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·TREATMENT OF ACUTE POLIOMYELITIS

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·MV
Second Edition
TREATMENT OF
ACUTE POLIOMYELITIS
WILLIAM A. SPENCER, M.D.
Edited by
From the
Departments of Pediatrics, Physiology, and Physical Medicine
Baylor University, College of Medicine
Southwestern Poliomyelitis Respiratory Center
Jefferson Davis Hospital
In Cooperation IV'ith
The National Foundation for Infantile Paralysis, Inc
THOMA
BOK
er
LEAD
CHARLES C THOMAS • PUBLISHER
Sprmgfield · Illinois • US A.

·CHARLES C THOMAS PUBLISHER
BANNERSTONE HOUSE
301-327 East Lawrence Avenue, Springfield, Illinois, USA.
Published simultaneously in the British Commonu ealth of Nations by
BLACKWELL SCIENTIFIC PUBLICATIONS, LTD, OXFORD, ENGLAND
Published simultaneously in Canada by
TELE KYERSON PRESS, TORONTO
This monograph is protected by copyright. No
part of it may be reproduced in any manner
without written permission from the publisher.
PUBLISHER
Copyright 1954, by CHARLES C THOMAS
First Edition, 1954
Second Edition, 1954
Printed in the United States of America

·CONTRIBUTORS V WILLIAM A. SPENCER, B.S, MD: Medical Director, Southwestern Poliomyelitis Respiratory Center. Assistant Professor of Physiology and Instructor in Pediatrics, Baylor University College of Medicine. ROBERT R. JACKSON, M D.: Assistant Medical Director, Southwestern Poliomychitis Respiratory Center, Instructor in Pediatrics and Physiology, Baylor University College of Medicine. EVA-MARIE PFEIFFER, M D.: Mcdical Director, Wolf Home Poliomyelitis Rehabilitation Unit. Instructor in Pediatrics, Baylor University College of Medicine. JACK B. MOHNEY, B S., M S., M.D.: Associate Professor and Chairman, Dcpartment of Physical Medicine and Rehabilitation, Baylor University Col. lege of Medicine. Physiatrist Consultant, Southwestern Poliomyelitis Respiratory Center. RUSSELL J BLATTNER, A.B., M.D, FA.A P.: Professor and Chairman, Department of Pediatrics, Baylor University College of Medicine HEBBEL E HOFF, AB, B.S., MA., PH.D., MD: Professor and Chairman, Department of Physiology, Baylor University College of Medicine. CW. DAESCIINER, A B., MD, F.A A.P.: Assistant Professor of Pediatrics, Baylor University College of Medicine Metabolic Consultant, Southwestern Poliomyelitis Respiratory Center Orto VOGEL, M.D. Assistant Clinical Fellow-Cardiology, Southwestern Poliomyelitis Respiratory Center. PAUL R. HARRINCTON, A.B, MD, F.A BOS.. Associate Professor of Orthopedic Surgery, Baylor University College of Medicine Orthopedic Consultant, Southwestern Poliomyelitis Respiratory Center. JACK RHILD, AB, M.D, FAAP: Clinical Associate Professor of Pediatrics, Baylor University College of Medicine. Pediatric Consultant, Southwestern Poliomyelitis Respiratory Center, HIENBENT HARRIS, AB, MD, FACS Professor and Chairman, Depart. ment of Otolaryngology, Baylor University College of Medicine Otolaryngology Consultant, Southwestern Poliomyelitis Respiratory Center. WILLIAM S FIELDS, A B, MD, FAAN: Professor of Neurology, Baylor University College of Medicine Neurology Consultant, Southwestem Poliomyelitis Respiratory Center FRED MI TAYLOR, A B, MD, F.A A.P. Associate Professor of Pediatrics, Baylor Unitersity College of Medicine FLORENCE M lleys, AB, MS, PHD Assistant Professor of Pediatrics, Baylor University College of Medicine. LAURA K. SMIT, AB, RP.T. Superessor of Physical Therapy-Education, Southwestern Poliomyelitis Respiratory Center.

·vi TREATAIENT OF ACUTE POLIOXIYELITIS Editu A. ROBINSON, R.N., B.S.: Supervisor of Nursing Education, South western Poliomyelitis Respiratory Center. MAURINE B. MITCHELL, B.A., M.A., M.S.V.: Director, Medical Social Service Department, Southwestern Poliomyelitis Respiratory Center and Wolff Home Poliomyelitis Rehabilitation Unit. ALARY STEVENS, R. N.: Supervisor of Nursing, Southwestern Poliomyelitis . Respiratory Center. LILLIAN PRUDEN, R.N.: Supervisor of Nursing, Wolf Home Poliomyelitis Rchabilitation Unit. CHARLOTTE D. BONE, O.T.R.: Supervisor of Occupational Therapy, Southwestern Poliomyelitis Respiratory Center. WALIE MI. VERNLAUD, A.B., M.A., Ed.D.: Director of Psychological Services, Southwestern Poliomyelitis Respiratory Center, Psychologist, Department of Pediatrics, Baylor University College of Medicinc, Associate Professor, Department of Pediatrics, University of Texas-Medical Branch. DOROTIY M. IDDINCS, A B., R.P.T.: Supervisor of Physical Therapy, Southwestern Poliomyclitis Respiratory Center. C. V. PARKER: Chief Engincer, Jefferson Davis Hospital. Grateful acknowledgment is made to the following personnel of the Respiratory Center who assisted in the preparation of the syllabus: Miss Virginia Fletcher, Mrs. Augusta Clark, Miss Johnnie Brock, Mr. John C. Miller, Mr. Richard C. Mathuas, and Mrs. Billye Bailey.

·FOREWORD TIS SYLLABUS is neither the first nor the last word in the treatment poliomyelitis. The frontispiece suggests that poliomyelitis has been recog ognized for as long as 3250 years. Principles enunciated here reflect our OWE experience during four years of almost exclusive attention to the management of acute and chronic poliomyelitis and are synthesized with the contributions of others who have dealt with this problem. The material was prepared as a teaching aid to demonstrate the many inter-related facets of modern poliomyelitis care, which indeed follow the general principles of comprehensive medical management. As a compendium it represents aspects of treatment which have evolved from the cooperative endeavors of the many medical disciplines represented in a respiratory center. The concise format is designed to emphasize the positive and practical considerations in the care of the patient. As a synthesis of experience in poliomyelitis care it necessarily reflects the local practices of those brought together to fulfill the broad needs of the patient. These center around expectant treatment as determined by premomtory signs. It is hoped that it will have some usefulness in guiding and encouraging that careful individualization which is the constant requirement of medical practice The editor expresses sincere appreciation to all who collaborated in the preparation of the syllabus and especially to Doctors Hebbel E. Hoff and Russell J. Blattner for invaluable guidance and encouragement. Miss Laura Smith deserves special acknowledgment for her months of diligent effort in assisting the editor in collecting, preparing and assembling the syllabus WILLIAM A SPENCER, M.D. August 15, 1954 Houston, Texas

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·Contributors Foreword CONTENTS 3 4 5 8 7 8 9 PARTI Possible Transmission of Poliomyelitis Ultimate Diagnosis of 1000 Suspected Poliomyeltis Admissions Final Diagnosis of Non-Poliomyelitis Admissions Ulumate Diagnosis of 914 Poliomyelitis Cases Diagnostic Criteria for Acute Poliomyelitis, Early Treatment of Uncomplicated Poliomyelitis Signs and Symptoms of Serious Poliomyelitis Frequency of Serious Complications in 246 Severely Il Poliomyelitis Patients. Signs and Symptoms of Respiratory Muscle Paralysis Signs of Progressing Respiratory Impairment Initial Adjustment of the Respirator Guides to the Use of the Respirator in the Acute Phase Rate and Pressure Adjustment of the Respirator Evidence for Satısfactory Adjustment of Respirator Pressure and Cycling Rate Conditions Complicating the Use of Artificial Respiration Signs of Progressive Asphyxia Laboratory Guides to Respiratory Management Signs and Symptoms of Impairment of Swallowing Immediate Measures in the Treatment of Impaired Swallowing Contraindications to Continuation of Conservative Treatment of Impaired Swallowing Signs of Failure of Conservative Treatment of Impaired Swallowing Indications for Tracheotomy Advantages and Disadvantages of Tracheotomy Signs of Central Disturbance of Respiratory Regulation Treatment of Central Disturbances of Respiratory Regulation Cardiovascular and Autonomic Abnormalities Circulatory and Other Conditions Requiring Immediate Treatment Cardiovascular Abnormalities of Minor Significance Signs and Symptoms of Pulmonary Complications Prevention of Pulmonary Complications Treatment of Pulmonary Complications Orygen Therapy Metabolic Disturbances in Acute Poliomyelitis 10 11 12 13 15 18 18 19 21 20 24 26 27 23 30 31 32 35 37 39 39 40 41 ·Treatment of Metabolic Disturbances in Acute Poliomyelitis Diet and Tube Feeding Urinary Bladder Retention Nursing Care-Acute Poliomyelitis–Routine Orders (S.W.P.R.C.) Nursing Care-Hygiene Equipment Necessary for Tracheotomy Tray Nursing Care of the Tracheotomy Significant Social and Emotional Factors in Poliomyelitis Psychological Factors 43 44 46 47 49 50 51 52 54 PART II POST-ACUTE AND CONVALESCENT TREATMENT OF POLIOMYELITIS Important considerations in the Convalescent Phase of Treatment Theoretical Components of Body Function in Health Theoretical Components of Body Function in Disease Theoretical Components of Body Function in Recovery from Disease Principles of Convalescent Care Causes of Muscular Weakness in Poliomyelitzs General Plan of Post-Acute and Convalescent Treatment Symptomatic Management of Muscular Discomfort Body Positioning of the Poliomyelitis Patient Range of Motion Manual Muscle Testing Procedures Used to Increase Muscle Strength and Coordination Stretching Assistive and Supportive Apparatus Increasing Functional Ability Orthopedic Surgery-General Considerations in Poliomyelitis Treatment of Metabolic Problems in Post-Acute Poliomyelitis Management of Nephrolithiasis Beginning IVeaning from Respiratory Assistance of the Immediate Post-Acute Patient Methods of Evaluating the Respiratory Patient for the Progressive Weaning and Rehabilitation Program Progressive Rehabilitation of the Convalescent Respirator Patient Physical and Occupational Therapy Progression in Respiratory Poliomyelitis Functional Activities for the Severely Involved Respirator Patient Early Evidence of Injudicious Respiratory Programming- Excessive Activity Signs and Symptoms of Severe Stress Removal of the Tracheotomy Tube 55 56 57 58 59 60 62 63 64 65 66 69 70 71 72 73 75 776 78 79 81 82 85 87 88 89 ·. Nursing Care-Post-Acute Respiratory Poliomyelitis-Routine Orders (SW.P.R C.) Management of Constipation and impaction Home Care Planning for the Respiratory Patient Discharge Planning 90 93 94 96 PART III . 98 99 100 102 101 107 APPENDIX Pulmonary Compartments--Vital Capacity Minimal Observed Vital Capacity Values in Adults and Children Ventilatory Measurements-Tidal Volumes Special Considerations in Water and Salt Loss in Poliomyelitis Correction and Maintenance of Salt and Water Needs Breathing Exercises Glossopharyngeal Breathing Vacuum Cleaner Assisted Cough for Respirator Patients Joint Range of Motion General Evaluation of Muscle Strength Respiratory Equipment Ceneral Considerations in Maintenance of Respiratory Equipment Operation of Respiratory Equpment-Tank Respirator Specifications of Commonly Used Respiratory Equipment 110 112 114 117 123 125 128 PART IV Bibliography 133

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·TREATMENT OF ACUTE POLIOMYELITIS ·ULTIMATE DIAGNOSIS OF 1000 SUSPECTED POLIOMYELITIS ADMISSIONS S.W.P.R.C. 1950-1954 Non-Poliomyelitis Non-Paralytic Poliomyelitis Paralytic Poliomyelitis Number Per Cent 151 15% 258 26% 591 59% Total .... 1000 100% • Diagnosis not changed on 1 year follow-up All who have had experience with infections caused by the poliomyelitis virus are aware of the many complexities encountered in diagnosing the disease. These are greatly enhanced by pressures exerted on the physician by an apprehensive public. However, there is no infallible method available at the present time for making a definite diagnosis of poliomyeltis during the earlier phases of the infection Diseases most commonly simulating poliomyelitis include: The various encephalitides and meningitides, infectious neuronitis, cerebral and spinal neoplasms and abscesses, pulmonary infections, specific diseases of muscles, bones joints, and acute emotional disturbances such as hysteria. The list of specific diseases which can be confused with acute poliomyelitis is long and varied. Nonetheless, this protean disease has certain clinical features which are sufficiently consistent to merit emphasis.

·5 FINAL DIAGNOSIS OF NON-POLIOMYELITIS ADMISSIONS TOTAL 151 78 CNS INFECTIONS 26 MISCELLANEOUS INFECTIONS 27 encephalitis etiol. not det. 6 mumps encephalitis. pneumonia, 1 pertussis encephalitis 2 influenza, I post-vaccinal encephalitis 2 U.R.I. I herpes zoster encephalitis. 2 roseola. 1 post-rabies vaccinal encephalitis. 3 otitis media. 10 pyogenic meningitis. 1 tonsiltis. 5 lymphocytic choriomeningitis. 1 sinus infection. 3 tuberculous meningitis. gastroententis. 1 herpes simplex meningo- 1 infectious mononucleosis. encephalitis infection etiol unknown, 1 arachnoiditis. I serum sickness 4 cerebral abscess I acute pyogenic cerebritis 1 CNS syphils. 11 infectious neuronitis 3 Coxsackie virus infection? 31 OTHER 1 tetanus. 2 rheumatoid arthritis. 16 OTHER CNS DISORDERS 1 arthralgia 4 brain tumor. I rheumatic fever. 4 cerebral vascular accident. 1 sprain-lumbar muscles 1 Idiopathic epilepsy. I trauna-left an. I infantile hemiplegia. I neuropathy. 1 acute cerebellar ataria. I cervical adenopathy. 2 acute meningo-myelitis etiol. I tenosynovitis. undet 1 spinal cord neoplasm. 7 hysteria. I general muscular rigidity. I angioneurotic edema 1 post-partum post L. P headache. 12 not determined. 2 infantile scury. The above diagnoses were those made on patients admitted to the hos. pital following outpatient admission screening in most instances. Careful historical and physical esamination frequently eliminated many non-polio admissions ·6 ULTIMATE DIAGNOSIS OF 944 POLIOMYELITIS CASES S.VY.P.R.C. 1950-1954 No. Patients Non-Paralytic 267 Paralytic TOTAL POLIOMYELITIS 914 Per Cent 28 72 677 100 Spinal Type Bulbar Bulbospinal TOTAL PARALYTIC 477 69 131 71 10 19 677 100 677 100 Paralytic Poliomyelitis Severe Poliomyelitis 246 36 246 100 Severe Poliomyelitas *Fatal Poliomyelitis 45 18 Including DOA's The percentage of “reported" poliomyektis patients with the non-paralytic form of the disease varies from 30 to 60 per cent. Because of this, comparative mortality figures are valueless if non-paralytic patients are included. The actual incidence of non-paralytic disease in a hospital experience depends upon: variability of the disease, diagnostic criteria, admission policy and thoroughoess of the follow-up evaluation. The Jow incidence of non-paralytic disease in this example is a result of admission screening and the centralization of severely involved patients in an acute treatment center. Severe disease is not necessanly synonymous with "bulbar poliomyelitis if all of the conditions posing a serious threat to hfe are included.

·7 DIAGNOSTIC CRITERIA FOR ACUTE POLIOMYELITIS . 1 . SUGGESTIVE • Fever of moderate degree without coryza, cough or diarrhes. Meningismus-stiff and painful neck and back-inability to flex spine which is “poker-like." Head drops back when shoulders are lifted "Tripod" sitting position. Headache. Malaise out of proportion to physical findings. Vomiting Muscle pain and tenderness-especially trunk and hamstrings (not unilateral). • Reflexes obtainable, occasionally hyperactive. CONFIRMATORY • Flaccid muscle paralysis often asymmetrical and regional with involvement of several muscles of the same segment. • Absent tendon reflexes in the affected areas. • Abnormal spinal fluid: cells more than 10 usually less than 500/cu. mm; polys early, lymphs later, Pandy positive, slight to moderate increase in protein content; normal sugar content; no bacteria on smear and culture (less 5% of CSF normal in acute phase), POSITIVE Isolation of vinis in the presence of the above. Increasing antibody titer during the course of the discasc. . . A definite program of management is indicated by the acceptance of poliomyelitis as a probable diagnosis. It is extremely important to establish the course of the disease by careful observation. The detection or anticipation of impairment of those body functions that determine survival de pends upon such evaluations of the patient. Beware of exhausting the patient just for the purpose of claborating the diagnosis ·8 EARLY TREATMENT OF UNCOMPLICATED POLIOMYELITIS . • Careful constant observation of those patients with signs of serious poliomyelitis. Supplement observation with careful measurement of the vital signs of temperature, pulse, respirations and blood pressure. Maximum rest without sedation, • Combat dehydration and maintain fluid and electrolyte balance. Careful comfortable positioning of the patient with gentle physi. cal measures to relieve pain or discomfort and to prevent deformities. • Reserve the use of antibiotics and chemotherapeutic agents for secondary infection and pulmonary complications. Strict bed rest for 7 to 10 days. . . Refinements and alterations in this program of management are directed by the degree of involvement and the presence of complicating factors such as dehydration and nutritional disturbances. There is no specific therapeutic agent which has been demonstrated to be capable of altering the course of motor-neurone involvement. It appears likely, that undue travel, exertional fatigue, profound and untreated metabolic disturbances, and impaired respiration may seriously compromise the acutely ill patient.

·9 SIGNS AND SYMPTOMS OF SERIOUS POLIOMYELITIS . . . . SUGGESTIVE History of unusual physical exhaustion during prodromal phase. Pregnancy. Rapid onset and progression of paralysis. Paralytic involvement of the shoulder girdle, • Involvement of any cranial Derve. "Toric." appearance with flushed facies-perioral pallor and conjunctival suffusion Irritability-restlessness-fitful sleep-apprehension. Higher temperature elevation without marked diurnal variatron, Tachycardia. Moderate hypertension. Nystagmoid-jerky ocular movements on lateral gaze and fixation (opsoclonia). Change in sensorium to severe anxiety-lethargy-confusion and unconsciousness. CONFIRMATORY Respiratory muscle paralysis. Impairment of the swallowing mechanism. Disturbances of vital autonomic and respiratory regulation. Pulmonary complications . . . . Recognition of serious poliomyelitis is not necessarily clear cut in the early stages of the infection. An apparently mild illness may progress rapidly to serious proportions. For this reason continuous observation of all patients with any of the suggestive signs and symptoms is imperative. Do not mask crucial symptoms or depress protective reflcres by sedation. Therapeutic manipulations such as application of hot packs are more exhausting than beneficial in such cases at this stage.

·FREQUENCY OF SERIOUS COMPLICATIONS IN 246 SEVERELY ILL POLIOMYELITIS PATIENTS S.W.P.R.C. 1950-1954 % Patients Incidence 100 246 180 132 73 53 50 Complication Total severely ill patients Respiratory muscle paralysis Impairment of swallowing Disturbances of circulatory and respiratory regulation Pulmonary edema 4 125 9 • Combinations of these complications in a single patient are not indicated in the above chart The incidence of severe poliomyelitis varies from epidemic to epidemic. This is probably a result of differences in the virus and in host susceptibility. The occurrence of serious complications in 36% of paralytic patients is somewhat larger than the usual incidence of 20-30% because of selective admission. Nevertheless, the frequency of such conditions in the course of the acute illness emphasizes the importance of their detection and treatment for the preservation of life. This is a separate problem from the ultimate disability which may result from the residual muscular paralysis.

