MICROBIAL DISEASES only when muscles that appear normal at rest are taxed by the exertion of normal physical activity. Treatment of Paralytic Poliomyelitis. The treatment of paralytic poliomyelitis involves
(1) the use of all measures to spare the life of the patient threatened by the involvement of vital areas,
(2) relief of discomfort,
(3) maintenance of weak muscles in as good a condition as possible until the normal neuronal function has sufficient time to return,
(4) immediate recognition and treatment of complications,
(5) efforts to prevent or ameliorate emotional disorders,
(6) surgical treatment of correctable defects, and
(7) social, economic, occupational, and physical rehabilitation. Patients with paralysis of swallowing, loss of function of the breathing muscles, pulmonary edema, or shock are in great danger of death.
The Question of Tracheostomy. Difficulty in deglutition, although it leads to the development of complex problems of infection and regulation of caloric, water, and electrolyte balance, is most important because of the danger of lethal obstruction of the airway. For this reason, it has been suggested that tracheostomy be performed in all such cases. However, this operation is followed by a high incidence of bronchopulmonary infections owing to drug-resistant organisms.
The preferred initial management of swallowing difficulty involves postural drainage, suction to keep the hypopharynx as free of fluids as possible, and maintenance of adequate intake of food and water by nasogastric intubation. The prone position takes advantage of the normal forward inclination of the trachea as an aid to drainage. Elevation of the foot of the bed 2 to 3 feet from the floor also helps to keep fluids out of the lower respiratory tract. Most important is judicious suctioning of the throat by an experienced physician or nurse. If, in addition, fluids and electrolytes are administered parenterally at first and later by gavage, most patients have little or no trouble. In some cases, however, tracheostomy becomes necessary, despite the risks. The indications for this operation are
(1) abductor paralysis of the vocal cords confirmed by indirect or direct laryngoscopy this makes the operation mandatory;
(2) pneumonia with an inability to clear the lungs of exudate the opening in the trachea permits easy toilet of the lower airway;
(3) repeated bouts of major degrees of pulmonary atelectasis requiring repeated tracheal catheterization or bronchoscopy; and
(4) inability to keep the airway rela-tively free of secretions this is often simply a matter of availability of a sufficient complement of experienced personnel. Respiratory Difficulty.
MICROBIAL DISEASES development of difficulty in respiration demands immediate recognition of its presence and the application of therapeutic measures based on the pathogenesis of the mechanisms involved. MICROBIAL DISEASES is mandatory that respiratory insufficiency resulting from weakness of paralysis of the chest muscles or diaphragms or both be differentiated from that owing to occlusion of the upper airway or that resulting from dysfunction of the respiratory center. The mode of treatment effect in one of these is not only of no help in the others but often is actually dangerous because it increases rather than alleviates the difficulty.
The characteristics of each of these forms of the respiratory problem have been discussed above. The therapy of choice for the weakness of the chest muscles or diaphragm is the respirator tank, chest cuirass, or rocking bed, in this order of preference; some clinicians prefer tracheal intubation plus positive pressure breathing in this situation; the writer has used this approach only as a last resort. For respiratory impairment caused by the accumulation of fluids in the upper airway, properly performed suction or tracheostomy is the treatment of choice (see above). When the respiratory center is involved but skeletal muscles and swallowing mechanisms are not affected, indicated therapy is the use of the electrophoretic respirator. Tank, cuirass, and positive pressure breathing are contraindicated when swallowing mechanisms or respiratory center dysfunction is the problem because it tends to aggravate these situations and may even lead to a fatal outcome.
MICROBIAL DISEASES The use of anti-microbial agents to prevent secondary bacterial infections in patients with the respiratory difficulty of any type is not only not beneficial but may be dangerous because of an increased risk of super-infection by organisms that may be difficult to eradicate. Infection. The treatment of infections of the lungs and urinary tract that complicate paralytic poliomyelitis is the same as that employed in these types of disease without nervous system infection. The frequency of involvement by drug-resistant organisms necessitates the determination of the resistance of the isolated bacteria to a variety of antimicrobial drugs. The specific details of the therapy of these types of disease are discussed elsewhere in this book. Circulatory Failure. There is no specific treatment for myocarditis.
When pulmonary edema supervenes in patients receiving artificial respiration, the use of positive interbank pressure or positive pressure breathing through a cuffed tracheostomy tube may be helpful. Shock is easier to prevent than to treat. Assurance of adequate oxygen saturation, prevention of dehydration, and early treatment of superimposed bacterial infection are of prophylactic value. When serious hypotension develops, a central venous catheter should be inserted and, depending on the level of venous pressure, plasma, whole blood, isoproterenol, or digitalis should be administered. Very large doses of corticosteroids have been recommended as a last resort. Tissue perfusion should not be sacrificed to maintain “normal” blood pressure. More important indications of effective Management are the absence of clinical manifestations of this syndrome and the presence of adequate urine secretion.