to 50 degrees. As a general rule, even the best surgical techniques do not completely straighten the patient’s spine. Also, surgery often does not improve ventilatory function. Surgical procedures include the following.

Rod Instrumentation

Rod instrumentation involves the insertion of metal rods (e.g., Harrington rod), hooks, screws, and wires to prevent the curve from moving for 3 to 12 months and to allow the fusion to become solid (Figure 24-5). The system provides disruption to the concave side of the spine and compression to the convex side. This action enhances stabilization, reduces any rotational tendency, and applies force to the spine to correct the curvature. Up to 50% improvement of the curvature may occur in patients who elect to have this procedure.

Other Approaches

Some physicians may try electrical stimulation of muscles, chiropractic manipulation, and exercise to treat scoliosis. There is no evidence that any of these procedures will stop the progression of spine curvature. Exercise, however, may improve the patient’s overall health and well-being. Prophylactic deep breathing and coughing (DB&C) exercises are also taught. Their long-term effect is debatable.

Bronchopulmonary Hygiene Therapy Protocol

A number of bronchial hygiene treatment modalities may be used to enhance the mobilization of the excessive bronchial secretions associated with kyphoscoliosis (see Bronchopulmonary Hygiene Therapy Protocol, Protocol 9-2).

Lung Expansion Therapy Protocol

Lung expansion therapy is ordered to offset atelectasis (see Lung Expansion Therapy Protocol, Protocol 9-3).

Physical Examination

Although the patient appeared to be well nourished, the lateral curvature of her spine was twisted significantly to the left. She also demonstrated anterior bending of the thoracic spine. She appeared older than her stated age, and she was in obvious respiratory distress. The patient stated that she was having trouble breathing. Her skin was cyanotic. She had digital clubbing, and her neck veins were distended, especially on the right side. The woman demonstrated a frequent but adequate cough. During each coughing episode she expectorated a moderate amount of thick, yellow sputum.

When the patient generated a strong cough, a large unilateral bulge appeared at the right anterolateral base of her neck, directly posterior to the clavicle. The patient referred to the bulge as her “Dizzy Gillespie pouch.” The doctor thought that the bulge was a result of the severe kyphoscoliosis, which had in turn stretched and weakened the suprapleural membrane that normally restricts and contains the parietal pleura at the apex of the lung. Because of the weakening of the suprapleural membrane, any time the woman performed Valsalva’s maneuver for any reason (e.g., for coughing), the increased intrapleural pressure herniated the suprapleural membrane outward. Despite the odd appearance of the bulge, the doctor did not consider it a serious concern.

The patient’s vital signs were as follows: blood pressure 160/100, heart rate 90 bpm, respiratory rate 18/min, and oral temperature 36.3° C (97.4° F). Palpation revealed a trachea deviated to the right. Dull percussion notes were produced over both lungs; crackles and rhonchi were heard over them as well. There was 2+ pitting edema below both knees. A pulmonary function test (PFT) conducted that morning showed vital capacity (VC), functional residual capacity (FRC), and residual volume (RV) of 45% to 50% of predicted values.

Although the patient’s electrolyte levels were all normal, her hematocrit was 58%, and her hemoglobin level was 18 g%. A chest x-ray examination revealed a severe thoracic and spinal deformity, a mediastinal shift, an enlarged heart with prominent pulmonary artery segments bilaterally, and bilateral infiltrates in the lung bases consistent with pneumonia and atelectasis. The patient’s arterial blood gas values (ABGs) on room air were as follows: pH 7.52, Paco₂ 58, 46, and Pao₂ 49. Her oxygen saturation measured by pulse oximetry (Spo₂) was 88%. The physician requested a respiratory care consultation and stated that mechanical ventilation was not an option at this time per the patient’s request and his knowledge of the case. On the basis of these clinical data, the following SOAP was documented.

Respiratory Assessment and Plan

10 Hours after Admission

The patient’s condition had not improved, and she was transferred to an intensive care unit. The physician had trouble titrating the cardiac drugs and decided to insert a pulmonary artery catheter, a central venous catheter, and an arterial line. Because of the woman’s cardiac problems, several medical students, respiratory therapists, nurses, and doctors were constantly in and out of her room, performing and assisting in various procedures. As a result, working with the patient for any length of time was difficult, and the intensity of respiratory care was less than desirable. Eventually, the patient’s cardiac status stabilized, and the physician requested an update on the woman’s pulmonary condition.

The respiratory therapist working on the pulmonary consultation team found the patient in extreme respiratory distress. She was sitting up in bed, appeared frightened, and stated that she was extremely short of breath. Both of her sisters were in the room; one sister was putting cold towels on the patient’s face while the other sister was holding the patient’s hands. Both sisters were crying softly. The woman’s skin appeared cyanotic, and perspiration was visible on her face. Her neck veins were still distended. She demonstrated a weak, spontaneous cough. Although no sputum was noted, she sounded congested when she coughed. Dull percussion notes, crackles, and rhonchi were still present throughout both lungs. Her vital signs were as follows: blood pressure 180/120, heart rate 130 bpm, respiratory rate 26/min, and rectal temperature 37.8° C (100° F).