·Il SIGNS AND SYMPTOMS OF RESPIRATORY MUSCLE PARALYSIS EARLY RESPIRATORY MUSCLE INVOLVEMENT IS NOT OBVIOUS . . . SUGGESTIVE • Involvement of the pectoral musculature especially the deltoid group. • Increase in respiratory rate. Shallow respirations. • Decreased ability to protrude abdomen (diaphragm). Diminished elevation of thorax on deep breath and abdominal splıntıng (intercostals). Decreased or unequal upper abdominal movement with "sniffing" (diaphragm). Paradoxical abdominal or thoracic movement on deep breathing Inability to tighten abdominal muscles on saising head. . Poor or absent cough (abdominal muscles). CONFIRMATORY • Absent breath sounds on auscultation Fluoroscopic evidence of diminished or absent range of movement of diaphragm and intercostal-diaphragm lag-unusual tenting • Decreased vital capacity below minimum normal values Respiratory muscle paralysis is the most common serious complication of poliomyelitis Early detection is essential: (a) to accustom the patient to respiratory assistance, and (b) to prevent asphyxia. Artificial respiration is eventually necessary in 80 per cent of all patients with respiratory muscle paralysis. Why wait for profound asphyxia to confim the presence of respiratory failure? Anticipate and present trouble by carly respiratory assistance. There is no evidence that artificial respiration increases respiratory muscle paralysis. Artificial respiration does diminish the work of breathing Asphyxia may produce irreversible deterioration. The onset of asphyxia is insidious and its symptoms may not be alarming entil too late. Don't blame such symptoms on poliomyelitis until asphyxia has been excluded by elective respiratory assistance, ·12 SIGNS OF PROGRESSING RESPIRATORY IMPAIRMENT . . . . . . DECREASING RESPIRATORY MUSCLE EFFORT IS THE INDICATION FOR RESPIRATORY ASSISTANCE GENERAL SIGNS Increasing respiratory rate. Decreasing respiratory depth. Increasing pulse rate. Rising blood pressure (slight to moderate). Fatigue-slight pallor. Poor tolerance to examination and nursing procedures. SPECIFIC Breathlessness. Inability to take deep breath on command. Any change in breathing pattern. Flaring of nostrils. LOOK Fluoroscopic evidence of poor pulmonary aeration (diminution or absence of diffuse pulmonary illumination on quiet breathing). Usage of accessory muscles-(uncommon until very late). Shortened duration of speech LISTEN • Diminished volume of vocalization-weak cry. Inequality or absence of breath sounds. Decreasing ability to count on one breath. MEASURE • Decreasing vital capacity which is below minimum normal values. . . . There is no doubt that clinical judgment and experience are important for the use of these signs in determining the optimum time for introduction of artificial respiration On the other hand the determination of minimum effective breathing is so inexact and so near to respiratory failure that there is no reason to prove this by withholding assistance. Early elective artificial respiration usually benefits the patient and has not been difficult to discontinue in the few patients who need it for brief periods or who do not progress to extensive respiratory muscle paralysis.

·13 INITIAL ADJUSTMENT OF THE RESPIRATOR NEVER LEAVE PATIENT UNATTENDED! SUCCESTED SETTING FOR THE TANK RESPIRATOR Rate/min Agc/yrs 0-2 2-5 5.10 10-15 Adult 30-40 2435 27-28 20 16-18 Pressure/ctn 11,0 -12+0 -14+0 -15.0 - 15+0 -14 to -18 The values for the initial adjustment of the respirator are given only as a starting point and are empirical Some clinicians prefer to use slight positive pressure on ctpiration. Careful pressure recording, however, reveals that most tank respirators always have some positive pressure on expiration when used with a patient. This probably results from unavoidable and relatively large inboard leaks during inspiration around the collar at thic neck. (See General Considerations in Maintenance of Respiratory Equip ment.) In our experience positive pressure on expiration in excess of 5 cm. of water is uncomfortable Individualization of respirator settings, especially pressure adjustment has been simplified by the routine measurement of tidal ventilation pro. duced by the respirator. (Sce Ventilatory Measurements-Tidal Volumes.) The TANK respirator is the device of choice for artificial respiration in the acute phase of the disease because it is simple, safe and the most effective Thus is very important because the tank respirator alone possesses the range of ventilatory cffectiveness which may be necessary in some severely ull patients and most of the auxiliary respiratory devices such as the cuirass respirators and the rocking bed are not suitable initially for continuous r.1.- 11 . intemiption of artificial respiration so the simplest and most effective device must be used. Ile should not be compromised by nor can he tolerate underventilation. This may occur more easily in the use of auxiliary devices because the adjustments to obtain the required higher pressures are critical, fitting of the shell is difficult to obtain and maintain, and prolonged ac- ·16 RATE AND PRESSURE ADJUSTMENT OF THE RESPIRATOR FACTORS IN RATE ADJUSTMENT • Rate is subjectively more important than pressure for synchronization so at first duplicate spontaneous rate. • Rate is decreased after synchronization to the point above which patient supplements respirator of rate is faster than suggested range. • If patient is apneic use table values and consider body temperature, faster early rates are not necessary when the patient is afebrile. Rapid rate approximating spontaneous rate is essential for coordination with irregular shallow breathing. FACTORS IN PRESSURE REGULATION Tidal ventilation should be proved to be adequate by measurement (see ranges of tidal ventilation). • Initial values are empirical and should be altered by measurement and the patient's general response when necessary. Pulmonary, circulatory complications and tracheotomy require higher pressures for adequate depth of breathing. The factors used in rate and pressure adjustment are self-explanatory, however, certain features should be pointed out. It is very desirable to let the patient determine the most acceptable rate setting of the apparatus and subsequently, ventilatory measurements should be used to determine appropriate ranges of tidal volume for the rate which is chosen and the pressure which will produce it Minute volume of ventilation has not been emphasized for the reason that suggested tıdal volumes are paired with rates which will correspond to those found desirable by most patients and which will achieve at least minimum minute volumes consisted with the needs of normal metabolism" in the uncomplicated patient. (See Appendix Ventilatory Measurements-Tidal Volumes.) Proper rate and pressure adjustments are easier to obtain in the cooperative patient. The actual effectiveness of artificial respiration may depend upon this because the patient must set up new patterns of swallowing and glottic coordination for breathing, swallowing and speech For these rea-

·TREATSIENT OF ACUTE POLIOMYELITIS
17
sons withholding artificial respiration may lead to a state in which its use is
unnecessarily complicated or even ineffective.
In the absence of ventilatory measurements a reasonably satisfactory ad.
justment can be obtained using the suggested range of rates and pressures
and clinical evidence for satisfactory adjustment of the respirator such as
outlined on the following page.

·18 EVIDENCE FOR SATISFACTORY ADJUSTMENT OF RESPIRATOR PRESSURE AND CYCLING RATE . . Disappearance or improvement in symptoms such as restlessnesssleeplessness-unfavorable changes in the vital signs. • Acceptance of the rhythm of the respirator with synchronization.. Disappearance of anxious facial expression-patient relaxes with dozing and slecp. . General improvement in sensorium and feeling of well being. Demonstration of adequate pulmonary ventilation (see Appendix). The physician must steer a course between hypoventilation and hyperventilation. Table values for adequate tidal volumes are minimum values, predicted from normal metabolic requirements Measured tidal volumes which clinically appear to be proper for the individual patient are often slightly larger than predicted values Avoiding extremely large tıdal vol. umes will minimize hyperventilation. By listening over the mouth of the sleeping patient with a stethoscope, und increasing respirator pressure a point will be observed at which inconscious inspiratory obstruction develops as a result of glottis closure. On the other hand decreasing the pressure will often produce restlessness, dilation of the nostrils and spontaneous respiratory efforts. Between these ho points proper ventilation may be assumed to occur. Such suggestions as these are of primary importance early in the use of artificial respiration Similarly, early introduction of artificial respiration permits many of the maneuvers and guides to be effectively utilized ·19 CONDITIONS COMPLICATING THE USE OF ARTIFICIAL RESPIRATION . Swallowing difficulty increases the likelihood of pulmonary aspiration. Airway obstruction prevents adequate pulmonary ventilation and must be corrected. Tracheotomy is necessary to achieve adequate ventılation and minimize aspiration in the respirator patient with swallowing difficulty and/or airway obstruction • Incoordination with the respirator is not a contraindication to artificial respiration if the spontaneous cfort is shallow in character and incffective. • A lost comatose respirator patients require a tracheotomy to preserve an unobstructed airway. • Pulmonary complications are more frequent in apncic respirator patients. • Ilypotension may be unfavorably influenced by artificial respiraton. Artificial respiration does not duplicate the normal breathing mechanism. It can produce adequate pulmonary ventilation in the uncomplicated pa. ticnt It does interfere with the mechanics of venous blood return during the inspiratory phase in contrast to normal breathing. Abdominal muscle weakness and the subjection of the entire body to the sub-atmospheric pressure of the ventilatory cycle contribute to this effect. Such circulatory cffects may be extremely undesirable in the hyr sive patient or when suitable compensatory responses are lacking The effect of respirator pressure patterns upon both pulmonary gas distribution and blood perfusion is not clear. The mechanism of heat loss through skin evaporation and radiation may be retarded. Artificial respiration may impede the removal of increased bronchopulmonary sccrctions. Upper airway secretions are aspirated into bronchopulmonary segments in the same fashion as with normal inspiratory efforts Thic patient is unable to cough and the respirator is a poor coughing de Nice The respirator patient's ability to protect lumself against aspiration may be ineffective since he is unable to control the cycling of the respira.

·20 TREATMENT OF ACUTE POLIOMYELITIS tor. This is likely since such protection depends upon coordination of swallowing-glottic closure and respiratory arrest. Artificial respiration must never be attempted in the presence of an obstructed airway or whenever factors contributing to aspiration have not been prevented or corrected, ·21 SIGNS OF PROGRESSIVE ASPHYXIA . . • Circumoral pallor-constricted pupils. Poor skin color and circulation (mottling of the skin). • Profuse sweating-especially on the forehead. Deterioration of well being and responsiveness. Progressive restiessness-inability to sleep. Apprehension ultimately leading to a panic state. Confusion-delirium. • Marked dilation of nostrils often with frank dyspnea. • Thready pulse-occasionally hypertension followed by hypotension. LATE • Appearance of facial components of breathing. Intermittent cyanosis-hallucinations-panic.coma-persistent cyanosis-death Asphyxia should be regarded as a complete failure of the brcathing mechanism. The extent to which biochemical alterations of orygen, CO, and hydrogen ion concentration are responsible for these signs is not known. It is clear that biochemical equilibrium is maintained for a surprising period in the face of progressive respiratory muscle paralysis and therefore alterations of these chemical variables must be considered to be evidence of failure of respiration. The signs of failure of breathing should not be used as an indication for artificial respiration. The carly demonstration of decreasing respiratory muscle power is the safest indication.

·22 LABORATORY GUIDES TO RESPIRATORY MANAGEMENT CENERALLY AVAILABLE Determination of pulmonary ventilation and compartments (see Appendix). SPECIAL STUDIES Arterial blood Oxygen content and per cent hemoglobin saturation, pH, CO, content and p CO. Gas Expired "alveolar" P CO2 CO2 excretion and oxygen uptake. + The value of pulmonary ventilatory measurements and vital capacity determinations has been clearly established. The special laboratory studies are of indeterminate therapeutic value at the present time. There is no doubt that chemical measurements are much less reliable than careful evaluation of the patient and clinical experience with respiratory disease. Preliminary examination of arterial pH and CO. content indicates that alkaline pHs and low CO, contents are frequently observed in acute poliomyelitis with respiratory muscle paralysis or even in the absence of involvement. This is important because of the emphasis which has been placed upon CO2 retention as a guide to decreasing respiratory muscle function. The reasons are not clear but some features of the acute disease warrant emphasis: The influence of severe apprehension in promoting hyperventilation; the role of metabolic alterations such as increased metabolism leading to high oxygen demand with a respiratory compensation promoting increased CO2 elimination; the presence of hypochloremic alkalosis; alteration of renal function; and other factors which influence blood gas and hydrogen ion regulation. When CO, retention with acidosis is observed in poliomyelitis in our experience it is usually associated with conditions productive of airway obstruction and serious impediment to pulmonary ventilation, See bibliography, ·THEATEET OF ACUTE POLIOMYELITIS 23 It should be noted that venous blood yalues are of po value and may be misleading Arterial orygen saturation is preserved over a wide range of orygen content especially in alkaline blood so that its determination has minimal value except as an indication of complete failure of respiratory function or as a sign of pulmonary and circulatory complications leading to decreased pulmonary gascous diffusion.

·24 SIGNS AND SYMPTOMS OF IMPAIRMENT OF SWALLOWING . Complaint of swallowing difficulty (do not test). Fluoroscopic demonstration of impaired swallowing with lipiodol. Weakness of anterior neck muscles. Accumulation of frothy secretions in the pharynx. Diminished gag reflex, incoordinate gagging with choking Absent or asymmetrical movement of the posterior pharyngeal wall. NORMAL ABNORMAL . (>) or . Absent or asymmetrical opposition of tonsillar pillars. Angle sign-lack of subglossal fullness and contour. G NORMAL ABNORMAL . Weak or absent elevation and descent of hyoid and thyroid cartilage against resistance of finger In most instances swallowing difficulty is a result of bulbar poliomyelitis with involvement of the Xth nerve motor nuclei. However, it is becoming increasingly clear that swallowing is an exceedingly complex act that involves elaborate brain stem neuro-regulatory activity and functional coordination.

·25 SIGNS AND SYMPTOMS OF IMPAIRMENT OF SWALLOWING . GENERAL Ilacking-spitting-drooling-fear of recumbency. Shallow often irregular respirations-improved after suctioning. LATE Change in appearance-poor color-fatigue-drowsiness-sleeplessness-lack of concern for accumulation of secretions. • Auscultation of coarse rhonchi and roughness in airflow at the mouth. Inspiratory stridor with vocal cord paralysis. Cyapotic episodes (too late). • . Prompt recognition and treatment of swallowing difficulty is essential to prevent: (a) upper airway obstruction, (b) tracheobronchial aspiration and lower airway obstruction; (c) underventilation resulting from shallow, inhibited and irregular respiratory efforts, and (d) choking with glottic spasm and prompt asphyxia and death. Swallowing impairment should also be considered an extremely serious development in the course of the dis. case because of the frequent association of serious often fatal disturbances of cardiovascular activity. Palatal paralysis has not been emphasized for several reasons: (a) in itself asymmetrical or absent movement of the soft palate and uvula produces nasal voice, not swallowing difficulty, and (b) it may occur as an isolated Indication of brain stem involvement or be associated with facial motor paralysis and no swallowing impairment or other evidence of severe illoess. It remains only as an important sign of extension or localization of the discase to the brain stem (bulbar poliomyelitis).

·26 IMMEDIATE MEASURES IN THE TREATMENT OF IMPAIRED SWALLOWING + REMOVE SECRETIONS AND PREVENT THEIR ACCUMULATION Allow only prope and side lying position. Use moderate Trendelenburg position (10°-15°). Use careful, skillful, intermittent, high vacuum Suction or combine constant, low vacuum suction. Avoid gagging and choking-iise multiple perforated rubber catheter, metal suction tip or indwelling polyethylene catheters. ELMIINATE NEED TO SWALLOW NO oral feedings, fluid or medications. Taitiate parenteral alimentation Use small, indwelling, nasogastric, polyethylene tube for drip feeding as soon as the patient is afebrile or earlier if course is uncomplicated and not progressive. Avoid gastro-intestinal distension (CLAN OFF NASOGASTRIC Tuse), large volume feedings, gastric retention due to excessive fat in formula to minimize vomiting and aspiration. The prevention of underventilation and asphyxia is the objective of treatmnent no matter what methods are employed. These serious and fatal complications appear to be a result of upper airway obstruction, aspiration, lower airway obstruction and irregular, shallow, voluntary inhibited breathing efforts. The nutritional handicap resulting from inability to swallow can be readily corrected through parenteral routes and by nasogastric tube feeding. On the other hand, liability to other hazards of swallowing dilficulty is still present because of the large volume of oropharyngeal and tracheobronchial secretions. Prevention of underventilation and asphyxia without doubt challenges all of the judgment, skill, experience and resourcefulness of the physician. Suitable management of this difficult condition can often be carried out by wise observation of cardinal symptoms and prompt effective treatment in the manner indicated.

·27 CONTRAINDICATIONS TO CONTINUATION OF CONSERVATTVE TREATMENT OF IMPAIRED SWALLOWING . The likelihood or actual development of respiratory muscle paralysis requiring artificial respiration. • Inability of the patient's coughing mechanism and the treatment method to remove tracheobronchial secretions. • Increased liability of the young patient to sudden fatal aspiration. • The hazard of oral feedings in the infant requiring artificial respiration, • The occurence of coma and absence of protective reflexes in some severely ill patients requiring artificial respiration. Overburdening of personnel and treatment facilities for continu. ous conservative management of the patient. • Development of fatigue and exhaustion without slecp or rest from treatment measures. Development and rapid progression of swallowing impalment carly in the course of severe disease. These contraindications obviously become more significant as evidence for failure of conservative treatment accumulates. Conservative treatment may be inadequate and radical surgical measures such as tracheotomy may be urgently indicated depending upon thc patient's general condition and the extent of involvement. Unfortunately patients with swallowing dificulty may also have extensive parallel impairment of the central regulation of vital autonomic and respiratory func tions which may be irreversible in nature. Ilovcict, detcnoration of the patient's general condition during treatment should not be blamed upon ncurologe involvement until underventilation or asphyxia has been pre vented or recognized and corrected.

·28 SIGNS OF FAILURE OF CONSERVATIVE TREATMENT OF IMPAIRED SWALLOWING Persistence of accumulated secretions-increasing production of secretions, • Deterioration of general condition-with the appearance of fatigue and exhaustion-lack of concern over inability to swallow. Poor color-frequently but not invariably rising pulse rate and blood pressure. • Persistence of shallow, irregular breathing. • Inability of the patient's protective reflexes to prevent choking and/or aspiration in spite of conservative measures. Pulmonary complications of atelectasis and pneumonitis. Choking with and without cyanosis, aspiration, evidence of underventilation, and deterioration of the general condition of the patient are not only serious signs of failure of conservative treatment but should be prevented by more radical measures such as tracheotomy. The decision to per. form a tracheotomy should not be lightly entertained but all too frequently it is utilized too late, after the patient has been seriously compromised Once again a careful course of action must be determined by individualiza. tion and consideration of the many factors influencing the efficacy of "con. servative" measures. Tracheotomy is not necessarily a simple solution to the many respiratory problems which may be encountered in the management of severe poliomyelitis.

·29 INDICATIONS FOR TRACHEOTOMY • Failure of conservative measures to maintain an unobstructed airway and adequate pulmonary ventilation. • The occurrence of aspiration and/or pulmonary complications such as atelectasis and pneumonitis in the course of swallowing dificulty. Respiratory muscle paralysis combined with any impairment of the swallowing mechanism. • To permit the adequate management of severe pulnyonary complıcations in the respirator patient. For the preservation of the airway in comatose patients. There is no doubt that tracheotomy is the most effective means of es. tablishing an unobstructed airway. It should be performed skillfully under local anaesthesia, high (first or second tracheal ring) and with dispatch. In general it should be performed only after an emergency airway has been established by endotracheal intubation or bronchoscopy. This is extremely important for the safe performance of a tracheotomy in children and occasionally in the adult patient. Artificial respiration must be continued during the tracheotomy procedure when tracheotomy is necessary in the respira. tor patient. Anaesthesia bag Intermittent positive pressure or the use of a chest-abdomen cuirass respirator is a satisfactory means of ventilating the paticnt. Oxygen should also be used during the procedure. Not infrequently the likelihood of progressive respiratory muscle impairment in association with swallowing difficulty can be anticipated. Thus carlier and less hazardous tracheotomy can be accomplished before the institution of artificial respiration.

