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A clinical guide for respiratory assessment for individuals with spinal cord injury.

September 2014


  1. Background
  2. Why is this information important?
  3. Resource Requirements
  4. Forms
  5. Instructions
  6. Definitions
  7. Training resources
  8. References
  9. Additional resources
  10. Other RHSCIR Respiratory Data (not completed by clinicians)



This toolkit is supported by the Rick Hansen Institute and was created by the following collaborators:

Colleen O’Connell, MD, FRCPC
Physiatrist and Research Chief
Stan Cassidy Centre for Rehabilitation

Deborah Tsui, MScPT
RHSCIR Site Lead
Hamilton General Hospital & Hamilton Regional Rehabilitation Centre

Renata Vaughan, RRT
Senior Respiratory Therapist
Hamilton General Hospital & Hamilton Regional Rehabilitation Centre


Brigida Lujan, RRT 
Respiratory Therapist 
G.F. Strong Rehabilitation Centre

Tova Plashkes, MScPT 
National Clinical Liaison 
Rick Hansen Institute

Kristen Walden, BScPT 
National Clinical Liaison 
Rick Hansen Institute

For questions or comments on this guideline, please contact clinical [AT] rickhanseninstitute [DOT] org.



The RICK HANSEN SPINAL CORD INJURY REGISTRY (RHSCIR) is a pan-Canadian prospective observational registry located at 31 major Canadian acute care and rehabilitation facilities. Across Canada, RHSCIR is collecting comprehensive SCI data for the purpose of improving SCI care and clinical outcomes. Using standardized research protocols and data collection forms, RHSCIR tracks the experiences and outcomes of people with traumatic SCI during their journey from injury, through acute care and rehabilitation to community reintegration. Details about participants' spinal cord injuries including extent of injury and level of paralysis, recovery, and success of various treatments are among the data recorded.

The data collected in RHSCIR contains powerful information that will help track the effectiveness of specific treatments, practices or programs for improving functional outcomes and quality of life after SCI. RHSCIR promotes, encourages and supports the pursuit of excellence in all areas of SCI health care management.

To learn more about RHSCIR, please visit www.rickhanseninstitute.org.




Individuals with spinal cord injury (SCI), particularly in tetraplegia, can have severe limitations in their respiratory function. Acutely, this can limit the individual’s ability to begin the healing and rehabilitation process (1). It can also lead to long term secondary complication risks such as decreased ventilation, pneumonia, sleep apnea, fatigue and other issues (1–3). With early diagnosis and treatment, we can determine what treatments are necessary to improve respiratory function and we can help to ensure fewer complications. With a thorough interdisciplinary team evaluation we can also ensure patient’s go home with the proper equipment to reduce the chances of a readmission for respiratory reasons. The literature shows that the most common cause of death in patients with chronic tetraplegic spinal cord injuries are respiratory complications (2).

Information regarding the incidence and severity of respiratory disease in the SCI population may be used to identify trends and subsequently used for program planning and resource allocation. Additionally, such information can serve as a basis for patient education as part of learning self-management and directing care.

Benefits to Clinicians and Patients

Being informed is a crucial part of an injured person’s recovery process. This information can be used as the basis for patient education, which is part of learning self-management and directing care.

Collection and reporting of this data can benefit clinician and patients by:

  • Understanding patients’ respiratory status and respiratory care needs.
  • Assessing cough strength/effectiveness (i.e. ability to clear secretions).
  • Screening/assessing for sleep disordered breathing (including obstructive sleep apnea, etc.) and need for appropriate therapies.
  • Optimizing respiratory support, including lung volume recruitment techniques, assisted coughs and ventilatory support.
  • Ensuring standards of practice are being met to ensure the best possible outcome for the patient.
  • Monitoring effects of treatment/therapy.
  • Ensuring the patient understands respiratory status to allow direction of care during their stay and after discharge.
  • Reducing the risk of secondary complications.
  • Reducing the risk of readmission after discharge.

