***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: Thirteen tetraplegic patients were included in the study of the effects of respiratory muscle training and of electrical stimulation of the abdominal muscles on their respiratory capabilities . Each patient was subjected for three 1 month lasting periods of the study : for inspiratory muscle training , expiratory muscle training and for a period without training . The sequence of these three periods was r and om for each patient . Respiratory tests ( RT ) measuring forced vital capacity ( FVC ) and forced expiratory volume in one second ( FEV1 ) were conducted before and following each monthly period . Measurements were taken under four sets of conditions : the patients ' unassisted efforts , their efforts combined with pressure manually applied by a therapist to the upper part of their abdomen , and their efforts accompanied by electrical stimulation ( ES ) of the abdominal muscles during the early phase of expirium , once triggered by the therapist and once by the patients themselves . RT values were increased following respiratory muscle training and inspiratory training apparently had a slightly greater effect than its expiratory counterpart . The increments of values of RT were statistically significant ( P<0.05 ) after the inspiratory muscle training .  RT measurements were greater when the patient 's voluntary effort was combined with ES of abdominal muscles than when it was not . This study concludes that respiratory muscle training is a potentially effective approach and that ES of the abdominal muscles has potentials to improve coughing in tetraplegic patients Study design : This was a prospect i ve observational study . Objectives : To review airway management of patients with acute cervical spinal cord injury ( CSCI ) who are admitted to the intensive care unit ( ICU ) and to develop a classification and regression tree ( CART ) to direct clinical decision making in airway management . Setting : This study was carried out in Australia . Methods : All patients with CSCI who required intubation and mechanical ventilation and who were admitted to ICU in three tertiary hospitals in Melbourne between October 2004 and May 2009 and two other interstate hospitals between December 2004 and December 2005 were included .  Airway management was recorded . Results : A total of 114 patients were included .  Tracheostomy insertion occurred in 68 patients ( 59.7 % ) . Using CART analysis , it was found that the variables forced vital capacity , the volume of pulmonary secretion and gas exchange were predictive of airway management on 82.3 % occasions with an 8.7 % extubation failure rate . Conclusion : A CART can be useful in clinical decision making regarding airway management in CSCI OBJECTIVE To evaluate if resistive inspiratory muscle training ( RIMT ) can improve lung function in patients with complete tetraplegia within half a year after trauma . DESIGN A prospect i ve study . The experimental patients received training with a Diemolding Healthcare Division inspiratory muscle trainer for 15 to 20 minutes per session , twice per day , 7 days a week for 6 weeks . SETTING Hospital-based rehabilitation units . PATIENTS Twenty patients who were in their first 6 months of complete cervical cord injury were r and omly enrolled into RIMT ( 10 patients ) and control ( 10 patients ) groups . MAIN OUTCOME MEASURE Spirometry , lung volume test , maximal inspiratory pressure , maximal expiratory pressure , and modified Borg scale measurements at rest were performed before training and at the end of 6 weeks of training . RESULTS Most of the pulmonary parameters showed statistically significant improvements within the RIMT and control groups , but the improvements were greater in the RIMT group . In addition , the improvements in total lung capacity , total lung capacity predicted percentage , vital capacity , minute ventilation , forced expiratory volume in 1 second predicted percentage , and the resting Borg scale in the RIMT group showed significantly greater improvement . CONCLUSION RIMT can improve ventilatory function , respiratory endurance , and the perceived difficulty of breathing in patients with complete cervical spinal cord injury within half a year after trauma Study design : Prospect i ve single centre study . Objectives : Pulmonary rehabilitation focuses on improving the expiratory muscle function in order to increase the reduced cough capacity in patients with cervical spinal cord injuries ( SCI ) . However , an improvement in the inspiratory function is also important for coughing effectively . Therefore , this study was to examine the significance of the inspiratory muscle strength on the cough capacity in the patients with a cervical SCI . Setting : SCI unit , Yonsei