·32 TREATMENT OF CENTRAL DISTURBANCES OF RESPIRATORY REGULATION • In uncomplicated patients-mild irregularity easily replaced by voluntary commands to breathe regularly may disappear spontaneously. • If irregularity persists and unfavorable changes in vital signs develop ventilatory measurements will usually verify inadequate ventilation hence use- Artificial respiration with assurance of an unobstructed airway. Oxygen therapy. Judicious sedation. Electrophrenic respiration. (Artificial respiration may be necessary for several days to a week followed by spontaneous recovery.) • In association with circulatory and other autonomic disorders prognosis is poor-respiration and circulation must be sustained by substitute devices and pharmacologic measures. . 9 In the critically ill patient adequate pulmonary ventilation may be achieved only with artificial respiration. Obviously asphyxia, inadequate circulation and severe metabolic and biochemical disturbances may be contributory. Correction of conditions such as asphyxia, preservation of blood pressure and maintenance of Auid and electrolyte balance are important supportive measures in the desperate situation, although frequently they will not be effective enough to prevent death due to profound hypotension, cardiac failure and arrest, pulmonary edema, massive intestinal hemonbage, renal failure, etc. In the absence of cardiovascular and other autonomic disturbancesserious threat to life may not develop, and an excellent recovery may be observed, ·33 CARDIOVASCULAR AND AUTONOMIC ABNORMALITIES . • SEVERE HYPERTENSION SYSTOLIC PRESSURE MORE THAN 200 mm Hg-Adult 160 mm Ilg-Child. Pulse pressure is reduced • BRADYCARDIA Usually of brief duration • HIYPERTHERMIA AND SEVERE CUTANEOUS VASOCONSTRICTION Body temperature in excess of 1089 may occur with cold, mottled and pale skin which is clammy to the touch. Skin circulation is sluggish and cyanotic SEVERE ITYTOTENSION- 90 mm Hg-febrile Adult. SYSTOLIC PRESSURE LESS THAN 60 mm lg-febrile Child. EXTREME TACITYCARDIA LEADING 180/min.-Adult. TO OUTPUT FAILURE-PULSE OVER 210/min.-Child. VENTRICULAR PREMATURE BEATS Especially in a series. • PULMONARY CONGESTION AND EDEMA Suggested by marked increase in hilar and lung markings and by characteristic ECG vector clockwise displacement and high, peaked P waves. Edema produces acute respiratory distress and abundant frothy, blood tinged secretions. • MYOCARDIAL FAILURE AND MYOCARDITIS Soft and poor heart sounds with progressive enlargement. ECG alterations EMBRYOCARDIA (170-180) fast, unmodified and regular heart rate which is usually terminal. SEVERE GASTROINTESTINAL DISTENTIOX-ILEUS . Fatal bulbar poliomyelitis is often associated with progressive elevation of body temperature to intolerable levels, cutaneous vasoconstriction, by. pertension and bradyrardia, followed by tachycardia and fatal hypotension ·34 TEATAIENT OF ACUTE POLIOMYELITIS or pulmonary edema and respiratory failure. Treatment measures should be employed even though the course of the disease may not be alterable. These signs and symptoms may be produced by a variety of conditions: brain stem damage; altered brain stem function as a result of nervous or chemical disturbances; changes in vital chemical equilibria of oxygen, CO2 and hydrogen ion concentration; specific damage to the cardiac muscle, etc. Over-compensatory or harmful body responses resulting from the "stress” of disease or treatment procedures may complicate the situation. It is usually not possible to separate causes. It is more important to prevent or eliminate conditions such as asphyxia which may produce failure of circulation and respiration.

·35 CIRCULATORY AND OTHER CONDITIONS REQUIRING IMMEDIATE TREATMENT JIYTERTIIERMIA. Attempt vigorous cooling of the body and cutane s vasodilation to promote heat loss. Alternately apply warm and cool ects to the entire body. Improve skin circulation by brushing and use 5% cohol intravenously (200-1,000 cc.) as a cutancous vasodilator. Avoid e use of ice and topical alcohol which may increase vasoconstriction by zessive chilling of the skin. INTERTENSION has been effectively treated with the parenteral adnistration of Rauwolfia serpentina extracts. The maximum dosage is 80 crograms per kilogram of body weight as the total dose per twenty-four urs. One-half is administered as a stat dose either intramuscularly or in. avenously for most rapid effect (30-120 minutes). The balance is given in to cight hour divided doses. A hypotensive drug which does not render patient unresponsive to vasopressors must be used since the natural urse of the discasc may terminate in fatal hypotension. Digitalis prepa. tions are useful adjuncts and appear to be without harm in the acute culatory failure which accompanies failing cardiac output and ECG idence of impaired cardiac activity. HYPOTENSION is usually effectively corrected with continuous drip travenous administration of a solution containing 4 mgm. of nor-cpi. phrine to 1,000 cc. of 5 or 10% invert sugar in water. The rate of adminration is entirely dependent upon the response of the blood pressure hich must be measured at frequent intervals. In some cases its use may be cessary for days to several weeks. Hypotension must be immediately corcted in order to preserve central nervous system function and renal tivity. Pressurc adjustments of the respirator designed to promote venous retum rough increasing espiratory positive pressure to the same value as iniratory negative pressure have not been remarkably effective in this contion There is no doubt that such a procedure has theoretical and capericntal mcrit. The parenteral administration of ephedrine may be of value and in addion it is a potent bronchial dilator. DISTENSION which may be gastric or generalized will lead to acute spiratory impairment in the respirator patient. It can tusually be miniuized with nasogastric intubation and intermittent or constant suction. tygen administration is of some value and prostigmine subcutancously in dosage of 01 to 0.5 cc. of 1:1,000 solution is particularly effective. Oral dings must le discontinued.

·. 36 TREATMENT OF ACUTE POLIOMYELITIS PULMONARY EDEMA has been uncommon. Avoidance of the use of plasma, plasma expanders and whole blood may be an important factor in minimizing pulmonary edema. In poliomyelitis, hypotension is apparently not a result of blood loss, so their use is usually contraindicated. The only exception is extensive blood loss from massive intestinal hemorrhage which is very rare. The slow intravenous administration of aminophylline (100- 500 mgm.) in 10-50 cc. of 50% glucose solution may be of value when combined with effective ventilation and satisfactory maintenance of blood pressure. Without doubt heroic treatment may be completely ineffective. MYOCARDIAL FAILURE AND MYOCARDITIS is best treated with digitalis preparations in conventional dosage. Rapid and large administration of parenteral fluids should be avoided.

·37 CARDIOVASCULAR ABNORMALITIES OF MINOR SIGNIFICANCE . Arrhythmias-pronounced sinus arrhythmia-wandering pact maker. Moderate tachyardia-rate less than 150/min. in adults, 180/min in children. • Moderate hypertension-systolic and diastolic. Paroxysmal supra-ventricular tachycardia of brief duration. • ECG abnormalities due to cardiac displacement (abnormal QRS vector in frontal projection, elevated S-T segment, deep waves, S, S. Ss pattern, etc.). Right bundle branch block, These should be recognized primarily because no treatment is indicated. In addition such findings do not signify a serious prognosis. In a number of cases ECG alterations and circulatory findings are suggestive of the type of body stress occasioned by severe illness and are therefore probably not specific. Prolonged Q-T time and shortened P-R intervals are good examples.

·38 SIGNS AND SYMPTOMS OF PULMONARY COMPLICATIONS TRACHEOBRONCHIAL ASPIRATION, ATELECTASIS AND PNEUMONITIS Deterioration of condition--poor color, loss of appetite, change in mental outlook, Recrudescence of fever, frequently polymorphonuclear leukocytosis. • Change in vital signs, increase in pulse rate, increase in blood pressure, poor peripheral circulation--may be signs of inadequate ventilation, Complaint of something in the throat. Auscultation of a double expiratory sound with a midpause or click-is noted frequently with atelectasis or tracheobronchial obstruction. Marked diminution in volume of outflow. • Reduction in tidal volume at high inspiratory pressures reflecting a change in lung pressure volume relationships. Radiographic changes in lung fields. Aspiration of purulent tracheobronchial secretions. . . . In some instances frank evidence of tracheobronchial aspiration or atelectasis may be present--shift of mediastinum, displacement of PMI and other findings suggestive of collapse of a lobe. These findings are not uniformly present especially in the respirator patient. Pulmonary complica. tions may occur with surprisingly few clinical signs and symptoms, so should be anticipated as a common cause of deterioration of the patient's condition or of unexplained fever.

·39 PREVENTION OF PULMONARY COMPLICATIONS . . PREVENTIVE MEASURES Prevent Irronchial aspiration of secretions by adequate and careful upper airway suction, Frequent change of position-avoid prolonged Trendelenburg. Insire adequate humidification of inspired air, Attempt to preserve muco-ciliary mechanism. Present trachcal drying and crusting. Change tracheotomy tube q 2 days. • Usc artificial cough maneuvers with the vacuum cleaner with any complaint of inability to clear throat or evidence of ac. cumulation of secretions. Usc intermittent deep breath-intermittent abdominal splinting to promote thoracic espansion. • Obtain serial smcars and cultures for determination of predominant organisms in tracheobronchial tree. Preventive measures are extremely important. Nevertheless the respiratory poliomyelitis patient has an increased liability to pulmonary complicate tions een under ideal circumstances. Causative factors include: (a) casy aspiration of contaminated secretions because of absent effective reflex protection of the airway; (b) inability to remove secretions, loss of cougliing ability, failure of cliary mechanism, increased amount and viscidity of sccrctions; (c) infrequent maximum lung expansion such as occurs with sighing and crercise, and (d) alterations of air distnbution in the lungs and changes in pulmonary blood flow as a result of prolonged immobilization in the supine position, respiratory muscle paralysis and artificial respiration. In any case the preventive measures should be routinely employed and prompt adequalc treatment should be caned out. Antibacterial therapy should be directed by the sensitivity of the predominant organism. Routinc prophylactic antibiotic therapy or chemotherapy may be inadvisablc be cause the ordinary lacterial flora are replaced by resistant organisms. The development of a pulmonary complication with this type of secondary in. ſection is olxiously most difficult to treat.

·40 TREATMENT OF PULMONARY COMPLICATIONS Treat infection early-specifically and adequately. Repeat tracheobronchial aspiration. Less traumatic bronchoscopy may be done through the tracheotomy when usual suction is ineffective. Correct for the effect of these complications in diminishing ventilation and increasing pressure requirements in the respirator, Prove adequacy of tidal exchange. • Use humidified oxygen and/or steam therapy. Alake frequent changes in body position–postural drainage. Ephedrine (SC) 30 minutes prior to endotracheal suction-occasionally prolonged dosage may be necessary. • Treat myocardial insufficiency secondary to extensive pulmonary complications with digitalization. If hemoglobin is below 10-12 gms. use repeated small blood transfusions, In addition to the measures previously outlined certain features are important in the satisfactory management of these complications. They include: (a) frequent bronchoscopy which is necessary for persistent atelectasis and whenever underventilation cannot be corrected by simple tracheal suction and reasonable respirator pressure adjustments; (b) pulmonary complications account for decreased distensibility of the lung so that higher respirator pressures are necessary to accomplish adequate tidal exchange (see Ventilatory Measurements-Tidal Volumes); (c) oxygen therapy is often necessary (see Osygen Therapy), and (d) occasionally senous impairment of cardiac function is observed. In many instances satisfactory treatment is possible. It should also be pointed out that upper lobe atelectasis may not produce serious impairment of pulmonary ventilation so that conservative treatment may be entirely adequate. In contrast lower lobe atelectasis is usually due to an obstructing mucous plug or inspissated mucopus in a primary bronchus. This condition requires immediate and energetic treatment because it almost always results in underventilation.

·11 OXYGEN THERAPY OXYGEN IS NEVER A SUBSTITUTE FOR PULMONARY VENTILATION . INDICATIONS FOR USE INCLUDE Supplementing oxygen partial pressure in the inspired air when adequate pulmonary ventilation cannot be achieved by any means. • To compensate for abnormalities of ventilation of lung tissue due to atelcctasis and pneumonitis. • To provide higher diffusion pressure when- An alveolar diffusion barrier is produced by pulmonary edema. Circulatory failure may cause impaired pulmonary blood flow. • To compensate for marked increase in orygen utilization in some respirator patients with fecr, infection, etc. Oxygen must always be humidified before inhalation. If a normal airway is the route of administration a Icnt, plastic canopy, disposable mask, or funnel may be used. The trachcotomized patient requires special considcration to protect the trachcobronchial mucosa froni cxtreme temperature changes and dry air/oxygen mixtures Several satisfactory nebulizing, fosging and mist producing devices are available. Wetting agents may promote dispersion and penetration of microscopic water droplets. An open delivery system with a close fitting delivery cup or chamber surrounding but not obstructing the tracheotomy tube is satisfactory. The total volume of the delivery system uld slightly larger than the tidal exchange. Concentrations of oxygen in cxcess of 50% are probably unnecessary.

·42 METABOLIC DISTURBANCES IN ACUTE POLIOMYELITIS . ALTERATION OF WATER BALANCE: Dehydration, loss of skin turgor with dry mucous membranes, polycythemia, oliguria. ELECTROLYTE DISTURBANCES: Evaluated by history and laboratory examinations may show: Elevated serum Na+. Lowered serum K+ and Cl- (hypokalemic alkalosis). Chronic Na+ depletion with low serum Na+ and K+. OXYGEN UPTAKE DISTURBANCES. (See Oxygen Therapy.) CO, ELIMINATION: Excessive-hypocapnia Deficient-hypercapnia. PH ADJUSTMENT: Acute patient may have normal, acid or alkaline arterial pH. pH is readily altered by hyperventilation or hypoventilation especially during artificial respiration. Slightly alkaline arterial pH (7.48-7.55) is well tolerated and be a compensation of the acute disease state in the respiratory or severely ill patient. may In the acute phase of poliomyelitis the problems of water and electrolyte metabolism are in many respects similar to those of any acutely ill patient. Poor intake gradually leads to deficits of both water and electrolytes. Excessive loss of gastric or oral secretions (latter particularly important in bulbar patients) increases the magotude of this deficit. In addition, high body temperature and respiratory disturbance increase insensible water losses. Clinical and laboratory evaluation should be combined for effective therapy. (See Special Considerations in Water and Salt Loss in Polio myelitis.) The elimination of CO2 may be normal or excessive when respiration is inadequate for 0, intake. This is due to the more rapid rate of diffusion of CO. (probably 25 times as rapid as 02). Hypocapnia may therefore appear when ventilation is sufficient for large O. needs. CO, excretion is not a solely reliable guide to complete ventilatory adequacy in the acutely ill poliomyelitis patient.

·TREATMENT OF METABOLIC DISTURBANCES IN ACUTE POLIOMYELITIS FLUID DISTURBANCES: Sec Appendix on Correction and Maintenance of Salt and Water Needs. ELECTROLYTE DISTURBANCES: Sce Appendix on Correction and Maintenance of Salt and Water Needs. • Remember not only to give maintenance fluid and salt but also to replace antecedent deficits which may be LARGE. Follow urine Cl with Fantus test and Sp. Gr. OXYGEN UPTAKE: See Orygen Therapy. Sct respirator to give amount of ventilation which achicves peak O: consumption. (Measured with ordinary BMR machine.) This is Os demand. • Eliminate pncumonitis and atelectasis insofar as possible. CO, ELIMINATION: Do not attempt to treat patient on the basis of CO, excretion. Oxygen consumption always takes priority. PII ADJUSTMENT: Arterial blood. • Alkalinc pll, low CO: and low Cl- and K+: Treat as hypochloremic alhalosis duc to cellular potassium deficiency. • Acid pll, low CO-probably present only with acidosis of starvation, fever and partial renal failure. Force fluids and cal. ories for good renal function, good circulation and adequate basal caloric intake. • Acid pll and high CO-CO, retention due to extreme respiratory failure. Treat by improving ventilation.

·42 METABOLIC DISTURBANCES IN ACUTE POLIOMYELITIS . ALTERATION OF WATER BALANCE: Dehydration, loss of skin turgor with dry mucous membranes, polycythemia, oliguria. ELECTROLYTE DISTURBANCES: Evaluated by history and laboratory examinations may show: Elevated serum Na+, Lawered serum K+ and Cl- (hypokalemic alkalosis). Chronic Na+ depletion with low serum Na+ and K+. OXYGEN UPTAKE DISTURBANCES. (See Oxygen Therapy.) CO2 ELIMINATION: Excessive-hypocapnia. Deficient-hypercapnia. PH ADJUSTMENT: Acute patient may bave normal, acid or alkaline arterial pH. pH is readily altered by hyperventilation or hypoventilation especially during artificial respiration. Slightly alkaline arterial pH (7.48-7.55) is well tolerated and may be a compensation of the acute disease state in the respiratory or severely ill patient. . . In the acute phase of poliomyelitis the problems of water and electrolyte metabolism are in many respects similar to those of any acutely ill patient. Poor intake gradually leads to deficits of both water and electrolytes. Excessive loss of gastric or oral secretions (latter particularly important in bulbar patients) increases the magnitude of this deficit. In addition, high body temperature and respiratory disturbance increase insensible water losses. Clinical and laboratory evaluation should be combined for effective therapy. (See Special Considerations in Water and Salt Loss in Polio myelitis.) The elimination of CO2 may be normal or excessive when respiration is inadequate for O2 intake. This is due to the more rapid rate of diffusion of CO, (probably 25 times as rapid as 03). Hypocapnia may therefore appear when ventilation is sufficient for large O2 needs. CO, excretion is got a solely reliable guide to complete ventilatory adequacy in the acutely ill poliomyelitis patient.

·43 TREATMENT OF METABOLIC DISTURBANCES IN ACUTE POLIOMYELITIS FLUİD DISTURBANCES: See Appendix on Correction and Maintenance of Salt and Water Needs. ELECTROLYTE DISTURBANCES: See Appendix on Correction and Maintenance of Salt and Water Needs. • Remember not only to give maintenance fluid and salt but also to replace antecedent deficits which may be LARGE. • Follow urine Cl with Fantus test and Sp Gr. OXYGEN UTTAKE: See Oxygen Therapy. Set respirator to give amount of ventilation which achieves peak Os consumption. (Measured with ordinary BMR machine.) This is O. dernand, Eliminate pneumonitis and atelectasis insofar as possible. CO, ELIMINATION: Do not attempt to treat patient on the basis of CO. cecretion Oxygen consumption always takes priority. PH ADJUSTMENT: Arterial blood. Alkaline pH, low CO2 and low Cl- and K+: Treat as hypochloremic alkalosis due to cellular potassium deficiency. • Acid pH, low COz-probably present only with acidosis of starvation, fever and partial renal failure. Force fluids and calories for good renal function, good circulation and adequate basal caloric intake. Acid pH and high CO-CO, retention due to extreme respiratory failure. Treat by improving ventilation.