Benefits to the Program

Collection and reporting of this data can benefit your program by:

  • Analysing staffing levels, determining what type of staff (e.g. RN, LPN, WOCN, OT, PT, research, etc.) are involved, and what the equipment and supply requirements are.
  • Facilitating larger system planning (e.g. feedback to EHS transport systems) to coordinate and improve service delivery between different points of care.
  • Creating continuity between health care providers.
  • Providing comparators to national data and a system of tracking to support requirements for Accreditation Canada SCI Acute and Rehabilitation Standards and Required Organizational Practices.
  • Reporting metrics to facility administrators to allow correlation of program expenditures (e.g. equipment, regular and overtime staffing requirements, etc.) with the patient population.
  • Ensuring that discharge locations are prepared to support the patients’ respiratory care needs, which can remove barriers to discharge.

What Happens Once I Collect the Data?

Providing invaluable data to RHSCIR: Once you collect the data, your facility’s Rick Hansen Spinal Cord Injury Registry (RHSCIR) coordinator will abstract this information from the medical record and input the data into a database along with additional data collected in the community through self-report (See Section 10: RHSCIR - ADDITIONAL RESPIRATORY DATA), and other clinical, demographic, socio-demographic, participant flow, and outcomes information. RHSCIR has developed a number of practices to ensure patient confidentiality is maintained and strict privacy policies and procedures are followed.

Providing a baseline for management of SCI across Canada:  The de-identified data from your site will be reported back to you on a quarterly basis providing information on your site’s respiratory assessment data, your patients’ use of therapies as well as their respiratory requirements when discharged to community.

To access your site’s data reports, click here. Please see your local RHSCIR coordinator, or designated representative, to receive this login information. If you are not sure who that is, please contact us at clinical [AT] rickhanseninstitute [DOT] org.


To complete collection of data as outlined in this toolkit, the following resources are required:


Estimated time required for good clinical practice:

Spirometry: 20 minutes

Peak cough flow: 15 minutes

Overnight oximetry: 50 minutes active clinical time, plus interpretation time 15-20 minutes


Spirometry: spirometer or pulmonary function lab

Peak cough flow and peak expiratory flow: peak flow meter

Maximal inspiratory and expiratory pressures: respiratory pressure metre

Overnight oximetry: oximeter with the capacity to record up to 12 hours of data and software program to download and analyze data



Respiratory Clinical Data Collection

There are two levels of collection. Sites should self-select which measures they are able to complete based on experience and resources.

The BASIC dataset, which includes three measures:

Vital Capacity, a measure of the amount of air the patient can expel from the lungs after a maximal inhalation.

Unassisted Peak Cough Flow, a measure of the patient’s ability to cough without help

Overnight Oximetry, one of the tools used to determine whether a patient has sleep disordered breathing, including obstructive sleep apnea (OSA).


And the ADVANCED dataset, which includes all the measures below in the RHSCIR data collection form.

 What you see here is the respiratory information collected, both by patient interview and chart review by your local RHSCIR coordinator. If you would like help developing a clinical form to put in your chart, please email clinical [AT] rickhanseninstitute [DOT] org.

 There is not a Clinical Form to insert in your chart here because each site's workflow is so different.




Refer to the end of this document for relevant definitions.

Looking for examples of other facilities' assessment forms and policies? Click here to login.


PLEASE NOTE: This is not meant to replace your facility’s protocols or existing practice at your site, but is the minimum amount of information required.

Timing of Assessment

Admission: Spirometry assessment should be completed within the first 24 hours of the patient being cognitively aware enough to complete them in the acute care setting. In the rehabilitation setting, within seven days of admission is considered standard. Early assessments may be at the bedside, and may not include all values.

Discharge: Within seven days of discharge is advisable to ensure proper supports are set up for discharge to the next facility or in the community.

It is advisable to perform some respiratory testing on all patients with SCI where the respiratory muscles have been affected. This would include those with a neurological level of injury of L1 (i.e. any cervical or thoracic injury) or above (4).

Specific instructions for spirometry and peak cough flow are available here. While we know that many clinicians are already familiar with these measures, it is a good idea to familiarize yourself with the instructions and differences with the assessment of those with SCI.

Instructions for overnight oximetry are specific to the equipment you use; please consult the manufacturer’s instructions.


Forced expiratory volume in one second (FEV1): is the volume expired in the first second of the FVC maneuver.

Forced vital capacity (FVC): total volume of air that a person can forcibly exhale during a maximal expiratory effort.

