E • COMPLICATIONS
195
paper on 'Respiratory and Metabolic Management in Acute Tetraplegia' have given a
detailed description of the synthetic amino-acid composition of the two Aminofusion
Solutions commonly used: Aminofusion 850 and Aminofusion forte and also of the 10-20
per cent Fructose solution combined with 4-6 per cent v/v Alcohol used for intravenous
transfusions in acute tetraplegia. The repeated assessment of the electrolytes is essential.
In particular, potassium deficit which delays the recovery of smooth muscle function
(Marks, 1950) must be restored (see also chapter on Renal Deficiency).
(5) Airway obstruction—Atelectasis
A most serious effect of the paralysis of the intercostals and abdominals is the inter
ference with the cough reflex, as the tetraplegic is unable or has greatest difficulty to
expectorate collection of sputum. It may be stressed that this is not only an immediate
danger for air-way obstruction in the acute stages but also later, should the tetraplegic
develop a bronchitis or other infection at any level of his respiratory tract. In the acute
stages, the fluid dysbalance increases the secretion which is accumulated in the bron
chioles and this is enhanced by keeping the patient in supine and head up position. The
resulting obstruction of the airways leads to atelectasis. As a result the mediastinum will
be pulled to the side of the collapsed lung, as shown in the X-ray, due to the difference
in the intrathoracic pressure. Moreover, the diaphragm is pulled upwards, thus increas
ing the respiratory distress. If the bronchial obstruction can be relieved by immediate
suction through an endotracheal tube, the atelectasis is reversible. It is obvious that the
airways must be kept clear by assisted respiration (see chapter on Physiotherapy) and by
liquifying the bronchial, tracheal and pharyngeal secretion by steam inhalation. For some
time, we have been using the Marshall-Spalding blower humidifier. This apparatus,
used in conjunction with a tracheostomy box, provides a steady stream ofwarm saturated
air or oxygen thus preventing crusting in the air-ways. A dust filter is fitted at the air-
intake to the blower to ensure a clean air intake by the patient. This unit can be incor
porated in the East-Radcliffe Respirator which we have used at Stoke Mandeville for
some years. Another humidifier is the Devill-Bliss nebulizer, marketed by the British
Oxygen Company. According to Sara (1965), adequate humidification at the optimum
temperature can be best achieved by nebulization of warmed water, and the Puritan
nebulizer incorporating a heating coil and a thermostat has been found satisfactory and
can be used in conjunction with the Bird intermittent positive pressure respirator
(Cheshire, 1964; Cheshire & Coats, 1966). We have not used sodium bicarbonate or
proteolytic enzymes (Taylor, 1960; Bremner, 1962), as we were satisfied with postural
drainage and humidification by nebulization. A new drug with mucolytic action is
Bisolvon (Bromhexine hydrochloride, Boehringer), which has proved effective in decreas
ing sputum viscosity, especially if signs of bronchitis are present. It can be given together
with tetracycline (8 mg) as Bisolvomycin in capsules of 250 mg (Burgi, 1964; Hamilton
et al.,
1970).
Bronchodilator drugs can be of great relief to the patient with respiratory distress.
Adrenaline, which is an effective bronchodilator, can be administered by inhalation with
a nebulizer containing i per cent solution of adrenaline or adrenaline and atropine