·DIET AND TUBE FEEDING . CRITICAL PHASE Maintain fluid and electrolyte balance. (See Special Considerations in Water and Salt Loss ... and Method of Correction and Maintenance...) Only calories are important in diet to provide minimum intake of 30 to 40 Cal/Kg. body weight as CHO. POST-ACUTE PHASE PATIENT ABLE TO SWALLOW Begin with regular soft diet and restrict whole milk to a pint per day in patients with extensive paralysis. • Diet unrestricted unless obesity occurs. PATIENT UNABLE TO SWALLOW · Nothing by mouth should be attempted Tube feeding is started after height of acute phase has passed. Begin with glucose water by gravity naso-gastric drip in calculated amount. (See Method of Correction and Maintenance of Salt and Water Needs.) . If no vomiting occurs (24 to 48 hours) add skim milk and strained orange juice for 24 hours. Example: Adult, 200 cc. of each alternating every 3 hours. Change milk to homogenized milk for the next 24 hours. Meet total water requirements. • Then start formula calculated for adequate amounts of Calories, Protein, Carbohydrates, Fat and total Auid volume. . Protein needs Vader 1 year-3.5 gm./Kg. 1 to 3 years -2 gr./kg. Over 3 years-1 gm./Kg., but if tolerated 1% to 2 gm./Kg Fat-1 gm./Kg, often not well tolerated by early convalescent polio myelitis patient. Calories-40 Cal/sg. Carbohydrates-make up calories with carbohydrates.

·TREATMENT OF ACUTE POLIOMYELITIS
45
2 eggs
59 gins.
30 gms.
174 gms.
EXAMPLE
ANALYSIS
1 pint of milk
75 gms. skim milk powder
Protein
Fat
1 egg white
CHO
100 gms Karo
Calories
1202
300 cc. apple juice
1000 cc.
• First 24 hours give X calculated amount and make up fluid volume
with water.
• Add water and electrolytes between feedings to meet total daily needs.
App. Vot

·48 URINARY BLADDER RETENTION . ACUTE STAGE OCCURENCE Less common in children and females, but frequent in adult males. Usually only occurs with bilateral lower extremity paralysis and abdominal muscle paralysis. TREATMENT If catheterization becomes necessary, put in an indwelling catheter using the strictest of sterile techniques. Prevent dehydration-maintain dilute urine. Specific treatment of urinary tract infection depends upon identification of causative organism. • Prophylactic use of sulfonamides or antibiotics is controversial. REMOVAL Try removal as soon as acute stage is over. Urge patient to void at least every 3 to 4 hours after removing catheter (before distention of bladder occurs). If difficulties occur, use Prostigmine (0.5 mg. in adults) or Furmethide (3 mg. IM). Apply gentle manual pressure over bladder area Repeat in 20 minutes if there is no result. If patient is still unable to void, recatheterize and again attempt removal in two days. Determine if incomplete emptying (residual urine) is contributing to infection if such is present. . . ce Especially in children conservative measures are often adequate so that catheterization is unnecessary. Frequent stimulation of voiding to prevent bladder distension and stimulant drugs are most important adjuncts. Inability to remove catheter seldom occurs utilizing this procedure. It has been our experience, however, that if the catheter has been allowed to remain in place for five weeks, removal becomes difficult or impossible, and chronic bladder and renal infections are usual consequences.

·47 NURSING CARE-ACUTE POLIOMYELITIS ROUTINE ORDERS (S.W.P.R.C.) . . . . T.P.R. and B/P q 4 hours (unless otherwise ordered). TBC. Patch Test on admission (for children 6 months to 14 years). CBC on admission. Urinalysis on admission, Serology on admission. Weight and height on admission. No SEDATION OR ASPIRIN (unless ordered). Hot packs for pain (or by doctor). (See Symptomatic Management of Muscular Discomfort.) Catheterizations are done by nurse or doctor ONLY. Orderlies and practical nurses are not allowed to catheterize patients on Polio Service. Oxygen is NEVER given without adequate humidification. Use open system cold humidifier or fogging device. (See Oxygen Therapy.) • Use ONLY RED SPECIAL EMERCENCY CIRCUIT OUTLETS for respiratory equipment. Do not plug any other equipment into these outlets. Charting must be accurate and detailed on acute patients Pulse and respirations should be counted for a full minute. Rectal temperatures are taken on all acute patients. Chart any progression and note time. Check Signs and Symptoms of Serious Polio and Signs and Symptoms of Respiratory Muscle Paralysis, Impairment of Swallowing, and Pulmonary Complications. Doctor should be notified at once of any marked progression, rise in blood pressure or pulse, or any untoward signs whatsoever, All acute patients in a respirator must be on the alarm system, even if there is a special nurse in the room. . SERIOUS POLIOMYELITIS • See Immediate Measures in the Treatment of Impaired Swallowing • If patient has any mucous accumulation, Trendelenburg posi- ·48 TREATMENT OF ACUTE POLIOMYELITIS tion (ordered by physician). Position on side and abdomen, NOT ON BACK. Have aspirating equipment available at all times. Always check bronchoscopy and tracheotomy tables. Be sure they are complete and all equipment functioning. KNOW WIAT ENT DOCTOR IS ON CALI, and advise him of patient's condition. Always have a respirator checked and ready for use. See Signs and Symptoms of Serious Polio, Signs and Symptoms of Impairment of Swallowing, and Signs and Symptoms of Respiratory Muscle Paralysis.

·49 NURSING CARE-HYGIENE . . ORAI, Toothbrush, toothpaste, emesis basin for routine mouth care. Special mouth care as indicated, especially to patients not receiving oral feedings. SKIN CARE Special emphasis to neck, back, and bony prommenices. BATH Complete daily bed bath. • Include range of motion to all extremities during bath, • Do not apply lotions and powders Keep skin clean and dry at all times. SCALP Massage daily to prevent pressure areas. Shampoo once a week. Patients may and should be shampooed when confined to tank. LINEN Change daily and P.R.N. Avoid wrinkles in sheets. • An extra draw sheet may be placed under pa. tient to facilitate turning patient. ELIMINATION • Patients should be closely observed for bowel and bladder elimination. (See Management of Constipation and Impaction.) . . Patients confined to the tank respirator demand and deserve excellent nursing care. Any nursing care procedure which should be performed for a critically ill bed patient should also be carried out for the tank bound patient by working through the portholes. Special attention must be given to the prevention of pressure areas especially of the neck and back. Frequent turning is one of the best preventive measures. Routine special back care is indicated. Neck care may be accomplished by soaping hand and massaging soap well into the neck. This serves to stimulate circulation and toughen the skin. This procedure may be done while patient is in the tank and without loss of pressure only when using the standard sponge rubber collar. A picce of foam rubber, not more than one-half inch thick wrapped in a soft diaper and placed around neck serves as an ercellent neckpicce both for patient comfort and relief of pressure from lung collar.

·52 SIGNIFICANT SOCIAL AND EMOTIONAL FACTORS IN POLIOMYELITIS . . DIAGNOSIS OF POLIOMYELITIS CARRIES WITH IT A SUPER-EMOTIONAL CHARGE • Unpredictability of outcome in the acute stage arouses anxiety in the patient and patient's family. Element of contagion causes- • Patient concern about other members of family. Family concem about other members. Reaction of neighborhood and community. • Widespread dramatization of disease by press, radio, television- • Serves to arouse guilt in parents regarding observation of publicized precautions. General idea of outcome-either permanent, severe crippling or death. Feeling of stigma arising from erroneous idea on the part of the public that occurrence of poliomyelitis is associated with inadequate personal and household hygiene, substandard living conditions . The Medical Social Service Worker can act as a bridge between the anxious family and the busy physician in establishing rapport and detecting social situations which may influence the patients' and families' acceptance of the medical program of management. Proper direction and utilization of social service activities by the physician will frequently help minimize and redirect the serious emotional and social consequences of this disease. Effective execution of home care planning and follow-up de pends on early and consistent medical social service coordination.

·SIGNIFICANT SOCIAL AND EMOTIONAL FACTORS IN POLIOMYELITIS . LONG TERM HOSPITALIZATION Frequent and considerable reassurance is required by the family during the isolation period. • Small children frequently fear they have been deserted by family. Prolonged hospitalization places strain on family relationship. Sacrificing of privacy is difficult for some patients in the communal type of living. • Financial hardships if family wage earner is the patient. Care of home and children if housewife is patient. Narrowing of interests with attention focused on physiological functioning results in an introverted patient Illness, resulting handicaps and long term hospitalization accentuates any pre-cxisting, faulty personality structures in patient and members of family PITYSICAL IMPAIRMENT Inability of patient and/or members of family to accept the inevitability of some degree of physical handicap. Need for adjustment to new way of life imposed on patient and family. • Relatives frequently become over-protective toward patient. • Conflict in patient around dependency vs. independency. Special adaptation of home and physical environment- • Coordination of community resources. Lack of resources. Change or modification of vocational goals. Attitude of employing groups toward handicapped individuals, . .

·PSYCHOLOGICAL FACTORS . . . ACUTE • Severe anxiety. Confusion, sometimes delirium. Stupor, sometimes coma. EARLY CONVALESCENCE • A shock-like reaction. Passivity. Regression, dependency, negativism. Guilt directed inwardly-diffuse self-blame in an attempt to find basis for his punishment. BEHAVIOR RESIDUALS Guilt directed Outwardly-patient tends to project his feelings of guilt by resentment and hostility to staff and/or family. Conflicting drives-dependency vs. independence. Emotional lability-tendency to over-react. Difficulty in concentrating-short attention span. Slowing down in ability to shift from one kind of mental activity to another. • Stress reactions in solving unfamiliar problems. • In residual paralysis, disturbance of the body-image and selfconcept may be a troubling problem. . . Intelligence tends to be somewhat higher than the general populat average. The mean verbal intelligence in an unselected series of 50 patie was 115, bright normal range. There are individual differences in this in the problems listed as characteristic of above stages. To meet a patiei psychological problems, that patient must be studied as a total react personality. There may be times when indicated medical procedures need to be : justed to the psychological readiness of the patient. Grouping and movi of patients may be used advantageously to promote a better understai ing of their condition to motivate and to encourage more out-going intere:

·55 POST-ACUTE AND CONVALESCENT TREATMENT OF POLIOMYELITIS IMPORTANT CONSIDERATIONS IN THE CONVALES- CENT PHASE OF TREATMENT 1 The goal of convalescent care is to attain the most useful function of which the patient is capable. This is reached by safe scheduling in which the physical activities required by the treatment program are balanced against the patient's tolerance. Practically, the attainment of this delicate balance throughout the recovery period is the largest problem in relabilitation Positive prescription of treatment in convalescence is most difficult. Treatment in the acute phase is naturally suggested by the vivid alterations in body function which rapidly develop at the onset. In contrast, the partial or complete recovery which occurs subsequently may take months or even years. The gradual nature of secovery processes makes evaluation of the patient increasingly intnmate and treatment needs less sharply defined. Complications also tend to be Insidious and obscure. Any scalıstic program places increasing physical demands upon the patient. The muscular component is readily apparent, but simultaneously de mands are placed upon other body functions which are not so clear but which may be of crucial significance. Recognition of these factors is implied in the cution of experienced clinicians to avoid fatigue." Fatigue is an unreliable guide to proper programing since it reflects not only a physiological compromise but, in addition, a sworly understood and relato tively inassessable psychological component. For these reasons a theoretical framework has been devised to define the principles which appear to be important cimical precepts for the safe conduct of the severely involved and are useful ia the optimum manager ment of the majonty of the patients. Respirator patient experience has undoubtedly emphasized, in the et treme, the principles and the more reliable olssersations which bear upon this most complicated situation. Vrtului act acearly the most active function posible ·58 THEORETICAL COMPONENTS OF BODY FUNCTION IN HEALTH NORMAL RESTING NORMAL ACTIVE EMERGENCY RESERVES RESERVES CAPACITY DEMANDS The bar graphs crudely illustrate the dynamic situation in which ca. PACITY FOR PTYSIOLOGIC WORK is the maximum abilty of the person to perform a particular function, e.g., respiration, circulation, muscular contraction, etc. DEMAND represents that proportion of the capacity which is utilized in the energy expenditure required by the particular activity. As a primary hypothesis it seems likely that an individual's capacity for physiological work of a particular kind normally exceeds any demands which are put upon it. In the case of breathing, quiet respirations involve minimal and most efficient energy expenditure for the work accomplished. The amount of work and the cost in energy can increase tremendously upon demand. In an emergency energy output can even temporanly exceed oxygen supply by virtue of anaerobic metabolism. The range through which increasing work output extends can be considered the reserve for meeting ordinary demands or sudden extreme needs occasioned by unusual activity, stress and disease.

·57 THEORETICAL COMPONENTS OF BODY FUNCTION IN DISEASE ACTE PHASE DECOMPENSATED PATIENT EMERGENCY RESERVE DEMAND I CAPACITY ASSISTED CAPACITY ASSISTANCE COMPENSATED CAPACITY OEMANOS 2.: REDUCED DEMAND PLUS ASSISTANCE TO REDUCED CAPACITY! The insult of a disease such as poliomyelitis reduces many of the body's capacities, cs, respiratory muscle paralysis decreases breathing capacity. When the reduction in capacity is severe, the demands of basal activity may exceed the maximum cffort which is possible. In the face of unavoidable demands upon inadequate capacities immediate correction must be made to prevent irreversible damage and death. There are three mcasures which are generally employed. (1) Reduce demand to the most basal state wluch can be obtained; (2) supplement or substitute for inadequate functions where possible, es, artificial respiration, (3) attempt to correct unsuitable or harmful body responses, e.g., severe hypertension, hypotension, etc. These principles are casily demonstrated in the treatment of severe respiratory impaiment and other ntal neuromuscular involvement. The decreased capacity of body functions such as circulation, metalvolism and even psychologic activity may be much less obvious. To some extent such considerations apply to most bodily activity in greater or lesser degrees depending upon the constitution of the person And the magnitude of the insult. The bar graphis illustrate the role of reduced demand and assistance or substitution in the presenation of life sustaining capacity ·60 CAUSES OF MUSCULAR WEAKNESS IN POLIOMYELITIS DIRECT VIRAL INVASION MOTOR NERVE CELL • Permanent destruction of the motor nerve cell with atrophy of denervated muscle fibers. Reversible changes with temporarily impaired nerve cell function and altered muscle contraction. . INTERNUNCIAL NERVE CELLS OF THE SPINAL CORD This may disrupt all but two neurone spinal reflex arcs and interfere with those descending tracts which end around internuncials as well as cross connections of segmental reflex arcs. • Permanent destruction or reversible damage with recovery, SUPRA-SEGMENTAL NEURONES Generalized hypotonia of central origin as seen in encephalitic forms. INDIRECT CAUSES • Reflex inhibition of muscular activity due to pain. Nutritional and metabolic disturbances leading to impaired muscle cell function, e.g., alkalosis, hypokalemia, etc. Potentiation of muscular weakness by fatigue and overstretching. Disuse atrophy. . . The most frequent and important cause of persistent muscular weakness is the invasion of the motor nerve cell by the virus agent. Clinical evaluation of this spinal cord process is obviously inexact. When nerve cell destruction is extensive enough to eliminate the majority of the motor units comprising a muscle, flaccid paralysis with absent tendon reflexes is observed. Apparently a considerable number of motor units can be inactivated before clinical evidence of "weakness" appears. Various grades of "weakness” cannot be directly related to the extent of motor nerve cell destruction. Treatment is nonetheless based upon the assumption that recovery of the cells can occur. Time alone decides whether significant destruction has occurred since 50-75% of the eventual recovery of muscle ·THEATIENT OF ACUTE POLIOVELTIS power will occur in three to six months and maximum recovery is generally seen within 18 months. The other causes of weakness probably contnbute in various degrees to the acute symptoms and account in part for some of the remarkable recoveries which clearly cannot be a result of reconstitution of the motor nerve cell population. 81 ·64 BODY POSITIONING OF THE POLIOMYELITIS PATIENT . . . . OBJECTIVES Maintain normal skeletal alignment. Prevent deformities. Protect weak muscles from continuous stretching. Relieve pain and restlessness. ACUTE STAGE Frequent and judicious change from back to side and abdomen (if tolerated) with use of pillows and rolls as needed to place shortened painful muscles in a rest position. Maintain body alignment within the limits of comfort. POST-ACUTE STAGE Gradual reduction in amount of pillows and rolls to those need ed for maintaining good body alignment. Support weak muscles. Hand rolls Foot board, shoes on board, Knee roll. Counteract muscle imbalance and habitual positioning. Change rest position of all joints at periodic intervals. Range of motion . . . . The nursing care of patients with poliomyelitis is identical to the care of any acutely ill patient. Attention to pressure areas, proper positioning, and range of motion are of primary importance in preventing decubiti, stasis, and deformity. Patients are turned and positions changed at least every two hours. Hands should be kept in a functional position, feet positioned to prevent foot drop, and lower extremities positioned to prevent outward rotation. Knee and ankle rolls should be of proper size-avoid the use of large soft pillows. Any one continuous position will produce detrimental effects on the further rehabilitation of the patient. Positioning and range of motion must accompany each other for good care.

·RANGE OF MOTION PURPOSE USE • To minimize fibrosis and contracture in muscles, tendons, fascia, and joints which occur from immobilization and habitual position. • To maintain and increase the present range of motion. When active motion of all joints cannot be performed by the patient, as in muscle paralysis or unconsciousness. Support the part firmly. Move the part just short of the point of pain through its full range if possible. Repeat each motion three to five times at least once daily. PROCEDURE . . Range of motion need not be done as a complete and separate procedure once the routine is learned It can be accomplished on an extremity or joint at a time during routine care such as the bath, taking of blood pressure and changing positions. In acute polio the muscle bellies are sore and tender. For the patient's comfort, he should be handled and moved at foints and bony prominences with the flat of the hand. Sec Joint Range of Motion for specific motions ·66 MANUAL MUSCLE TESTING . EVALUATION OF INDIVIDUAL MUSCLE STRENGTH BY THE USE OF MUSCLE ACTION, PALPATION, CRAVITY AND MANUAL RESISTANCE USEFUL FOR Diagnosis: Presence, pattern and extent of muscle weakness. Prognosis: Area of involvement. Rate of progression of weakness. Magnitude of loss of muscle power. Rate and extent of recovery. • Treatment and its evaluation in: Muscle re-education Assistive supports and splints. Permitted functional activity. Reconstructive surgery. GRADING (Lovett system-the basis for most present day grading.) 100% Normal Complete range of motion against gravity with full resistance. (A normal muscle, regardless of age, build, occupation, etc. has a resilient (springy) feeling when resistance is applied.) 75% Good Complete range of motion against gravity with moderate resistance. (A GOOD muscle will play out when resistance is applied.) 50% Fair Complete range of motion against gravity. Complete range of motion with gravity eliminated. 10% Trace No motion of the part, but contraction of the muscle or tendon is felt. 0% Zero No motion or contraction present. Physicians will find it valuable to be familiar with general group muscle testing for diagnosis and planning the treatment program. (See General Evaluation of Muscle Strength), but usually rely upon the skill of the physical therapist for a detailed muscle examination. In the diagnostic and ·TREATMENT OF ACUTE POLIOSTYELITIS 67 acute stages of poliomyelitis a quick general evaluation of muscle strength is sufficient, so that the patient is not unnecessarily exhausted. Poliomyelitis, especially in the stage of progression, is characterized by asymmetrical weakness involving muscle groups around the same spinal segment. After the patient has been afebrile for 48 hours a detailed muscle test is in order. It is recognized that muscles perform in groups and that their actions arc overlapping. Nevertheless, no two muscles have exactly the same action and no motion can be performed normally without all of its muscular components. With good knowledge of muscle function, careful positioning and observation, the strength of each muscle can be differentiated and a treatment program instituted ·68 PROCEDURES USED TO INCREASE MUSCLE STRENGTH AND COORDINATION . MAXIMUM RECOVERY OF BALANCED MUSCULAR ACTIVITY REQUIRES CONTINUOUS ATTENTION INITIALLY Protect Weak Muscles by Avoiding Continuous or Purposeless Activity Bed rest. Support weak muscles. Protect • Limit physical activity. and Utilize Splinting Which Assists Function and Pre- Coordinate vents Substitution. See Assistive and Supportive Apparatus. Institute Muscle Re-education • Retrain “proprioceptive mechanism”-awareness of the dynamic position of muscles, joints and entire body members. • Increase muscle power. • Achieve and strengthen coordinate patterns of motion. Prevent Substitute Action of Strong Muscles for Weak Strengthen Ones-Leading to Imbalance and Deformity, Do Not Overuse Weakened Muscles (overuse produces progressive incoordination--development of faulty motion patterns and loss of power.) LATER (3 to 9 months) SELECTIVELY STRENGTHEN APPROPRIATE MUSCLES BY HYPERTROPHY TO Compensate for muscular imbalance. Obtain maximum strength for useful work or appropriate substitute activities Obtain maximum endurance in function. . As pain and soreness subside passive range of motion is established. Then a program of re-education of the muscular system is started. This consists of progressively increasing the work of the muscle by manual assistance, ·TREATMET OF ACUTE POLIOBYLITIS 69 changes in the amount of friction upon the part being moved, increasing the work of the individual muscle against the effect of gravity and resist. ance. At no time is the patient allowed to produce jerky motions or utilize other than the desired muscle or muscles. These pnnciples are accomplished most effectively by the physical therapist Careful employment of auxiliary aids such as hydrotherapy, sling suspension and counterbalancing wcights may assist the physical therapist in attaining the desired end result.