Rehabilitation Hospital , Seoul , Korea . Methods : The vital capacity ( VC ) , maximum inspiratory pressure ( MIP ) , and maximum expiratory pressure ( MEP ) were measured . Moreover , the unassisted peak cough flow ( PCF ) and assisted PCF under three conditions were evaluated . Results : All three assisted cough methods showed a significantly higher value than the unassisted method ( P<0.001 ) . The VC correlated with the voluntary cough capacity and the MIP ( R=0.749 ) correlated more significantly with the VC than the MEP ( R=0.438 ) ( P<0.01 ) . The MIP showed a higher correlation with both the unassisted PCF and all three assisted PCFs than the MEP ( P<0.001 ) . Conclusions : The management of the inspiratory muscle strength should be considered in the pulmonary rehabilitation at cervical SCI patients We examined the effects of ventilatory muscle endurance training on resting breathing pattern in 12 C6-C7 traumatic quadriplegics at least 1 year post-injury . All subjects had complete motor loss below the lesion level . Subjects were r and omly assigned to a training ( N = 6 ) , or a control group ( N = 6 ) . Baseline tests included measurement of resting ventilation and breathing pattern using mercury in rubber strain gauges for 20 minutes in a seated position ; maximum inspiratory mouth pressure ( MIP ) at FRC , and sustainable inspiratory mouth pressure for 10 minutes ( SIP ) ; lung volumes , and arterial blood gases ( ABG 's ) . The training protocol consisted of breathing through an inspiratory resistor equivalent to 85 % SIP for 15 minutes twice daily , 5 days a week for 8 weeks . Both trainers and controls attended the lab every 2 weeks for re assessment of MIP and SIP and the inspiratory resistance was increased in the training group as SIP increased . At the end of 8 weeks , baseline tests were repeated . All subjects had normal ABG 's . There was a significant increase in mean MIP and SIP in both the control group ( 30 % ± 19 % and 31 % ± 18 % respectively ) , and in the training group ( 42 % ± 24 % and 78 % ± 49 % respectively ) . Although the absolute values for both MIP and SIP were greater in the training group than in the control group , the differences were not significant . The alterations in resting breathing pattern were also the same in both groups . Mean frequency decreased significantly in the control group ( 20.2/minute to 16.9/minute ) and , while insignificant , the change in frequency in the training group was the same , 19.4/minute to 16.4/minute . Mean tidal volume ( Vt ) increased 18.2 % of baseline Vt in the control group and 17.0 % baseline in the trainers , result ing in no change in minute ventilation . As MIP and SIP increased similarly in both groups , the data from the control and trainers was pooled and timing changes re-evaluated pre- and post- study . A significant decrease in mean Ti/Ttot was observed , while no change in Vt/ Ti was found . We concluded that the testing procedure itself provided the stimulus result ing in a significant increase in MIP and SIP . The addition of training did not increase MIP and SIP further . The increased MIP and SIP result ed in a slower and deeper breathing pattern and a significantly shorter Ti/Ttot in both trainers and control subjects OBJECTIVE To compare the effects of inspiratory resistance training and isocapnic hyperpnoea vs incentive spirometry ( placebo ) on respiratory function , voice , thorax mobility and quality of life in individuals with tetraplegia . DESIGN R and omized controlled trial . PATIENTS / METHODS A total of 24 individuals with traumatic , complete tetraplegia ( C5-C8 , American Spinal Injury Association ( ASIA ) Impairment Scale ; AIS A ) were r and omly assigned to 1 of 3 groups . They completed 32 supervised training sessions over a period of 8 weeks . Before and after the training period , the following tests were performed : body plethysmography , inspiratory and expiratory muscle strength , subjective breathing parameters using a visual analogue scale , voice measurements , thorax mobility and quality of life . Cohen 's effect sizes and Kruskal-Wallis tests for differences between pre- and post-training values were calculated . RESULTS Compared with placebo training , inspiratory resistance training showed high effect sizes for inspiratory muscle strength ( d = 1.13 ) , the subjective ability " to blow one 's nose " ( d = 0.97 ) and the physical component of quality of life ( d = 0.82 ) . Isocapnic hyperpnoea compared with placebo showed a high effect size for breathlessness during exercise ( d = 0.81 ) . We found a significant effect of inspiratory resistance training vs placebo ( p = 0.016 ) and vs isocapnic hyperpnoea ( p = 0.012 ) for inspiratory muscle strength . CONCLUSION In individuals with motor and