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Therefore, it is vital that, as soon as the spinal cord injury occurs, the patient is closely monitored, providing respiratory treatment both with medical and rehabilitation objectives in mind, the latter in the area of respiratory physiotherapy, performing regular respiratory function assessments.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The questionnaire presented is an international consensus document designed to collect, in an orderly and systematic manner, the initial respiratory assessment data which should be applied to all patients with spinal cord injury, and that we thought important to have in our language so that it can be used by spinal cord injury units where Spanish is spoken.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> We agree with you that a more comprehensive assessment of the respiratory system should be done; this is also recommended by ISCOS and ASIA, spinal cord injury scientific societies.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> First, it is necessary to use the consensus document, and if a worsening of the spinal cord injury is detected, the respiratory system should be studied more thoroughly.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In response to your comment about this questionnaire not meeting all validation characteristics so as to be considered a health questionnaire, we simply say that we followed the recommendations imposed by the ISCOS regulations, and as it is not a health questionnaire, where a health field is being measured, we did not consider necessary to apply any other recommendations. At present, the part of the study where the usefulness of this questionnaire is assessed with a group of patients with spinal cord injury is pending publication.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In your letter you also comment about the need to evaluate cough efficacy in patients with spinal cord injury, a statement with which we do not completely agree, because we believe that patients with spinal cord injury do not behave exactly like those with neuromuscular diseases, since they have many peculiarities and differences depending on the level of spinal cord injury, especially due to changes in the vegetative nervous system.</p><p id="par0030" class="elsevierStylePara elsevierViewall">To illustrate, spinal cord injury causes paralysis of the respiratory muscles with restriction of maximum inspiration and impaired ability to cough, causing an increased risk of atelectasis and secretion retention. But these patients, unlike the neuromuscular disease patients, also have an obstructive ventilatory defect, which is not only caused by the collapse of the airway or the presence of secretions in the airway, but by a particular constriction tendency, something that differentiates them from other patients with neuromuscular disease. Bronchial hyperreactivity is common in patients with high spinal injuries above T7, since they present autonomic system dysfunction, e.g., lack of sympathetic innervation and/or insufficient stretching of the airway smooth muscle due to decreased inspiratory capacity.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In order to make a correct assessment of respiratory function and implement a successful treatment, it is important to understand the pathophysiology of spinal cord injury and how the respiratory system is affected, depending on the degree and location at neurological level.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> It is important to know the location of the neurological injury, since all respiratory muscles below that level will be affected, but it is also important to know the degree of neurological involvement of the injury, e.g. the neurological level, since all the motor complete injuries (ASIA A and B) are completely non-functional below the level of injury; however, in motor incomplete injuries (ASIA C and D) the degree of muscle involvement is variable. It is also important to know that there are other factors that influence respiratory system dysfunction, some of them spinal cord injury dependent, such as time and position, and other independent, such as age, obesity, previous respiratory history, smoking history and respiratory complications or injuries that have occurred during the acute phase of spinal cord injury.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">We agree with you that simply performing a spirometry does not provide all the information, also, that it would be advisable to study respiratory muscle strength and cough strength in these patients. In our experience, the most useful information in order to treat the respiratory system from a rehabilitation point of view is obtaining data about the strength of the inspiratory muscles, as training seems to improve it and, in turn, causes an increase in cough peak flow.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> But obviously, it is necessary to study both, inspiratory/expiratory forces as well as peak cough in order to consider an adequate rehabilitation treatment at different stages of spinal cord injury, which aims to retrain the ventilatory pattern depending on muscle preservation, train the inspiratory muscles, achieve maximum inspiratory capacity, create an effective cough, either manually or assisted, through the use of respiratory devices: ambu-bag or a cough assistance device when necessary.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> As for the training of the expiratory muscles, there is controversy in the medical literature; our group does not engage in training this musculature.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">We open the possibility to all respiratory system specialists who work with patients with spinal cord injury – pneumologists, rehabilitation physicians and respiratory physiotherapists – to standardize the respiratory assessment, so that medical and rehabilitation strategies can be established in the field of respiratory physiotherapy. In that way we will contribute to improve the socio-functional situation and quality of life of this population group, with the ultimate goal of reducing respiratory complications and increase survival.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Gómez-Garrido A, González-Viejo MA. Respuesta. Med Clin (Barc). 2016;146:235–236.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International spinal cord injury pulmonary function basic data set" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Biering-Sørensen" 1 => "A. 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