·72 INCREASING FUNCTIONAL ABILITY EARLY • Teach normal patterns and actions, e.g., use crutches to maintain normal relationship of parts in the walking pattern to stimulate further recovery and balanced action. • Work below maximum tolerance of the patient. LATER (6 to 12 months) OVERDEVELOP RESIDUAL ABILI. TIES TO SUBSTITUTE FOR LOST MOTIONS-INCREASE WORK DEMANDS Increase proprioceptive senses through repetitive practice. Hypertrophy remaining useful muscle fibers by high resistive exercises. • Develop skill in substitute actions, e.g., moving from wheel chair to bed using arms, tying shoes with one hand, Utilize assistive devices where needed to increase function and endurance. • Develop endurance by repetitive highly resistive exercises and skills to the point beyond which performance suffers. Utilize surgical procedures to restore motion, stabilize, and eliminate appliances. Useful functional achievement is the goal of all rehabilitation programs. The patient should be tested to determine his independent ability to perform ordinary daily acts such as dressing, brushing teeth, eating, walking, climbing stairs, etc. and a program for attainment should be outlined. Goals are based on the muscular capabilities, the physiological capacity, the practical need for the activity and the patient's desire. Retraining and substitution of residual abilities is similar to the programn of activity analysis and the development of skill and endurance used in the training program for the superior athlete.

·73 ORTHOPEDIC SURGERY GENERAL CONSIDERATIONS IN POLIOMYELITIS PREVENTION IS MORE DESIRABLE TILAN CORRECTION AIMS • Prevent deformities of bony structures of primary importance for the growing child. • Restorc or assist useful function. • Eliminate appliances and apparatus while maintaining function. • Correct deformities. EMPLOY EXTREMELY CAREFUL EVALUATION OF THIE PATIENT IN ORDER TO INSURE THE EFFECTIVENESS OF SURGICAL PROCEDURES Effectiveness of surgical procedures depends as much upon the functional capacity to take advantage of the result as upon the perfection of the operation, c.5, a probably successful opponens transplant may be contraindicated in the absence of extensor digitorum communis function. • The specific procedure used and the end result obtained depend upon patient cooperation and the adequacy of follow-up сиге. . • Utilize accurate estimations of bone age in planning surgical procedures. Stabilization and fusion operations are performed to assist function, increase stability, correct associated deformities or clim. Inate the need for appliances. • Tendon transplants are used to substitute for a lost function or to redirect a deforming force. • Transplants for motors should use muscle which has at Icast 70% of normal strength. Proper combinations of stabilization and transplants may achieve better function than either alone. Thiesc factors are presented to and the physician in understanding the molc of orthopedic surgery and to faalitate its effective employment at the most suitable time. The Orthopedist must see the patient carly and follow ·76 MANAGEMENT OF NEPHROLITHIASIS . PREDISPOSING FACTORS • Long standing immobilization with demineralization and hypercalcuria, infection of the urinary tract, oliguria, urinary stasis, and constitutional factors. PREVENTIVE MEASURES (see Urinary Bladder Retention and Treatment of Metabolic Problems in Post-Acute Poliomyelitis) Maintain adequate urine volume with large fluid intake to obtain urine sp. g. of 1.010 to 1.020. Evaluate for the presence of stones with serial abdominal plane film radiography for early treatment. Avoid high vitamin D intake. Utilize serial urinalysis and urine culture to permit prompt, adequate and specific anti-bacterial therapy. Mobilize the patient as soon as practical: use early physical therapy, see that there are frequent changes of body position, attempt early skeletal weight bearing using the standing bed. Use periodic renal functional studies with history of infection and evidence for hypertensive cardiovascular renal disease. COMPLICATIONS Uretero-pelvic and ureteral obstruction-signaled by fever, polymorphonuclear leucoytosis, dull flank pain and/or intermittent colic, microscopic hematuria and pyuria which absent at the onset. ACUTE renal shutdown, TREATMENT • Use IV pyelography to determine functional status of the kidney and establish site of obstruction if such exists. Instrumentation is necessary to dislodge stone or remove it if possible. • Ureteral catheterization to by-pass stone and promote pelvic drainage and irrigation. Surgical intervention may be necessary to preserve kidney if instrumentation fails and renal shutdown persists. ALWAYS retrench respiratory schedule in respirator patients Use whole blood transfusions if hemoglobin is low. may be ·TREATMENT OF ACUTE POLJOMYELITIS 77 Preventive measures may be inadequate and impossible to attain. Treatment for secondary infection must be prompt to avoid chronic renal inflammatory disease and subsequent impairment in renal function. The pri. mary lazard of renal shutdown must be corrected if possible. There is little doubt that these intercurrent complications appear to interfere severely with the respiratory patient's rehabilitation program and retrenchment is essential.

·78 BEGINNING WEANING FROM RESPIRATORY ASSISTANCE OF THE IMMEDIATE POST-ACUTE PATIENT . . . . ESTABLISH CONFIDENCE IN THE PATIENT AND FAMILY DURING THE ACUTE STAGE Absolute familiarity with equipment by the entire staff to avoid apprehension due to "accidents." Avoid having patient or family dictating treatment. PRELIMINARY POST-ACUTE EVALUATION Tidal volumes in the tank respirator. Vital capacity if possible, • Obserye breathing muscles. • ECG Frequent blood pressure and pulse, CBC Muscle test. TREATMENT FOR THE FIRST TIYO WEEKS Establish hospital routine and eliminate special privileges for patient and family. Discontinue oxygen therapy. Reset pressure and/or rate of tank respirator to the lowered needs of convalescence to avoid hyperventilation • Set and maintain daily breathing schedule • Introduce cuirass respirator twice daily, beginning with fifteen minute periods and increasing to one-half to one hour · Breathing alone three times a day IF vital capacity is more than one-half of tidal volume. (If this is the case only three to five minutes should be allowed. If vital capacity is more, periods may be up to, but not exceed one-half hour.) Bath during a.m. and physical therapy during p m. cuirass times. Remove urethral catheter, Remove tracheotomy tube. . . After becoming accustomed to the cuirass respirator and short periods slaap in un danner pf the nation' hanemine 2.2. men .. -- ·79 METHODS OF EVALUATING THE RESPIRATORY PATIENT FOR THE PROGRESSIVE WEANING AND REHABILITATION PROGRAM . RE-EVALUATION OF THE PHYSIOLOGICAL RESERVES WITII REPETITION AT LEAST MONTHLY THEREAFTER FACTORS USED IN DETERMINING PROGRAM Vital capacity value: Its magnitude; relation to tidal volume needed for breathing and breathing muscles used, rate of increasc, appearance of a decrease, appearance of plateaus or sudden changes; variation between horizontal and sitting values (with and without abdominal support). • Maximum breathing capacity values: Which indicate increase, decrease and dissociation from vital capacity values. • Tidal volume: In tank and cuirass respirator to determine ade quacy of ventilation in different devices and for avoidance of hyperventilation • Fluoroscopic obscrvation: Use of breathing muscles, pulmonary deration, pulmonary complications and cardiac silhouette (if patient can breathe alonc for 5 minutes). • CBC: For appearance of anemia or polyethemia due to hy. poxia. · ECG: Ilcart ratc, rhythm disturlances (especially nodal shythm, intermittent nodal rhythm or escaped beats). P-R distance, width of Pand QRS, Q-T time, frontal and spacial projection of QRS and T-vector, presence or alsence of RS-T deviation, cvidence of stress. • Blood pressure and pulse: (Taken for stability of 2 day series) lor pattern of mean values, evidence of hypertension, intolchance to upright position and physical activity. • Blood chemistries and urinalysis: For evaluation of renal function. Complications of any variety influence capacity for unassisted breathing There is no substitute for clinical judgment for optimum care. Oloset13. tion of the patient's general appearance, appetite, attitudes, cooperation, signs of fatiguc, and needs for rest should be made. All of the above with a ·78 BEGINNING WEANING FROM RESPIRATORY ASSISTANCE OF THE IMMEDIATE POST-ACUTE PATIENT . + . ESTABLISH CONFIDENCE IN THE PATIENT AND FAMILY DURING THE ACUTE STAGE • Absolute familiarity with equipment by the entire staff to avoid apprehension due to "accidents." Avoid having patient or family dictating treatment. PRELIMINARY POST-ACUTE EVALUATION Tidal volumes in the tank respirator. Vital capacity if possible, Observe breathing muscles. ECG Frequent blood pressure and pulse. CBC Muscle test. TREATMENT FOR THE FIRST TIVO WEEKS • Establish hospital routine and eliminate special privileges for patient and family Discontinue oxygen therapy. • Reset pressure and/or rate of tank respirator to the lowered needs of convalescence to avoid hyperventilation. • Set and maintain daily breathing schedule Introduce cuirass respirator twice daily, beginning with fifteen minute periods and increasing to one-half to one hour. Breathing alone three times a day IF vital capacity is more than one-half of tidal volume. (If this is the case only three to five minutes should be allowed. If vital capacity is more, periods may be up to, but not exceed one-half hour.) Bath during a.m. and physical therapy during pm. cuirass times. Remove urethral catheter. Remove tracheotomy tube. 2 + . After becoming accustomed to the curass respirator and short periods Laman afhendinni Loncinnti ·79 METHODS OF EVALUATING THE RESPIRATORY PATIENT FOR THE PROGRESSIVE WEANING AND REHABILITATION PROGRAM . • RE-EVALUATION OF THE PHYSIOLOGICAL RESERVES WITH REPETITION AT LEAST MONTHLY THEREAFTER FACTORS USED IN DETERMINING PROGRAM Vital capacity value: Its magnitude; relation to tidal volume needed for breathing and breathing muscles used, rate of increase, appearance of a decrease, appearance of plateaus or sudden changes, variation between horizontal and sitting values (with and without abdominal support). • Maximun breathing capacity values: Which indicate increase, decrease and dissociation from vital capacity values. Tidal volume: In tank and cuirass respirator to determine adequacy of ventilation in different devices and for avoidance of hyperventilation. Fluoroscopic observation: Use of breathing muscles, pulmonary aeration, pulmonary complications and cardiac silhouette (if patient can breathe alone for 5 minutes). • CBC: For appearance of anemia or polycythemia due to hypoxia. • ECG: Heart rate, rhythm disturbances (especially nodal rhythm, intermittent nodal rhythm or escaped beats), P-R distance, width of P and QRS, Q-T time, frontal and spacial projection of QRS and T-vector, presence or absence of RS-T deviation, evidence of stress. Blood pressure and pulse: (Taken for stability of 2 day series) for pattern of mean values, evidence of hypertension, intolerance to upright position and physical activity. Blood chemistries and urinalysis: For evaluation of renal function, Complications of any variety influence capacity for unassisted breathing. . There is no substitute for clinical judgment for optimum care Observation of the patient's general appearance, appetite, attitudes, cooperation, signs of fatigue, and needs for rest should be made. All of the above with a ·80 TREATMENT OF ACUTE POLIOMYELITIS consideration of the patient's feelings, staff observation of his attitudes and objective tests should be used in determining the pacing of the patient's entire program. It is recognized that even with these guides the patient may be advanced too rapidly. Breathing aid should be increased and/or activity decreased until the patient becomes stable in his various responses. Then the program should be gradually progressed again. Intercurrent complications-infections, etc-always require retrenching in the direction of increased respiratory assistance.

·81 PROGRESSIVE REHABILITATION OF THE CONVALESCENT RESPIRATOR PATIENT . . • A schedule is unchanged for at least one to two weeks so that adequate observation can be made. Patient and nursing staff should not alter the schedule. . Gradual weaning from the tank respirator during the day depends upon early progressive use of less effective breathing aids. • Introduce the rocking bed. Increase the cuirass respirator time. Increase breathing alone tune IF breathing muscles and physiological reserves permit. Gradually increase the variety and extent of activity using the cuirass respirator during such activities. (Physical and Occupational Therapy Progression in Respiratory Polio.) Evaluate the patient for sitting and performing functional activities without using breathing aids. Start with the reclining chair and evaluate responses to the upright position. Gradually assume full upright position. • Change to cuirass or rocking bed at night if possible, starting with 1 night a week, of tolerated, increase to 2, etc ... • If elimination of respiratory aid at night is to be considered, at should be done 1 night a week and then 2 and so on... Carefully consider the physiological reserves and the practicality of walking before attempting such physical effort Walking should not be considered if the vital capacity is below 800 cc. in an adult • Use breathing aid at night and/or for rest periods in order to conserve energy for increased activity during the day. :-.- •1 1 This is a continuous slow process over weeks and months, each change followed by a period of observation. Only one variable is changed at a time so that the breathing schedule is increased while activity is held constant or vice versa Sacrifice weaning speed if necessary to allow neuromuscular rehabilitation to proceed concomitantly. It is obviously more desirable to have a well adjusted, functional, clear thinking individual using breathing help than to have a chronically underventilated, tired, stressed and irritable patient who breathes unaided.

·82 PHYSICAL AND OCCUPATIONAL THERAPY PROGRESSION IN RESPIRATORY POLIOMYELITIS . PHYSICAL ACTIVITY CATEGORIES O NO TREATMENT • No physical or occupational therapy procedures except po. sitioning to maintain good body alignment and comfort. 1. MUSCLE EVALUATION AND JOINT MOTION: To evaluate neuromuscular status, relieve muscle pain, and maintain joint motion. • Initiated 48 hours after febrile stage, All motions (with the exception of shoulders) can be carried out in tank respirator (see Range of Motion). • Usually between the 5th and 15th day from onset the patient can tolerate the cuirass respirator for periods sufficiently long enough to carry out all procedures adequately. II. STRETCHING, MUSCLE REEDUCATION AND OCCUPA. TIONAL THERAPY IN BED: To increase range of motion and re-establish coordinated neuromuscular patterns of motion. All procedures may be done in the cuirass respirator from the back-lying position, • For posterior muscle groups the therapist must support the weight of the part and use gravity assisting exercises. III. HYDROTHERAPY OR STANDING BED: Hydrotherapy utilized to relieve muscle pain and tightness and for muscle reeducation. Standing bed to achieve weight bearing and promote circulatory adjustment to the upright position. Transportation of patient may require portable motor for cuirass respirator Hydrotherapy and standing bed accomplished using cuirass as ordered. Hydrotherapy and standing bed may be done on alternate days if both are indicated. , Utilize abdominal support and leg binding to minimize venous pooling Exercise procedures done at another period during the day ·TREATMENT OF ACUTE POLIOMYELITIS 83 The standing bed is utilized as a convenient and practical method of gaining the necessary circulatory adjustment to the vertical position and at the same time to start weight bearing. Patients are started at 30° and over a period of days and weeks the angle and the time are increased Frequent pulse rate and blood pressure determinations are taken before, during and following the procedure and the patient is observed for color, presence of perspiration, and general feeling of well being as aids in judging the rate of progression.

·84 PHYSICAL AND OCCUPATIONAL THERAPY PROGRESSION IN RESPIRATORY POLIOMYELITIS . PHYSICAL ACTIVITY CATEGORIES IV. RECLINING CHAIR, HYDROTHERAPY, STANDING BED, OCCUPATIONAL THERAPY IN SHOP: To prepare for function and coordination of breathing and balance with activity. Patients are started in a reclining chair (lounge type with undercarriage) and gradually increased in time and an gle towards vertical. Beginning muscle reeducation in overhead arm slings--activities of a light nature. Procedures are spread over the day either using the cuirass or breathing alone depending upon medical order. V. SITTING STRAIGHT: To gain function in the upright position probably using slings and adaptive equipment. Utilize full reclining back wheel chair for short periods. Change to conventional straight back wheel chair if possible and practical for the patient. • If it is decided that patient may now sit without breathing aid, he should be dropped back to category IV and progressed to his tolerance. VI. NO CARDIO-RESPIRATORY PROBLEM • Patient is managed as uncomplicated poliomyelitis. O . The respiratory patient needs and can receive all the procedures that are ordinarily given in uncomplicated poliomyelitis, but can accept them only if given over an extended convalescent period. These categories are uti. lized as a general guide to increasing energy demands on the patient. They are arrived at by evaluation and joint staff conference with the physiatnst and orthopedist prescribing the specific procedures which are allowed by the tolerance categories Infections always require retrenchment, the patient is put back to activity categories of 0 or I followed by gradual resumption of activity:

·85 FUNCTIONAL ACTIVITIES FOR THE SEVERELY INVOLVED RESPIRATOR PATIENT . . . OBJECTIVES Function in the upright position. Promotion of outgoing interest and self confidence. Development of occupational and social usefulness. METHODS: Integrate energy consuming activities gradually ac cording to the patient's tolerance and ability (see Methods of Evaluating the Respiratory Patient ... and Physical and Occupational Therapy Progression), • Increase sitting angle and sitting tolerance. Increase neck and trunk balance, Coordinate breathing and talking in the upright position. Utilize activities requinng small energy expenditure-reading, needlework, etc. PRIMARY FUNCTIONAL GOALS: Self help and self care are stressed with manual activities used to develop the required motions. Such goals are relatively low in energy expenditure and of high functional importance. Reading (turning pages). Communication (write, type, talk on phone). Self feeding SECONDARY FUNCTIONAL GOALS: Increase scope of activities in ratio to physical and mental ability. • Personal care (make-up, shave, brush teeth, comb hair). Sedentary occupation (household duties, office work). • Dressing, propelling wheel chair. Transferring (to bed, wheel chair, toilet, shower, car, etc.). Walking, climbing stairs, etc . In respirator patients only limited activity can be achieved due to the markedly reduced physiological and muscular capacities for work. Goals of attainment should be set which will accomplish the most useful function with the least expenditure of energy. Full exploration of the possible scope of activity is necessary as well as penodic evaluation and the use of self ·86 TREATMENT OF ACUTE POLIOMYELITIS help devices if a much greater and more desirable end result is attained. Accomplishments are greater than would be suspected possible from the ex. tent of paralysis. Children are able to complete their education, mothers can supervise and help in the household and often supplement the income. Many patients have become partially or totally financially independent through occupations such as merchandising, selling services, teaching in all of its aspects, abstracting, translating, providing answering services, man. aging businesses, and acting as technical consultants.