sensory complete tetraplegia during the first year post-injury , inspiratory resistance training is more advantageous than isocapnic hyperpnoea , performed 4 times a week for 10 min Adults and children with neuromuscular disease exhibit weak cough and are susceptible to recurrent chest infections , a major cause of morbidity and mortality . Mechanical insufflation/exsufflation may improve cough efficacy by increasing peak cough flow . It was hypothesised that mechanical insufflation/exsufflation would produce a greater increase in peak cough flow than other modes of cough augmentation . The acceptability of these interventions was also compared . Twenty-two patients aged 10–56 yrs ( median 21 yrs ) with neuromuscular disease and 19 age-matched controls were studied .  Spirometry was performed and respiratory muscle strength measured . Peak cough flow was recorded during maximal unassisted coughs , followed in r and om order by coughs assisted by physiotherapy , noninvasive ventilation , insufflation and exsufflation , and exsufflation alone . Subjects rated strength of cough , distress and comfort on a visual analogue scale . In the neuromuscular disease group , mean±sd forced expiratory volume in one second was 0.8±0.6 L·s−1 , forced vital capacity 0.9±0.8 L , maximum inspiratory pressure 25±16 cmH2O , maximum expiratory pressure 26±22 cmH2O and unassisted peak cough flow 169±90 L·min−1 . The greatest increase in peak cough flow was observed with mechanical insufflation/exsufflation at 235±111 L·min−1 ( p<0.01 ) . All techniques showed similar patient acceptability . Mechanical insufflation/exsufflation produces a greater increase in peak cough flow than other st and ard cough augmentation techniques in adults and children with neuromuscular disease Stolzmann KL , Gagnon DR , Brown R , Tun CG , Garshick E : Risk factors for chest illness in chronic spinal cord injury : A prospect i ve study . Objective : Chest illnesses commonly cause morbidity in persons with chronic spinal cord injury . Risk factors remain poorly characterized because previous studies have not accounted for factors other than spinal cord injury . Design : Between 1994 and 2005 , 403 participants completed a respiratory question naire and underwent spirometry .  Participants were contacted at a median of 1.7 yrs [ interquartile range : 1.3–2.5 yrs ] apart over a mean ( SD ) of 5.1 ± 3.0 yrs and asked to report chest illnesses that had result ed in time off work , spent indoors , or in bed since prior contact . Results : In 97 participants , there were 247 chest illnesses ( 0.12/person-year ) with 54 hospitalizations ( 22 % ) . Spinal cord injury level , completeness of injury , and duration of injury were not associated with illness risk . Adjusting for age and smoking history , any wheeze ( relative risk = 1.92 ; 95 % confidence interval : 1.19 , 3.08 ) , pneumonia or bronchitis since spinal cord injury ( relative risk = 2.29 ; 95 % confidence interval : 1.40 , 3.75 ) , and physician-diagnosed chronic obstructive pulmonary disease ( relative risk = 2.17 ; 95 % confidence interval : 1.08 , 4.37 ) were associated with a greater risk of chest illness . Each percent-predicted decrease in forced expiratory volume in 1 sec was associated with a 1.2 % increase in risk of chest illness ( P = 0.030 ) . Conclusions : In chronic spinal cord injury , chest illness result ing in time spent away from usual activities was not related to the level or completeness of spinal cord injury but was related to reduced pulmonary function , wheeze , chronic obstructive pulmonary disease , a history of pneumonia and bronchitis , and smoking OBJECTIVE To assess the effectiveness of expiratory muscle training on the pulmonary function of spinal cord injured patients . DESIGN R and omized controlled trial . SETTING Acute inpatient rehabilitation hospital . PARTICIPANTS Patients ( N=29 , 22 men and 7 women ) with recent traumatic , motor complete , spinal cord injury ( SCI ) at or above level T1 consecutively admitted to an SCI rehabilitation service . Subjects were r and omized to either resistance training ( n=16 ) or sham 
    Output:
    
A significant benefit of RMT was revealed for five outcomes : vital capacity ( mean difference ( 95 % confidence interval))=0.41(0.17–0.64 ) l , maximal inspiratory pressure=10.66(3.59 , 17.72 ) cmH2O , maximal expiratory pressure=10.31(2.80–17.82 ) cmH2O , maximum voluntary ventilation=17.51(5.20 , 29.81 ) l min−1 and inspiratory capacity=0.35(0.05 , 0.65 ) l. No effect was found for total lung capacity , peak expiratory flow rate , functional residual capacity , residual volume , expiratory reserve volume or forced expiratory volume in 1 second .
Conclusion : RMT  increases respiratory strength , function and endurance during the period of training .