Several of the patient’s hemodynamic indices were elevated: CVP, RAP, PA, RVSWI, and PVR.* Her oxygenation indices were as follows: increased and O₂ER and decreased Do₂ and . Her and were normal.^† No recent chest x-ray film was available. Her ABGs on an Fio₂ of 0.28 were as follows: pH 7.57, Paco₂ 49, 44, and Pao₂ 43. Her Spo₂ was 87%. On the basis of these clinical data, the following SOAP was documented.

Respiratory Assessment and Plan

24 Hours after Admission

At this time the respiratory care practitioner found the patient watching the morning news on television with her two sisters. The woman was situated in a semi-Fowler’s position eating the last few bites of her breakfast. The patient stated that she felt “so much better” and that “finally I have enough wind to eat some food.”

Although her skin still appeared cyanotic, she did not look as ill as she had the day before. On request, she produced a strong cough and expectorated a small amount of white sputum. Her vital signs were as follows: blood pressure 140/85, heart rate 83 bpm, respiratory rate 14/min, and temperature normal. Chest assessment findings demonstrated crackles, rhonchi, and dull percussion notes over both lung fields. The rhonchi were less intense, however, than they had been the day before.

Although the patient’s hemodynamic and oxygenation indices were better than they had been the day before, she still had room for improvement. Her hemodynamic parameters, still abnormal, revealed an elevated CVP, RAP, PA, RVSWI, and PVR. All other hemodynamic indices were normal. Her oxygenation indices still showed an increased and O₂ER and a decreased Do₂ and . Her and were normal. The patient’s chest x-ray film, taken earlier that morning, showed some clearing of the pneumonia and atelectasis described on admission. Her ABGs on an Fio₂ of 0.35 were as follows: pH 7.45, Paco₂ 73, 49, and Pao₂ 68. Her Spo₂ was 94%. On the basis of these clinical data, the following SOAP was recorded.

Respiratory Assessment and Plan

Discussion

This case provides an excessive amount of extraneous historical and personal material. This was done to demonstrate, in part, how the respiratory care worker must cut through to the core of the case in the SOAP notes. Care of the patient with symptomatic advanced kyphoscoliosis consists of (1) treatment of the conditions that can complicate it (e.g., bronchitis, pneumonia, atelectasis, pleural effusion) and (2) treatment of the underlying condition itself.

In the first assessment, the SOAP documented excessive bronchial secretions and a likely infection because of the thick yellow sputum and recent history. The patient had a good ability to mobilize the secretions as charted by a strong cough. The chest radiograph confirmed atelectasis and consolidation. Although acute alveolar hyperventilation on top of chronic ventilatory failure was present, the possibility of impending ventilatory failure was real. The therapist’s decision to oxygenate the patient with a low Fio₂ (0.28), administer bronchial hygiene and mucolytic aerosols, and be prepared for ventilator support were all appropriate. The patient’s secondary polycythemia and cor pulmonale would have been expected to improve as overall oxygenation improved, although this improvement could take some time. The digital clubbing and cor pulmonale itself suggested that the hypoxemia was long-standing.

At the time of the second assessment, the intensity of the patient’s respiratory distress was increasing. This was verified by the continued observation of the high pulse and respiratory rate, excessive bronchial secretions, dull percussion notes, acute alveolar hyperventilation on top of chronic ventilatory failure with moderate to severe hypoxemia, atelectasis on the chest x-ray film, and poor response to oxygen therapy. Undoubtedly, impending ventilatory failure was more likely. Atelectasis is often refractory to oxygen therapy, suggesting that therapeutic bronchoscopy might have been worthwhile. At that point in time, the up-regulation of the Oxygen Therapy Protocol (Protocol 9-1), Bronchopulmonary Hygiene Therapy Protocol (Protocol 9-2), and Aerosolized Medication Protocol (Protocol 9-4) were all justified by the clinical indicators.

In the last assessment, the clinical manifestations associated with the patient’s disorder had all decreased substantially. The down-regulation of the Oxygen Therapy Protocol, Bronchopulmonary Hygiene Therapy Protocol, and Aerosolized Medication Protocol was appropriate. The recommendation of pulmonary rehabilitation and family education was appropriately considered. The ABGs were most likely at the patient’s baseline level, because the pH was in the normal range. In fact, according to the pH (normal but on the alkalotic side of normal) the patient’s usual Paco₂ was most likely somewhat higher than the last assessment value.

Comparison with baseline values (if available) would be appropriate at such a time, and consideration of cuirass ventilation, a rocking bed, or positive expiratory pressure (PEP) to assist nocturnal ventilation might be in order. Oxygenation easily can be assessed by oximetry at home. This case is an excellent example of the value of hemodynamic monitoring (specifically the normal PCWP) in differentiating left-sided from right-sided cardiac failure.