·87 EARLY EVIDENCE OF INJUDICIOUS RESPIRATORY PROGRAMING EXCESSIVE ACTIVITY EMOTIONAL LABILITY: Disinterest-addiction to respuatory aids, to the immediate environment and personnel-lack of motivation or unreasonable drive. SPONTANEOUS BREATHING IS PROGRESSIVELY DYSPNEIC AND RAPID ALTERATION OF VITAL SIGNS Pulmonary compartments: Vital capacity-arrest of progressive increase (utiuze average of several measurements). MBC-relatively low. Circulatory measurements: Increase in average pulse rate. Instability of 48 hour series of pulse rate. Sught increase in average diastolic pressure of 48 hour series. • Serial and progressive ECG evidence of shortened P-R time and prolonged Q-T time. BLOOD CHEMISTRIES: Progressive elevation of serum Ca++ and fall of serum K+ - Nat high normal to elevated. BLOOD ELEMENTS: Increasing or decreasing Hgb. URINE: Decreasing Sp Gr-increasing volume. . Determination of stress which ultimately produces serious physiological decompensation is an important aspect of the convalescent care of severe paralytic poliomyeltis. The case with which limited body reserve is exceeded appears to depend upon complex factors such as. (a) residual circulatory and respiratory insufficiency; (b) the metabolic and nutrtional status of the patient, (c) the speed and manner of resumption of physical activity, (d) severity of muscle paralysis, and (e) individual constitutional characteristics Separate identification of the contributing factors is not often possible or so important as the elimination of injudicious respiratory scheduling and excessive activity. The detection of excessive activity may be simplified by the comparison of repeated surveys of the time indicated.

·88 SIGNS AND SYMPTOMS OF SEVERE STRESS 1 4 . . Irritability-drowsiness-fatigue-lack of cooperation. Increased need and desire for breathing assistance-dyspnea- "all or none" effort. Increase in body weight-edema--puffy facies Hirsutism-seborrhea-acne. • Nutritional disturbances-gastrointestinal disturbances with distension, vomiting, bleeding, Dehydration--temperature elevation. Decreased vital capacity. Progressive alteration of vital signs. Marked increase in pulse rate and instability, Systolic and diastolic hypertension. ECG evidence of marked decrease in P-R time and prolongation of Q-T, QRS vector alterations with altered T waves and Q-T-T separation-high peaked P waves. Blood chemistries–Na+ retention and K+ depletion - elevated Ca++ increased B.U.N. Urine-elevated 17-ketosteroids--failure of renal concentration and/or oliguria . . ► . Since severe stress involves many body functions there is no single reliable indicator. Early detection depends upon single observation of parallel changes in several body functions such as mental condition, declining vital capacity, circulatory status, elevated blood pressure, altered serum electrolytes, etc. Most frequently, the trend of a series of relatively simple anto forestalla imnrnner nrogression of respiratory and physical i versus inactivity may *ion, such as markedly elevated blood pressure, which may be irreversibie. there is increasing evi. dence that the poliomyelitis patient may achieve more useful activity and a better respiratory prognosis with fewer intercurrent metabolic and circulatory complications if such a philosophy of treatment is utilized. It is a cautious program of evaluation, care and rehabilitation which initially takes more time and effort ·89 REMOVAL OF THE TRACHEOTOMY TUBE . PREREQUISITES Ability to swallow fluids and solids without aspiration. Absence of pulmonary pathology by X-ray. • Demonstration of effective swallowing with lipiodol by fluoroscopy. DISADVANTAGES OF RETAINING TUBE UNNECESSARILY Stimulation of excessive secretion so long as foreign body (tube) is in the trachea. This necessitates more nursing care and handicaps accurate evaluation of the breathing reserve. • Slower progress in weaning from respiratory aid is observed. • Addiction to unnatural airway occurs especially in children. PROCEDURE • If large tube was used, decrease size and length over a period of several days. Close tube during the day for several periods as long as tolerated. Open for suction only as needed. Gradually close for 24 hour periods, only opening for suctioning After two or three days remove the tube. • Use artificial coughing devices and coughing maneuvers in the tank respirator to prevent accumulation of secretions. • Steam inhalations for two or three days liquefies secretions. • If failure occurs (rarely) replace the tube. • Before attempting removal in one to two weeks obtain traucheal culture and sensitivity tests and place patient on prophylactic antibiotics. . . As soon as prerequisites are present, removal procedures should be started. Remove tracheotomy tube even if some suctioning is necessary, since mucus will be present as long as the tube is in place ·NURSING CARE-POST-ACUTE RESPIRATORY POLIOMYELITIS ROUTINE ORDERS (S.W.P.R.C.) • When reinstituting oral feedings in the patient recovering from impairment of swallowing, a nurse should always be in attendance. • Breathing schedules are posted on the bulletin board, in the patient's room and in the Kardex. Schedules are ordered by the doctor. Patients are to be kept on schedules as much as possible and no changes are made unless approved by the doctor. EXAMPLE OF BREATHING SCHEDULE C.F. 9 to 12 12 to 5 5 to 9 5 P.M. to 9 A.M. 3/13/53 Alone Monaghan Alone Monaghan . There are activity schedules and therapeutic appliance schedules on bulletin boards in patients' rooms RESPIRATORY STUDY CHARTS: See example on page 92. These charts are run for 48 hours. They are ordered by the doctor who fills out the schedule. The charts are started at 6 A.M. and completed at 6 A.M., 48 hours later. The patient's pulse, respirations and blood pressure are taken BEFORE he is changed to another type of breathing aid and before he starts breathing alone. The respiratory rate of mechanical breathing equipment should be counted and recorded in “Respirations” column. If a patient spends all day in the same type of breathing aid or if he is completely weaned, the vital signs should be taken every 4 hours, 6 A.M. to 10 P.M. for 48 hours. If the patient spends more than 4 hours in one type of respiratory aid, the vital signs should be taken at the end of 4 hours.

·THEATMENT OF ACUTE POLOMYELITIS 91 Example: 8 to 2 2 to 5 5 to 9 9 P.M. to 8 A.M. Monaghan Rocking Bed Monaghan Tank . The blood pressure, pulse, and respirations should be taken at 7:55 A.M. before taking patient out of tank; at 12 noon because he has been in the same type of aid for 4 hours; at 1:55 before taking patient off rocking bed, at 8:55 before taking patient out of Monaghan • Medications containing iron are to be given between meals and are never given with milk • Enemas are given PAN. An oil retention enema may be given if necessary. See Management of Constipation and Impaction. Respiratory patients MUST be able to breathe 15 to 30 minutes alone before they are taken to the bathtub. Check with nurse in charge before taking such a patient for the first time. • Patients may leave the hospital with doctor's permission for specified times.

·RESPIRATORY STUDY SHEET 4 DATE B-11-14 NAME de-WM. 29 Yrs. Wt. 136, Rt. 74 Order: 9-11:30 Cuirass 4-6 Rocking Red 11:30 - 1:30 Rocking Bed 6 - 8:30 Cuirass 1:30 - 4 Cuirass 8:30 p.a. - 92.n. Tank Resp. RRJM, D. Kind of breathing Respito Blood Data Time RB, M,T, Alone) Pulse tlon roto pressure 18.11.546 A.MI TANK 80 I (20) ²0/? GATIEN 83 JBREATH TANK auto 9: CUIRASS 100 T (20) Pos/ PER (PERIOD 10: cuRASS → 175 10:30 COLLING BED c (20) islas 12: ROCKING BED 1:30 P.M.) → Cuirass 10a RB.(18) 75730 2; 3: 4: CUIRASS ROCK BEL c (20) (150/10 5: 6; Pockin BED CWRASS 90 R.B. (18)}14/05 7: 8:30 CHILASS → TANK 84 T(0) 1390 9: 10; TANK 7 (20) (140/? 17 & 12 1 & 2 3 & 4 5&6 Record blood pressure, pulse, respiration five minutes before changing from one kind of breathing to another. If patient is continuously in one kind of breathing aid, take values again two hours and four hours after starting. Don't stop tank or rocking bed when taking values.

·93 MANAGEMENT OF CONSTIPATION AND IMPACTION . PREVENTION IS BEST-NORMAL FLUID INTAKE AND DIET ARE IMPORTANT ENCOURAGE ELMINATION AT REGULAR INTERVALS • Avoid use of cathartics. • Give soap suds enema every other day if necessary for proper elimination • Give oil retention enema if S.S.E. is not effectual. Manually break up and remove fecal impactions with well lubricated gloved index finger. Do Not Ethaust Patient • Feces formation is minimal during parenteral alimentation CAUSES Dehydration-minimal bulk in diet. • Absence of effective abdominal muscle contraction with increase in intra-abdominal pressure • Distention of bowel and disturbances in motılity. Never give more than two successive enemas especially to the respiratory patient. If after two enemas good results have not been obtained, the pa. trent should be allowed to rest a few hours Then he should be given an oil retention enema and placed in slight Trendelenburg position for one half hour, which aids the patient in retaining the oil Follow with a soap suds enema, Patients with severe constipation may benefit by an ol retention enerna the night preceding soap suds enerna. Patients with fecal impactions may complain of abdominal discomfort, nausea and vomiting Objectively, impaction can be noted by abdominal distension, by palpation of the abdomen, or by difficulty in inserting a rectal thermometer or rectal tube. If the impaction is high, it may be necessary to give an oil retention ene. ma followed by soap suds enema until the bowel is cleaned out. The danger of exhausting the patient is always present and these treatments should be spaced over a period of hours or days depending on the number of treat. ments necessary and the patient's condition. The respiratory patient is especially distressed when suffering from a fecal impaction and usually requires maximum breathing aid if prolonged treatment is necessary.

·94 HOME CARE PLANNING FOR THE RESPIRATORY PATIENT PRELIMINARY . . EARLY AND PROGRESSIVE PLANNING IS ESSENTIAL Periodic evaluation and programing by the entire staff. Discussion of the program and aims with the patient and family. PSYCHOLOGICAL AND SOCIAL ADJUSTMENT Gradual adjustment of the patient and family to the practical significance of his medical, social, and psychological prognosis (including the fact that the patient may not make full recovery). Exposure to group of similarly impaired patients, and especially to those who return from home for check-ups. Evaluation of patient and family. Encourage participation in outside social activities (with doctors and nurses in attendance). Gradual introduction of the family to the complications of care. Attendance at above social activities with patient. Short home visits with doctors and nurses in attendance and later assuming full responsibility. Week-end home visits. Definite plans for home care outlined with the patient and the family several months previous to anticipated discharge. POINTS WHICH DETERMINE PROGRAM Pattern of response in serial evaluation of the physiological re- . . serves. . Fatigue response to carefully regulated breathing, physical and occupational therapy schedules. . Occurrence and response to intercurrent infections and complications. Requirements for further rehabilitation. Resources of family and community (financial, emotional, interpersonal relationships, vocational, etc....). · Availability of medical follow-up and remedial hospitalization.

·TREATBIENT OF ACUTE POLIOMYELITIS 05 The ultunate purpose of treatment is decentralization of the patient from special services to home care This should be kept in mind throughout the patient's stay and the foundations for successful weaning of the patient from the hospital should be started upon admission of the patient. There must be integration and joint participation in the planning for the home care of severe respiratory patients. Each member of the hospital team should be kept informed of the patient's progress within the area of each of the other members of the team Only in this manner is it possible to have consistency and continuity in the attitude presented by each of the staff to the patient and his family. Repetitive reassurance and interpretation from each area is required for the complete adjustinent of the patient an! his family. Without this underlying philosophy, the structure of the hospital program as well as home care fails ·96 DISCHARGE PLANNING . MEDICAL REQUIREMENTS Evaluation of the family composition and physical setting of the home to determine the needs of the individual. · Adaptation of the patient to less expensive and complicated breathing devices. . Well defined schedule within the patient's tolerance, keeping in mind that the initial phase of home adjustment is fatiguing. Complete summary, status report, and outline of medical care to the patient's responsible physician, • Orientation and instruction of the family and attendant prior to discharge on diet, care, equipment and simplified physical and occupational therapy procedures. • Insistence on the hazard of intercurrent complications, their signs, etc. • Periodic re-evaluation as dictated by the patient's individual requirements. COMMUNITY PARTICIPATION Provision of special respiratory and mechanical devices (breathiog aids, wheel chair, lifter, emergency generator) and attendant as deemed necessary in cooperation with the financially responsible groups. • Provision for maintenance and repair of equipment. • Provision for emergency hospitalization and supplementary respirator aids. • Evaluation and solicitation of recreational, educational, and you cational facilities. Arrangements for transportation to home including vehicle, power, moving of equipment and patient care ADJUSTMENT OF PHYSICAL SETTING Room location and size, door widths, emergency exit. Wiring and power. Bathroom facilities. Bed-type and height. Storage space for equipment. Provision for going outside the home-ramp, portable breathing aid. .

·TREATMENT OF ACUTE POLIOMYELITIS 97 Treatment should not be considered completed upon the patient's discharge from the hospital. Through periodic re-evaluation the patient's program can be supervised and continued at home when maximum benefit from specialized and expensive hospitalization has been reached. Such a plan also gives the patient and family security and self confidence to take on home care. It may be desirable to have therapeutic" interims at home to neutralize "hospitalitis," to practice learned activities and to gain better emotional adjustment in order to proceed more effectively with intensive rehabilitation at a later date. Home care for the severely involved patient demands adequate medical follow-up and the assurance of hospital readmission for intercurrent problems MEDICAL RESPONSIBILITY DOES NOT CEASE WITH DISCHARGE ·98 APPENDIX PULMONARY COMPARTMENTS-VITAL CAPACITY PULMONARY COMPARTMENTS Maximum Inspiratory Capacity VITAL CAPACITY Tidal Air NIMIM TOTAL CAPACITY Maximum Expiratory Capacity Residual Air . VITAL CAPACITY: May be taken with any recording BMR, spirometer or ventilation meter in a child over five to six years of age and adults. Vital capacity variation may be as much as 1000 cc about a mean value for a particular standard of reference such as age, height, weight, body surface area, etc.... • Decreasing or obviously low vital capacity values are most significant clinically. Repeated vital capacity measurements usually demonstrate the decreasing muscle reserve of respiratory paralysis. • The pattern of the vital capacity maneuver is important in de termining whether inspiratory or expiratory capacity is lost and if air trapping occurs. USE OF TANK ARTIFICIAL RESPIRATION IS USUALLY INDICATED WHEN VITAL CAPACITY DECREASES TO Adults Adolescents Children 1500-1000 cc. 1000- 750 cc, less than 500 cc. Eighty per cent of the patients with failing vital capacity will -:finivornirtinn orantınlla. (low) ·MINIMAL OBSERVED VITAL CAPACITY VALUES IN ADULTS AND CHILDEN (Values given are 2 s.d.'s below the mean) CHILDREN AND ADOLESCENTS VS. AGE: *-* Male 3 Female 3 V.C. 2 2 (liters) AGE in YEARS (Ferris et olyo . CHILDREN AND ADOLESCENTS VS. HEIGHT: 3 -X Malo .. Female 3 V.C. 2 2 (Liters) 100 120 1160 HEIGMT in CENTIMETERS Tho (Ferris et al) ADULTS VS. AGE : - Malo Female 3 V.C, 2 2 (Liters) 1 Toate schoy AGE In YEARS (Baldwin, Courand & Richards)* (Fowler) ** . and ** See bibliography, ·100 VENTILATORY MEASUREMENTS-TIDAL VOLUMES TIAL VOLUME MEASUREMENTS OF SPONTANEOUS QUIET BREATHING ARE FAR TOO VARIABLE TO BE OF CLINICAL USEFULNESS. Factors effecting the significance and accuracy of this measurement include: acute illness, metabolic alterations, apprehension, unsteady state, error and resistance of the device. TIDAL VOLUMES MEASUREMENTS ON RESPIRATOR PA. TIENTS ARE EXTREMELY VALUABLE For the initial adjustment of respirator pressure. . Adults Rate Tidal Volume Male Female Large-200 lbs. Medium-150 lbs. Small-100 lbs 20-12 20-12 20-12 450-650 cc 400-550 cc. 300-450 cc, 450-550 cc. 350-500 cc. 300-400 cc. Children Large 80 lbs. Medium-50 lbs. Small 35 lbs. 24-18 30-20 32-25 225-250 cc. 140-170 cc. 100-110 cc. For the avoidance of underventilation and excessive ventilation. : When repeatedly measured at the same pressure setting, since they reflect changes in the condition of the lungs and chest. DECREASING TIDAL VOLUMES AT THE SAME RESPIRA- TOR PRESSURE (AND RATE) OCCUR WITH Use of endotracheal airway (-20 to 25%). Airway obstruction, Pulmonary complications such as atelectasis and pneumonitis. Circulatory complications such as cardiac failure, pulmonary congestion or edema. DETERIORATION OF THE PATIENTS GENERAL CONDI. TION IS MOST OFTEN THE RESULT OF INADEQUATE PULMONARY VENTILATION . • Values from nomogram prepared for N.F.I.P by Edward P Radford, Jr., MD., Department of Physiology. Harvard School of Public Health.

·TREATDIENT OF ACUTE POLIOMYELITIS 101 EXCESSIVE VENTILATION CAN BE DETECTED WHEN THIE DEPTII (OR RATE) OF BREATHING IS MUCH LARGER THAN THE ABOVE AVERAGES Hypocapnia may produce circulatory alterations such as flushing, tetany, numbness and tingling and general discomfort also may occur.

·104 CORRECTION AND MAINTENANCE OF SALT AND WATER NEEDS INITIAL REPLACEMENT NEEDS FOR THE DEHYDRATED POLIOMYELITIS PATIENT Naci mg./kg Nat meg. Ks. XCI mg./kg. K meg./kg. Total Water cc./K& Ist 24 hrs. Ist 24 hrs. Ist 24 hrs. Infant Child Adult 200-300 150 100 3-48 2-3 1-2 200 150 70-100 23 2 1-1.5 250 120 75-90 EXAMPLE: HO in L. Total Na* and Total K (meg) 20 Kg Infant 30 Kg Child 70 Kg. Adult 1.5 36 6-7 30 60-90 105 23 60 85 . . 600 cc. TYPE OF FLUID SELECTED Replace water with 5-10% glucose or invert sugar in water. Replace salt with 0.85% NaCl and 0.3% KCI solution. Composition Amount Totals 10$ invert sugar in water 60 cc./kg. 1800 cc. 0 85% NaCl in water 20 cc /kg 03% KCl in 10% invert sugar and water 40 cc./kg. 1200 cc Total 3800 cc EXAMPLE Analysis 30 Kg. Child 120 cc. FLO/K8 /24 hrs. 98 meg of Na+ as Na Cl- 48 meq. of Kas K+CI- CALORIC REQUIREMENT AT LEAST 40 /Kg./Day-which is at the least maximum protein spaning. (In example above CHO-330 gm. or 11 gm./kg. or 44 Cal./kg.) COMMON EQUIVALENTS (APPROXIMATE) I gm. Na+Cl- - 16 meq. Na+ or I meq. Nat - 60 mgm. NaCl. I gm K+Cl-- 13 meq. K+ or 1 meq. K+ - 75 mgm. KC). 0.3KC) - 40 meq. K+/L or 4 meg. K+/100 cc. . 0.85% NaCl - 160 meq. Na+/L or 16 meq. Na+/100 cc. .