Maximal expiratory pressure (MEP): maximal expiratory pressure maintained for one second after full inhalation.

Maximal inspiratory pressure (MIP): maximal inspiratory pressure maintained for one second after full exhalation.

Overnight oximetry: recording taken while the patient is sleeping of their oxygen oximetry.

Peak cough flow (PCF): maximal flow rate achieved during a coughing maneuver.

Peak expiratory flow (PEF): is the maximal expiratory flow rate achieved during the FVC maneuver.

Vital capacity (VC): total volume of air that a person can exhale at a steady rate, and represents the difference between total lung capacity and residual volume.



Assessment Forms and Chart Inserts- here you'll find examples of pre-printed orders, policies and guidelines as well as assessment and charting sheets relating to respiratory assessment and treatment.


1. Alvisi V, Marangoni E, Zannoli S, Uneddu M, Uggento R, Farabegoli L, Ragazzi R, Milic-Emili J, Belloni GP, Alvisi R, Volta C a. Pulmonary function and expiratory flow limitation in acute cervical spinal cord injury. Arch Phys Med Rehabil. Elsevier Inc.; 2012 Nov;93(11):1950–6.

2. Jensen MP, Truitt a R, Schomer KG, Yorkston KM, Baylor C, Molton IR. Frequency and age effects of secondary health conditions in individuals with spinal cord injury: a scoping review. Spinal Cord. Nature Publishing Group; 2013 Dec;51(12):882–92.

3. Sankari A, Bascom A, Oomman S, Badr MS. Sleep disordered breathing in chronic spinal cord injury. J Clin Sleep Med. 2014 Jan 15;10(1):65–72.

4. Craven C, Verrier M, Balioussis C, Wolfe D, Hsieh J, Noonan V, Rasheed A, Cherban E. Rehabilitation Environmental Scan Atlas: Capturing Capacity in Canadian SCI Rehabilitation. Vancouver: Rick Hansen Institute; 2012.



If you are new to pulmonary function testing, there are instructions for all the tests in the registry available on the SCI2 site. If you are viewing this document in paper form, ask your RHSCIR Local Site Coordinator for login information.

Hamilton Health Sciences has a training document and video about breath stacking and assisted cough for patients and families: www.hamiltonhealthsciences.ca/documents/Patient%20Education/SCI-KeepingLungsHealthyPORTRAIT.pdf.

The SCIRE project has evidence-based resources for respiratory management of SCI: www.scireproject.com/rehabilitation-evidence/respiratory-management.

Gibson GJ, Whitelaw W, Siafakas N, Supinski GS, Fitting JW, Bellemare F, Loring SH, Troyer A De, Grassino AE. ATS/ERS Statement on respiratory muscle testing. Am J Respir Crit Care Med. 2002 Aug 15;166(4):518–624.

Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, Crapo R, Enright P, van der Grinten CPM, Gustafsson P, Jensen R, Johnson DC, MacIntyre N, McKay R, Navajas D, Pedersen OF, Pellegrino R, Viegi G, Wanger J., ATS/ER Task Force. Standardisation of spirometry. Eur Respir J. 2005 Aug;26(2):319–38.

Eng J, Teasell RW, Miller WC, Wolfe D, Townson A, Hsieh J, Connolly S, Noonan V, Mehta S, Sakakibara B, Boily K. Spinal Cord Injury Rehabilitation Evidence. 4th ed. Vancouver; 2012.

Park JH, Kang S-W, Lee SC, Choi WA, Kim DH. How respiratory muscle strength correlates with cough capacity in patients with respiratory muscle weakness. Yonsei Med J. 2010 May;51(3):392–7.



In addition to the clinically collected data outlined in this toolkit, there will also be data collected by RHSCIR from those participants who consent to the community follow-up RHSCIR. This includes subjective information and is collected upon discharge to the community and during subsequent RHSCIR community follow up interviews (data collection points). This portion of data does not require any clinician time, but is collected by registry personnel and will also be made available to your facility. These questions are collected by the RHSCIR team at one year, two years, five years, and then every five years from their date of injury.



For questions or comments on this guideline, please contact clinical [AT] rickhanseninstitute [DOT] org.