·TREATAIENT OF ACUTE POLIOMYELITIS 105 . RATE OF FLUID ADMINISTRATION (assuming 15 gtts. - 1 cc.) Maximum 4 gtts./Kg/min. for 1-2 hours-then 2 gtts /Kg/min. for 4-6 hours. • Remainder for even distribution over next 8-12 hours, IV ROUTE IS PREFERABLE-use Gardner-Murphy polyethylene type needle. . Calculate 24 hour needs and MIX. • Based upon moderately severe debydration and absence of significant vomiting and diarrties during therapy.

·104 CORRECTION AND MAINTENANCE OF SALT AND WATER NEEDS INITIAL REPLACEMENT NEEDS FOR THE DEHYDRATED POLIOMYELITIS PATIENT* Naci mg.kg. Nat meg./kg. KC1 mg./kg. K meq Kg. Total Water cc./kg. Ist 24 lurs. Ist 24 hrs Ist 24 hrs. Infant Child Adult 200-300 150 100 3-48 2-3 1-2 200 150 70-100 23 2 1-1.5 150 120 75-90 EXAMPLE: HI,O in L. Total Na+ and Total K+ (meg) 10 Kg Infant 30 Kg Child 70 Kg Adult 1.5 36 6-7 30 60-90 105 23 60 85 TYPE OF FLUID SELECTED Replace water with 5-10% glucose or invert sugar in water. Replace salt with 0.85% NaCl and 0.3% KCl solution. Composition Amount Totals 10% invert sugar in water 0.85% NaCl is water 03% KCl in 10% invert sugar and water 60 cc./kg. 20 oc./K8. 1800 cc. 800 cc. 1 200 cc. 40 cc /kg Total 3600 cc. EXAMPLE: Analysis 30 Kg. Child 120 cc. HO/Kg /24 hrs. 96 meg. of Na* as Na+Cl- 48 meq. of Kas KºCI- CALORIC REQUIREMENT AT LEAST 40 /Kg./Day-which is at the least maximum protein sparing. (In example above CHO-330 gm. or 11 gm./kg. or 44 Cal./Kg.) COMMON EQUIVALENTS (APPROXIMATE) I gm. Na+Cl- - 16 meq Na+ or 1 meq Na+ = 60 mgm. Naci I gm. K+Cl-- 13 meq. K+ or 1 meq. K+ - 75 mgm. KCI. 0.3% KCI - 40 meq. K+/L or 4 meq. K+/100 ce, 0.85% NaCl - 160 meq. Na+/L or 16 meq. Na+/100 cc.

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·106 CORRECTION AND MAINTENANCE OF SALT AND WATER NEEDS + . MAINTENANCE FLUIDS--AFTER INITIAL REHYDRATION NaCl needs less since antecedent deficit now replaced. KCI needs remain high due to stress and continuous urinary loss. Water needs usually less (unless large urinary volume is noted, especially in adults). Average requirements: Water-85 cc./Kg./day. .85% NaCl-5 cc./Kg./day. .3 % KCL–30 cc /Kg./day. Given in a 12-14 hour period. EVALUATION OF PATIENTS RESPONSE TO THERAPY Clinical improvement in hydration, sensorium and pulse. Good urine volume with normal specific gravity 1.014-1.020. Usine chlorides by Fantus test 3-5 gms. per liter. Weight gain of 3-5% in first 24-48 hours. DANGER POINTS Overhydration-watch rate of suid administration and remember plans are for a 24 hour period. Underhydration-is not good when antecedent and current loss. es are greater than predicted or intravenous administration. Potassium intoxication may occur when patient anuric or oliguric. Na and Cl retention may result of stress is severe and prolonged. • Err on side of low sodium intake when in doubt as to patient's needs. C . .

·BREATHING EXERCISES The following is a list of bseathing exercises that may be useful for the palio respiratory patient. It will be noted that three types of strengthening exercises are presented: Conventional muscle re-education. • Resistance to the stronger area in an attempt to force breathing in the weaher. Pressure or resistance to the desired muscles. The latter type has been found to be the most effective, but each type has been found valuable in individual patients. The weaning schedule is used as the primary method for increasing vital capacity, but breathing exercises for strengthening are deemed useful in assisting the patient to become aware of the respiratory muscles and what they do, and thereby gain maximum efficiency froin them. CHEST MOBILITY USING TANK RESPIRATOR Increased negative pressure for maximum inspiration. Increased intra-tank positive pressure for forced maximum expiration. Abdominal binder to increase thoracic expansion MANUAL STRETCHING OF THE THORAX, TRUNK AND SHOULDERS Nock-all motions in the tank as soon as possible (flexion, rotation, lateral flexion, extension). • Rotation of trunk in tank respirator using the hips as a lever. Lift the chest up and move the chest laterally in the tank respirator. • Lateral Rexion of the trunk-by the hips in the tank and by the shoulders on the bed. Trunk flexion-can be started in the tank by raising the hips and later on the bed by raising the shoulders. • Rotation of trunk on the bed by hips and shoulders. • Increased shoulder range of motion-particularly ferion and ab duction POSITIONING Inter-scapular pillow'. Slight fetion of the neck and back. • Abduction of shoulders with pillows, triangles, etc. + . P ·108 TREATMENT OF ACUTE POLIOMYELITIS MUSCLE RE-EDUCATION INSPIRATION . . . . Diaphragm Concentrate on rise or ballooning of the abdomen on inspiration eliminating accessory breathing • Manual resistance on upper chest to force diaphragmatic breathing. Put diaphragm on a stretch-maximum expiration plus thumb pressure up and under costal angles attempting to gain rebound and give the patient a sensation of where to contract. Resist the descent of the diaphragın by thumb pressure up and under anterior rib cage. • Place the patient in Trendelenburg and have him use the diaphragm against the resistance of the abdominal contents. Additional hand pressure may be used. Sniffing. Lateral Chest Consciously hold back on the accessories and attempt lateral expansion. • Manual pressure to lateral chest utilizing stretch and kinesthetic sense. Manual resistance to lateral chest. For unilateral deficiencies: a) Resist the better side and force breathing in the opposite. b) Resist both sides holding back on the better side. c) Manual pressure to the weak side. • Patients with the use of hands and some ability to take resistance to inspiration: a) Resist self with strap around chest. b) Push up against lateral chest and give self resistance, Upper Chest Consciously eliminate accessories and attempt to gain chest rise. Manual pressure over sternum or pectoral areas for resistance and/or kinesthetic sense. Manually resist and hold back on the abdomen and attempt to force upper chest breathing. General Inspiration above the aid of the respirator. Strengthen accessory muscles of breathing by muscle re-education other than breathing exercises . . . .

·TREATMENT OF ACUTE POLIOMYELITIS 103 • Patient push down with the head on the bed frequently and as soon as possible to maintain and increase strength of the posterior neck and back extensors used in stabilizing the head for accessory neck breathing. Manually resist chin and/or forehead and have the patient breathe in, EXPIRATION Strengthen abdominals, lattissimus dorsi by re-education other than expiratory exercises. Emphasize forced expiration: Hissing, humming, whistling, singing. Cough at the end of a maximum expiration. Blow against resistance-soap bubbles, sailboat, whistles, ping pong ball, blow bottle, balloon, • Manual assistance over lower ribs and abdomen to gain more expiration. Patient can be taught to do this if upper extremities are strong enough. .

·114 JOINT RANGE OF MOTION NECK 1. Flexion: Lift the head bringing the chid up to the chest. e 2. Lateral Flexion: Move the bead laterally bringing the ear to the shoulder, 3. Rotation: Rotate the head turning the face completely to the left and then to the right. 4. Extension: Extend the neck. This can only be done in the side-lying or face-lying positions or if the patient is in the tank respirator, it can be done by lowering the head piece. TRUNK 1. Flexion: Flex the back by raising the head and shoulders bringing the head towards the knees. er 2. Lateral Flexion: Place your arm under the patient's neck and your hand under the opposite scapula. Pull the patient toward you laterally flexing the trunk. Hold the opposite hip down if he starts to move as a whole. 3. Lateral Flexion in Tank Respirator: Support both legs with one hand under the thighs and the other under the ankles and pull the legs and hips toward you. of 4. Rotation: Place one hand on the pelvis on the far side and the other under the scapula. Hold the pelvis down and rotate the upper trunk toward you in a twist.

·TREATMENT OF ACUTE POLONIYELITIS 115 5. Rotation in the Tank Respirator: Cross the far leg over the near leg. Place one hand under the hip and the other on the far shoulder. Hold the shoulder down and pull the hip over toward you twisting the trunk. HITS 1. Flexion: Place one hand under the knee and one under the ankle. Flex the hip and knee bringing the knee toward the chest. 2. Hamstrings and Quadriceps: Flex the hip to 90' and hold it there. Extend the knee and then flex it by lifting at the ankle, 3. Abduction: With one hand under the knee and one under the ankle move the leg out to the side to a 45° angle. 4. Rotation: Place one hand on the knee and one on the foot. Roll the leg in and then roll it out, FOOT 1 Dorsi and Plantar Flexion; Place one hand on the heel and the other on the forefoot. (a) Pull the heel down and push the forefoot up and (b) Pull the forefoot down and push the heel up. 2. Inversion and Eversion: Place one hand on the leg just above the ankle and the other on the forefoot. Turn the foot in and out. 3 Toe Fiction and Extension: Place one hand on the forefoot and the other over the toes. Bend the foes down and then bring them back straight. SHOULDER 1 Flexion: Place one hand under the elbow and one supporting the hand Raise the am straight up and bring it back toward the bed.

·116 TREATMENT OF ACUTE POLIOMYELITIS 2. Abduction: Using the same holds take the arm out to the side to a 90° angle. T 4 3. Rotation: Place the arm in abduction and flex the elbow to 90°. Maintain this position of the shoulder and elbow and take the hand back toward the bed. Then move it forvard in an arc toward the bed. tra ELBOW 1. Flexion and Extension: Hold at the wrist and flex the elbow bringing the fingers to the shoulder then straighten the elbow, 2. Supination-Pronation: Hold the elbow Rexed to 90°. Then turn the hand so that the palm is toward the face and then turn it in and around toward the feet, WRIST 1. Flexion-Extension: Hold the elbow flexed to 90° and then flex and extend the wrist. 2. Abduction Adduction: With the elbow flexed to 90° move the wrist medially and laterally. FINGERS 1. Flexion: Flex the elbow to 90° and hold at the wrist to keep it from moving. Place your other hand over the dorsum of the fingers and curl them down into the palm. Each of the three joints normally goes to a right angle. 2. Extension: Using the same positions straighten the fingers. 3. Abduction: Spread the fingers apart and then bring them together THUNB 1. Flexion: Bring the thumb across the palm of the hand to the base of the little finger. 2. Extension: Bring the thumb back to a right angle with the palm. 3. Abduction: Bring the thumb directly forward from the forefinger. 4. Opposition: Touch the tip of the thumb to the tip of the little finger.

·GENERAL EVALUATION OF MUSCLE STRENGTH The following procedures may be done in five minutes or less for general detection of weakness in muscle groups. Muscles will appear to be weak or laccid if there is an increase of tonus (spasm) in the antagonist. Range of motion should be checked passively so that an erroneous picture of weakness is not obtained. Resistance is given just to the point where the muscle gives. A normal muscle-regardless of age, weight, etc -has a "spring back feeling while weak muscles play out with resistance. If the patient is unable to move the part into the desired position the muscles are probably weak, but not necessanly faccid. Assist the motion and ask if the patient can hold it. Observation and palpation of muscle bellies and tendons is valuable throughout COMPLETE CHECK IN THE SUPINE POSITION STERNOCLEIDOMASTOIDS (and accessory neck flexors) and ADDOMINALS: The patient raises the head and shoulders up from the bed and looks at the feet. Resist the head and palpate the abdominals. (Note: this is often dificult or impossible with increased tonus of the erector spinae. Abdominal strength can be estimated by palpation during forced expirations as in coughing or by resisting leg raising.) ERECTOR STINAE (cervical, thoracic and lumbar): Place your hand under the patient's head and have him hold down while you try to raise him up. Patient should be able to hold the back rigid with muscles of 70% and above strength. (Note, this is not a very accurate test since most patients have increased muscle tonus in this group. A more accurate measurement can be found with the patient in the prone position) SHOULDEN: Have the patient raise the hand and arm and point to the ceiling Nesist in four directions-flexion, extension, abduction, and adduction | Flexion: ANTERIOR DELTOID, CORACOBRACHIALIS d ·118 TREATMENT OF ACUTE POLIOXIYELITIS 2. Extension: LATISSIMUS DORSI, TERES MAJOR, POST. DEL- TOID olt 3. Abduction: MIDDLE DELTOID, AND SCAPULAR ADDUCTORS (MIDDLE TRAPEZIUS, RHOMBODS) le 4. Adduction: PECTORALIS MAJOR ELBOW: Patient bends the elbow. Resist in two directions and rotation. 1. Flexion: BICEPS BRACHII, BRACHIALLS, BRACHIORADIALIS 2. Extension: TRICEPS BRACHII ok 3. Pronation: PRONATOR TERES, PRONATOR QUADRATUS. Pa. tient turns the palm toward the feet, resist in the opposite direction. 4. Supination: SUPINATOR BREVIS, BICEPS BRACHDI. Patient turns palm toward face, resist in the opposite direction. WRIST AND FINGERS 1. Extension: EXTENSOR CARPI RADIALIS AND ULNARIS, EX- TENSOR DIGITORUM COMMUNIS, EXTENSOR POLLICIS LONGUS AND BREVIS. Have the patient extend the wrist and spread the fingers. Resist the fingers. 2. Flexion: LUMBRICALES, FLEXOR DIGITORUM SUBLIMUS, FLEXOR DIGITORUM PROFUNDUS, FLEXOR CARPI RA. DIALIS AND ULNARIS. Place your fingers in the patient's hand, have him close his fingers in a fist, resist by trying to open the hand ·TREATBIEXY OF ACUTE TOLOVYELITIS 119 TIIUNEB OPPONENS POLLICIS, ABDUCTOR POLLICIS LONGUS AND BRSVIS, FLEXOR POLLICIS LONGUS AND BREVIS. Have the patient touch the tip of the thumb to the top of the little finger. Resist by pulling the thumb and little finger apart. (Note. for true opposition the thumbnail should be parallel to the palm.) IUP Resist in four directions-fexion, extension, abduction, and adduction, 1. Flexion: ILIOPSOAS, SARTORIUS, RECTUS FEMORIS. Have the patient raise the leg straight up from the bed. Resist toward the bed. (Note: if the patient can raise the leg, the muscles arc 50% or better.) 2. Extension: GLUTEUS MAXIMIUS, IAMSTRINGS. Have the patient attempt to hold the log on the bed while you try to lift it up (Note: Dormally he should be able to hold it stuff and you should be able to lift him as a unit up to his upper back or head.) 3. Abduction: GLUTEUS MEDIUS AND MINIMUS, TENSON FAS. CIAE LATAE. Place the patient's legs in abduction, have him hold them while you try to push thetn in. This can be done well bilaterally. 4. Adduction: ADDUCTOR MAGNUS, LONGUS, BREVIS, TECTIN CUS. Have the patient try to hold the legs together while you all the Legs apart. KNEE Support the thigh ia 20 to 40 degrees of Bexion, Resist extension and flexian.

·120 TREATIENT OF ACUTE POLIOMYELITIS 1. QUADRICEPS FEMORIS—The patient extends the knee, resist at the foot. 2. HAMSTRINGS-The patient bends the knee and you resist the motion: FOOT, ANKLE, AND TOES 1. Dorsi Flexion: TIBIALIS ANTERIOR, EXTENSOR DIGITORUM LONGUS, EXTENSOR HALLUCIS LONGUS. Have the patient dorsiflex the foot, try to push it into plantar flexion. a9 2. Plantar Flexion: GASTROCNEMIUS AND SOLEUS. The patient pushes the foot down, try to push it into dorsi flexion. (Note: if this muscle gives because of weakness, marked involvement is present.) 3. Inversion: TIBIALIS POSTERIOR, TIBIALIS ANTERIOR. Have the patient swing the foot down and in, resist in the opposite direction. 4. Eversion: PERONEUS BREVIS AND LONGUS. Have the patient swing the foot down and out, resist by pushing the foot in. 5. Toe Extension: EXTENSOR DIGITORUM LONGUS AND BREVIS, EXTENSOR HALLUCIS LONGUS. The patient extends the toes --resist toward flexion 6. Toe Flexion: FLEXOR DIGITORUM LONGUS AND BREVIS, LUMBRICALES, FLEXOR HALLUCIS LONGUS AND BREVIS. The patient curls the toes and you try to open them.

·TEATTENT OF ACUTE FOLOXYELITIS 121 OTHER USEFUL CHECKS IF THE PATIENT CAN ASSURE POSITIONS PRONE POSITION 1. ERECTOR SPINAE (CERVICAL, THORACIC AND LUNIBAR), GLUTEUS MATTIUS AND FAMSTRINGS. Have the patient raise the head and shoulders from the bed and legs it possible. Ren sist at the head and heels and check where the patient breaks. (Note: at least 50% muscles are needed to do this without resistance.) 2. MIDDLE AND LOWER TRAPEZIUS, RUIOMBOIDS AND POS- TERIOR DELTOD. Arms in abduction-the patient keeps the head on the bed and raises the arms up. (Note: 50% or better muscles are needed to do this.) Resist at the wrists. SITTING OR STANDING: DELTOID, TRAPEZIL, RHOMBOIDS Ilave the patient abduct both anns, resist at the wrists and view from the back STANDING 1. GLUTEUS MEDIUS: The patient stands on one leg. If the pelvis drops on the opposite side (positive Trendelenburg) or the trunk shifts to the same side, there is marked weakness of the Cluteus Medius ť ·122 TREATMENT OF ACUTE POLIOMYELITIS 2. GASTROCNEMIUS-SOLEUS Have the patient stand on one leg and rise up on that toe There is marked weakness if he cannot do this. ha 3. Have the patient squat down on the heels and rise to the standing position without using the hands. Children and young adults can normally do this but if there is any weakness in the legs, particularly the QUADRICEPS, AND GASTROCNEMIUS-SOLEUS, they will lose their balance or be unable to go all the way down. WALKING weakness or tightness of each individual muscle group in the lower extremities and trunk causes a particular type of gait. Usually this is communicated to hip position. Watch for dropping of the pelvis, shifting of the trunk laterally, anteriorly, or posteriorly over the stance leg, locking of the knee on stance, slapping of the foot. New polios do not walk in hip and knee flexion and it is also unusual for them to walk stiff-legged. Weakness in the feet can be checked readıly by having the patient walk on the toes (view from behind) and walk on the heels (view from the front).

·RESPIRATORY EQUIPMENT 123 Optimum use of cquipment such as cuirass respirators and rocking beds depends largely upon the experience and proficiency of the personnel and adequate mechanical maintenance. Operation is best demonstrated by bedside instruction and participation. The absolute necessity of familiarity with cquipment cannot be overemphasized for its successful employment in the care of the convalescent respirator patient. Cuirass Tespirators have been utilized for brief periods for nursing care and physical therapy in the earliest afebrle phases in the uncomplicated patient. In general cuirass respirators and rocking beds have not been utilized as a primary breathing aid at the onset of respiratory muscle paralysis because there is little doubt that they have less maximum ventilatory effectiveness than the tank respirator. The following section on the maintenance and specifications of commonly used respiratory equipment is based upon the experience of a Respiratory Center and the Equipment Maintenance Pool of the National Foundation for Infantile Paralysis, Inc., at Jefferson Davis Ilospital. The section is intended to highlight important general information not readily available. It is not complete nor an it be since any single cxpericnce will not include all of the different types of equipment available throughout the entire country. An example is intermittent positive pressure brcathing apparatus Thus material must not be considered cither an endorsement or a criticisma of a particular manufacturer's product. The majority of the manufacturers continuously modify or alter equipment, based upon experiences reported by users. Thus descriptions of apparatus cannot keep pace with changes. These suggestions, however, apply to currently available apparatus. This information has been included in the syllabus because proper opera. uon and maintenance of respiratory equipment is obviously of the utmost importance for the successful medical carc of the respirator patient.

·124 GENERAL CONSIDERATIONS IN MAINTENANCE OF RESPIRATORY EQUIPMENT UNDERSTAND THE MACHINE BEFORE MAINTENANCE OR REPAIRS ARE ATTEMPTED! o Always read the manual of instructions and follow the lubrication instructions. Do not over oil the motors. Keep the equipment clear of the walls and furniture to prevent moving parts from being damaged. • Avoid the use of other large electrical appliances on the same circuit. Promptly replace wom or defective plugs and cut or bruised cords. • Keep a lamp or circuit tester available in order to check quickly the outlet for power. Know in advance the position of an alternate outlet on another circuit. • Lock or block the casters before working on equipment. CAUTIONS Do not attempt to repair or lubricate machines while they are in operation-injuries and damage to equipment will result. Do not leave machine plugged in circuit even though switch is off. Some wiring is exposed and electrical shock can occur. 2 . PREVENTIVE MAINTENANCE IS CHEAPER AND SAFER THAN EMERGENCY REPAIR!

·125 OPERATION OF RESPIRATORY EQUIPMENT TANK RESPIRATOR TO CHECK OPERATION OF TANK RESPIRATOR Place a piece of cardboard or a pillow in the head opening. Tum on the motor and adjust valve to increase negative pressure. The gauge should record at Icast a maximum negative pressure of 28-30 cm. of water at a rate of 20 strokes per minute. COMAION FAILURES AND THEIR CORRECTION INSUFFICIENT NEGATIVE PRESSURE • On tanks check for leaks around portholes, collar, extra outlets, cot adjusting handles. In cuirass respirators check boses and sheils. Negatire pressure release valve sometimes sticks in the open position. If gauge does not move, check connecting hose to gauge, if present. IIcad end gaskets will go bad, but more often there is a towel, sheet or strap presenting an adequate scal. EXCESSIVE POSITIVE PRESSURE-usually is caused by an inboard lcak on the negative stroke. • Look for Icaks allowing too much air to be drawn into the respirator on the negative stroke and which cannot be exhausted on positre stroke. Maximum negative pressure will be decreased. Sometimes the positive valves stick closed or connecting rods and han dles come loose and do not open the valve. Find the vale to which the control connects and tum this valve by hand in an emergency. MOTOR FAILURE-is not usually due to a burned out motor on the tank respirator. Check the following things first, Belt in place. Electric plugs for tightness of connection (Emerson has extra plugs on motor). Plug a floor lamp into the plug on the side of the tank. If light operates, current has traveled to the switch on the tank. If light fails to op crate, tank connecting electrical cord may be faulty or damaged by moving parts. Then plug clectric lamp into the plug on the motor. It lamp lights when switch is on, the short is between motor plug and motor. If lamp fails to light, the trouble is in the switch. • Afotor Farlurp-have replacement motor available. . .

·120 SPECIFICATIONS OF COMMONLY USED RESPIRATORY EQUIPMENT EMERSON TANK RESPIRATOR Power: 110 V AC 60 cycle. Motor: 1/3 HP 5.6 Amps plus 60 W electric light in tank and accessory plug. Weight: 700 pounds. Width: 32%"-by removing cot clamps, a width of 30%" can be achieved Height: 61"-remove gauge and it will be 55". Length: 96"-shortened 3" by removing head rest. Lubrication: Instructions are on the side of the tank near the gauge. DRINKER COLLINS ADULT TANK RESPIRATOR Power: 110 V AC 60 cycle. Motor: % HP 4.2 Amps plus 40 W light with guard in tank. Weight: 608 pounds. Width: 31%. Height: 584". Length: 754". Lubrication: Instructions are on the side of the machine. MAINTENANCE SUGGESTIONS Connecting liose can be replaced with automobile windshield wiper hose on models where gauge is on the side panel. Arm port doors often leak. In an emergency more pressure can be obtained with shims under the clip that holds the port shut. Failure to change rate is usually due to failure of the split pulley. Apply lubricant to pulley so that it works freely and separates easily. MONAGHAN HOSPITAL MODEL CUIRASS RESPIRATOR Power: 110 V AC 60 cycle. Motor: 1/6 HP 3.4 Amps. Weight: 200 pounds crated. Width: 20%. . Height: 37". Length: 40'. Lubrication: Follow instructions in back door panel. MAINTENANCE SUGGESTIONS To eliminate noise on pulley at gear case, apply one drop of ou on stationary end of end bearing surface while motor is stopped. To eliminate squeak of belt, apply two eye droppers of any standard ·TREATOIENT OF ACUTE POLIOMTELITIS brake fluid to inside surface of belt while motor is stopped. For any other maintenance, see manual or call nearest dealcr. DO NOT PUT ILANDS INSIDE MACHINE WHILE MOTOR IS OPERATINGI 127 HUXLLY CUIRASS RESPIRATOR UNIT Power: 110 V AC. Weight: 96% pounds. Width: 17". lleight: 25". Length: 16" BATTERY RECTIFIER Weight: 69% pounds. Weight: 394 pounds. Width: 94". Width: 104". Height: 10% Height: 12". Length: 174". Length: 20", JENERAL DESCRIPTION This respirator comes in a standard 110 V AC unit to operate on ordinary house current and in a battery rectifier operated unit (4-5 hours) for the purpose of transporting patients or as a safety measure for power failure. The power unit and respirator are basically the same. It uses a motor and gar box to move a piston in a cylinder through a complete cyclc thus developing both positive and negative pressure. Valves are controlled by knobs on top to adjust negative and positive pressure. The speed is regulated by changing the motor pulley ratio by using the knob on the side of the unit. An electrical speedometer indicates the respirations per minute on the top of the machine The 24 volt unit will operatc from ordinary house current, 110 V AC 60 cycles, when used with the rectifier and batteries. Simply plug the rectifier into a wall outlet, plug battery and respirator into rectifier and it works the same as a straight 110 V AC unit The rectifier and battery should be plugged into the wall outlet at all times, even if the unit is not being used, to maintain a full battery charge MAINTENANCE SUGGESTIONS Read the instruction book. Oil Leaks There should be a breather cap on top of the gear bor. If not, one should be secured from the manufacturer. If it has a brother and Icals, obtain a new gear bor.

·128 THEATBIENT OF ACUTE POLIOMYELITIS Insufficient Negative Pressure There is often a leak at the shell. Careful fitting of the shell is required. Repositioning of the patient may produce a shel leak. Other causes of insufficient negative pressure may be due to a bad gauge, a hole in the bellows, sticking of the relief valve on the bottom of the bellows in the open position, or failure of the knob to operate the negative pressure valve. To make a simple check of the negative pressure adjustment valve with the machine running, turn valve to decrease and listen closely, then tura completely to the other extreme and a change should be heard. If the plastic knob has become loose on its shaft, remove it and manually turn the shaft until the knob can be replaced. If it is the valve which is broken, consult the manual for this is a major repair. • Leaks in the bellows of the earlier models can be detected by noting the frayed edges on the bellows and the sound of escaping air. Adhesive tape will seal it until arrangements for a repair can be made. Other Problems Thumping noises are usually caused by two things: (1) articles falling into the outlet for the hose connection. If they cannot be easily removed, obtain an exchange machine before too much damage is done. (2) Gear case wear will cause the machine to thump after it has made its up stroke and starts down. To find this fault (keeping the hands and tools out of the machine while it is run- 2 1 gear case can be changed without any great difficulty by a mechanic. Power failures seldon occur unless there is a defective cord or a damaged plug UNIVERSAL MODEL MONAGHAN PORTABLE CUIRASS RESPIRATOR Model 100A, 103 and 115A Power: 110 V AC 60 cycle house current or 24 V batteries for 34 hour trips. Other voltage characteristics can be supplied by factory. Weight: 52% pounds. Width: 10.

·NEATLIENT OF ACUTE POLIOMYELITIS lleight: 16". Length: 334". RECTIFIER AND BATTERY BATTERY PACK Weight: 335 pounds. Weight: 43% pounds Width; 8". Width: 8". Height: 8". Height Il". Length: 16". Length: 16". General Instructions: In black and white lettering bolted to front of machine ENERAL DESCRIPTION There is a dial type gauge on the front of the machine reading from 0 to 60 pressure and 0 to 60 vacuum in millimeters of mercury. When attached by a small hose to the shell, it gives actual pressure at the shell (chest). This machine operates from a S HP, high speed, 24 V centrifugal blot er with utilization of both suction and pressure outlets. Thic pressure is changed from positive to negative by the means of a four way valve oper. ated by an electric solenoid. Rate and per cent of cycle occupied by inspiratory negative pressure are timed by an electronic device. The amount of positive or negative pressure is determined by the amount of leak to the atmosphere through ports operated by adjusting knobs similar to those on other respirators It is well to note that the hand operation is sumplc but the hose must be moved from its normal fitting and inserted in the emergency fitting on the front opposite end from the normal fitting Then simply pull the red handle up and down at the desired rate MAINTENANCE SUCCESTIONS Study the manual BEFORE repairs become necessary, • In rough handling or on land trips clectronic components may vibrate loose. It is simple to change tubes and relays since radio tube connections are used. These parts are located on the lack of this machine at the upper left. Each one will fit only in the proper socket, Check to see that the connections ase tight. • To change brushes in this machins, read the manual or the instructions which come with the new brushes. They will last a long time tf installed properly CAUTIONS Do not cover the ventilation holes on the outside of this machine with pillows or sheets, otherwise overheating and damage scadily occur. . .

·130 TREATMENT OF ACUTE POLIOMYELITIS Do not check the gauge by closing your hand over the hose as the excessive pressure will break the gauge. • As with any chest respirator, keep small children from dropping small articles in the hose outlets. Results can be amazing. Coins, bobby pins, even paint brushes have been removed from many chest respirator machines. This hazard applies to all models by any manufacturer. BURNS ROCKING BED Power: 110 V AC 60 cycle. Motor: 1/3 HP 5.6 Amps Weight: 300 pounds. Width: 37"--can be laid on side and will go through 30" door. Height: 32"-without mattress. Length: 78". Lubrication: Use a few drops of light electric motor oil on motor each month. Use automobile transmission oil on gear case. Keep level to side plug on gear case. EMERSON ROCKING BED Power: 110 or 230 V. Normally 110 V AC 60 cycle unless ordered special. Power consumption at 110 V-8.8 Amps (starting load 17 Amps). Plug: 2 prong standard plug with ground wie clip. Weight: 865 pounds crated. Width: 39'-will go through a 36" door by removing one handle Height: 39"-including mattress. Length: 78. Lubrication: Grease all parts on bed where grease fittings are found, once per month. Oil motor very sparingly once a month using light electric motor oil. The pulley on the gear case should be greased very sparingly or it will cause grease to sling out onto the drive belt. Oil should be kept up to and not above side plug on gear case. Use a transmission oil 600 W or equal. CAUTION Bed should be blocked so that it cannot creep while it is in motion thereby striking on a piece of furniture and causing damage to the end, other furniture and the patient. NEVER ATTEMPT TO REPAIR OR LUBRICATE A BED WHILE IT IS OPERATING!

·131 TREATMENT OF ACUTE PLOMYELITIS AMERICAN HOSPITAL-TOMAC-ROCKING BED Power: 110 V AC. Motor: FIP 10 Amps-should be fused with 30 Amp. fuses. Width: 37X". IIcight: 36". Length. 794". Lubrication: Speed reducer or gear box-keep od to overflow with 600 W or equal oil. Grease: Worm gear assembly and oil bearing-use Keystonc 45 grease or equal and light 10 SAE oil on oil fitting. GENERAL DESCRIPTIOX Tilting plane-from 0 to 10% of the foot end below horizontal and 0° to 5° above horizontal Speed-of bed ranges from 10 to 30 complete oscillations per minutc. Degree of tilt-of bed is variablc from 0° to 30° above and below horizontal. This piccc of equipment is of very sturdy construction and is identical in principal of operation to other rocking beds Variation of frequency of tilt, relation of tilt to horizontal and degree of tilt is accomplished in a diffcrent fashion with controls in unusual locations . MAINTENANCE SUGGESTIONS This piece of cquipment appears to have few mechanical problems when it is lubricated as per instruction manual. Decreased clearance of bed frame and under frame duc to the scar or movement of adjusting nuts holding the bed frame to the eccentric connecting link may be corrected by tightening the nuts from time to time. If bed is not so equpped, the top retaining nut can be replaced with an automotive nut and cotter key and be used to hold a proper adjustment. A check for tightness of all socket head set screws will prevent their working loose If adjusting handles work loose, it may be necessary to drill some shafts to make a hole to retain set screw locking action CAUTIONS • Do not work on the under part of a rocking bed while it is plugged into power All manufacturers expect you to use this safety measure on their equipment. Keep chairs and other furniture clear as, with all rocking beds, damage to bed, furniture and patient can occur .

·130 TREATMENT OF ACUTE POLIOMYELITIS • Do not check the gauge by closing your hand over the hose as the excessive pressure will break the gauge. As with any chest respirator, keep small children from dropping small articles in the hose outlets. Results can be amazing. Coins, bobby pins, even paint brushes have been removed from many chest respirator machines. This hazard applies to all models by any manufacturer. BURNS ROCKING BED Power: 110 V AC 60 cycle. Motor: 1/3 HP 5.6 Amps. Weight: 300 pounds. Width: 37"-can be laid on side and will go through 30% door. Height: 32"-without mattress. Length: 78". Lubrication: Use a few drops of light electric motor oil on motor each month. Use automobile transmission oil on gear case. Keep level to side plug on gear case. EMERSON ROCKING BED Power: 110 or 230 V. Normally 110 V AC 60 cycle unless ordered special. Power consumption at 110 V-8.8 Amps (starting load 17 Amps). Plug: 2 prong standard plug with ground wire clip. Weight: 865 pounds crated. Width: 39"-will go through a 36" door by removing one handle. Height: 39"-including mattress. Length: 79'. Lubrication: Grease all parts on bed where grease fittings are found, once per month. Oil motor very sparingly once a month using light electric motor oil. The pulley on the gear case should be greased very sparingly or it will cause grease to sling out onto the drive belt. Oil should be kept up to and not above side plug on gear case. Use a transmission oil 600 W or equal. CAUTION Bed should be blocked so that it cannot creep while it is in motion thereby striking on a piece of furniture and causing damage to the end, other furniture and the patient. NEVER ATTEMPT TO REPAIR OR LUBRICATE A BED WHILE IT IS OPERATING!

·TREATMENT OF ACUTE POLIOMYELITIS 131 AMERICAN HOSPITAL-TOMACROCKING BED Power: 110 V AC, Motor: 4 HP 10 Amps-should be fused with 30 Amp. fuses Width, 37%”. Height: 36". Length: 794". Lubrication: Speed reducer or gear box-keep oil to overflow with GOO W or equal oil. Grease: Worm gear assembly and ou bearing--use Keystone 45 grease or equal and hight 10 SAE oil on oil fitting. NERAL DESCRIPTION Tilting plane-from 0 to 10° of the foot end below horizontal and 0° to 5° above horizontal Speed-of bed ranges from 10 to 30 complete oscillations per minute. Degree of tilt--of bed is vanable from 0° to 30° above and below horizontal This piece of equpment is of very sturdy construction and is identical in principal of operation to other rocking beds. Vanation of frequency of tilt, relation of tult to horizontal and degree of tilt is accomplished in a different fashion with controls in unusual locations, . MAINTENANCE SUGGESTIONS This piece of equipment appears to have few mechanical problems when it is lubricated as per instruction manual. Decreased clearance of bed frame and under frame due to the wear or movement of adjusting nuts holding the bed frame to the eccentric connecting link may be corrected by tightening the nuts from time to time. If bed is not so equipped, the top retaining nut can be replaced with an automotive nut and cotter key and be used to hold a proper adjustment. A check for tightness of all socket head set screws will prevent their working loose If adjusting handles work loose, it may be necessary to drill some shafts to make a hole to retain set screw locking action. CAUTIONS • Do not work on the under part of a rocking bed while it is plugged into power. All manufacturers expect you to use this safety measure on their equipment. Keep chairs and other fumiture clear as, with all rocking beds, damage to bed, furniture and patient can occur .

·132 TREATMENT OF ACUTE POLIOMYELITIS McKESSON RESPIRAID ROCKING BED Power: 110 V AC. Motor: Direct current motor operated from rectified 110 V AC supply. Maximum consumption 24 Amps. Weight: 550 pounds. Width: 40% Height: 50". Length: 78". GENERAL DESCRIPTION This bed consists of a platform operating on a curved sector with a matching base support. Control of the bed is accomplished by a direct current motor of variable speed and there is provision for continuous adjustment of extent inclination through a motor driven variable length offset arm. This type of control requires an elaborate rectifier which was accomplished by vacuum tubes in earlier models and by selenium rectifiers in later models. Operation of the bed is adequately described in the manufacturer's literature. Maintenance problems have been concerned with electronic power supply of the first models and mechanical considerations similar to other rocking beds. Frequency of oscillations is adjustable up to thirty times per minute.

·BIBLIOGRAPHY 133 REFERENCES-page 15 1. Hodes, H. L., Spencer, W. A, Wluttenberger, J. L., Wilson, J. L, and Wright, J.: Management of Poliomyelitis Patients with Respiratory Difficulty. New York. Additional Notes for the exhibit prepared by the National Foundation for Infantile Paralysis, 1952 REFERENCES-page 22 2. Dickinson, D. G, Wilson, J. L., and Graham, B. D.: Studies in respiratory insufficiency. I. Carbon dioxide and oxygen studies in early respiratory paralysis in polomyelitis. Am. J. Dus. Child., 86.265-272, Sept., 1953. 3. Astrup, P., Gøtzche, H, and Neukirch, F.: Laboratory investigation during treatment of patients with poliomyelitis and respiratory paralysis. Brit. M. J., 4865:780-786, Apnl 3, 1954. 4. Unpublished data: Southwestern Poliomyelitis Respiratory Center REFERENCES-page 31 5 Hoff, H. E, and Spencer, W. A: Neurophysiology of Respiration and Genesis of Central Regulatory Disturbances of Respiration and Cir culation in Bulbar Poliomyelitis. Respirator Center Conference Trans. actions, sponsored by National Foundation for Infantile Paralysis, Boca Raton, Florida, Jan., 1951. REFERENCES--page 99 6. Ferris, B. G., Whittenberger, J L., and Gallagher, J. R. Maximum breathing capacity and vital capacity of male children and adoles. cents Pediatrics, 9 659-670, June, 1952. 7. Ferris, B. G, and Smith, C W.: Maximum breathing capacity and vital capacity of female children and adolescents Pediatrics, 12:341-352, April, 1953 8 Baldwin, E. deF., Coumand, A., and Richards, D. W., Jr.: Pulmonary insufficiency, physiological classification, clinical methods and standard values in normal subjects Medicine, 27:243-278, Sept, 1918. 9 Fowler, W. S Specific Tests of Pulmonary Function, in Methods of Medical Research, Vol 2 Chicago, Yr. Bk. Pub., 1950, pp 181-188. REFERENCES-page 100 10. Rahn, H., et al: Pressure volume diagram of thorax and lungs. Am. ) Physiol., 146.161-178, 1946. 11 Ferris, B. G., Jr, Whittenberger, I L., and Affeldt, J. E.. Pulmonary function in convalescent poliomyelitis patients. I. Pulmonary subdivisions and maxmun breathing capacity. New England J. A1, 246 24, pp 917-923, June, 1952.

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