Φυσικοθεραπεία. Ηρακλής Τσαγκάρης. Β Κλινική Εντατικής Θεραπείας Πανεπιστήμιο Αθηνών Αττικό Νοσοκομείο

Φυσικοθεραπεία Ηρακλής Τσαγκάρης Β Κλινική Εντατικής Θεραπείας Πανεπιστήμιο Αθηνών Αττικό Νοσοκομείο

Φυσικοθεραπεία Κάθαρση Κάθαρση αεραγωγών Τοποθέτηση Αναπνευστικές ασκήσεις

Κάθαρση των αεραγωγών Προβληματικός βήχας (π.χ( νευρομϋικά) Προβληματική ποιότητα εκκρίσεων (π.χ.( CF) Προβληματική βλεννοκροσσωτή κάθαρση (π.χ.( πρωτοπαθής δυσκινησία των κροσσών) Προβληματική ανατομία (π.χ.( βρογχεκτασία)

Τεχνικές - Μέθοδοι

Chest/conventional physiotherapy (CCPT) This technique has tradi- tionally included postural drainage, percussion and vibration. Postural drainage is a technique in which the patient is positioned to facilitate gravity drainage of secretions from the airways.

Postural drainage with percussion and vibration (PDPV) Percussion is a technique of clapping the chest wall. Vibration applies fine shaking of the chest wall, usually during the expiratory phase. Percussion and vibration can be applied using either manual or mechanical techniques. A. Gallon. Evaluation of chest percussion in the treatment of patients with copious sputum production. Respir Med 1991;41: 45 51 51 9 pts Sputum production 0.831 g/min (control) vs 1.040 (slow percussion) and 1.231(fast percussion)

Forced expiration technique (FET) Sometimes called huff coughing, this technique consists of one or two huffs from mid-to to-low lung volumes with the glottis open, followed by relaxed diaphragmatic breathing.

Pursed-lip breathing Involves inhaling through nose slowly and exhaling through pursed lips.

Active cycle of breathing techniques (ACBT) This technique includes breathing control, thoracic expansion techniques, forced expiration technique (FET), and may include conventional chest physiotherapy.

Autogenic drainage (AD) Autogenic drainage consists of the following three phases: : (1) "unsticking" the mucus in the smaller airways by breathing at low lung volumes (ie, tidal breaths are performed below functional residual capacity); (2) "Collecting" Collecting" the mucus from the intermediate-sized airways by breathing at low to middle lung volumes; and (3) "evacuating" evacuating" the mucus from the central airways by breathing at middle to high lung volumes.

Positive expiratory pressure (PEP) This technique uses a device, through which the patient exhales against a pressure of 10 20 cmh2o. During high PEP, the patient exhales against a pressure ranging from 40 to 100 cmh2o. It improves mucus clearance by either increasing gas pressure behind secretions through collateral ventilation or by preventing airway collapse during expiration.

Airway oscillating device (AOD): flutter This technique uses a device that produces PEP with oscillations in the airway during the expiratory phase.

Intrapulmonary Percussive Ventilation (IPV) IPV delivers a series of pressurized mini-bursts of inhaled air and continuous therapeutic aerosol through a nebulizer; ; IPV patients breathe through a mouthpiece, and then cough to clear the loosened secretions In the available studies, the numbers of patients have been small (4 to 24), the patient populations different, the treatment settings different (in-hospital versus out- patient), and IPV has been compared to different alternative airway clearance modalities (e.g. e.g., flutter valve, and/or chest wall compression device, and/or standard chest PT and drainage). Also, outcome measurements differed amongst the studies, variously including factors such as sputum volume, sputum viscosity, pulmonary function data or radiographic changes depending on the study design and patient population. There is minimal data directly comparing the performance of a chest wall compression device with that of IPV.

High-frequency chest compression (HFCC) ThisThis technique uses an inflatable vest that attaches by hoses to an airpulse generator producing pressures to about 50 cmh2o at frequencies of 5 25 Hz.

Ο ρόλος της φυσικοθεραπείας στην Xρόνια αποφρακτική πνευμονοπάθεια Βρογχεκτασίες Κυστική ίνωση Αποκατάσταση Νευρομυικά νοσήματα Χειρουργικούς ασθενείς Μηχανικό αερισμό

Xρόνια αποφρακτική πνευμονοπάθεια

COPD & physiotherapy The authors conclude not only that the physical therapeutic techniques used with COAD patients are extremely diverse in nature, but that the investigations of their validity have been neither comprehensive nor conclusive. Immediate study is needed to define more specific physiological aims for each modality; more selective and effective treatment can then be performed and the true potential of chest physiotherapy realized. Reid, Physiother Can, 1983

NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop Summary ManualManual or mechanical chest percussion and postural drainage may be beneficial in patients producing more than 25 ml sputum per day or with lobar atelectasis. AJRCCM 2001; 163: 1256-1276 1276

Chest 2001;119:1185-1189

ACCP Evidence-Based Clinical Practice Guidelines Chest 2006;129:28S-32S

ACCP Evidence-Based Clinical Practice Guidelines 8. In stable patients with chronic bronchitis, the clinical benefits of postural drainage and chest percussion have not been proven, and they are not recommended. Level of evidence, fair; net benefit, conflicting; grade of recommendation, I 9. In patients with an acute exacerbation of chronic bronchitis, the clinical benefits of postural drainage and chest percussion have not been proven, and they are not recommended. Level of evidence, fair; net benefit, conflicting; grade of recommendation, I Chest 2006;129:104S-111S 111S

ACCP Evidence-Based Clinical Practice Guidelines In patients with COPD, huffing should be taught as an adjunct to other methods of sputum clearance. LevelLevel of evidence, low; benefit, small; grade of recommendation,, C

Βρογχεκτασία

Φυσικοθεραπεία και βρογχεκτασία REVIEWER'S CONCLUSIONS: This review only provides evidence of the benefits of inspiratory muscle training and provides no evidence of the effect of other types of physical training (including pulmonary rehabilitation) in bronchiectasis. Cochrane Database Syst Rev 2002;(3):CD002166 Bradley J; Moran F; Greenstone M

Chronic cough due to bronchiectasis: : ACCP evidence-based clinical practice guidelines A variety of manual and mechanical interventions, including chest percussion, vibration, postural drainage, mechanically assisted cough, and airway oscillation, are used commonly to facilitate the expectoration of mucus. These maneuvers are also referred to as chest physiotherapy, and formerly as pulmonary toilet. Their primary role is to facilitate the clearance of lower airway secretions in conditions associated with the hypersecretion of mucus and the inability to expectorate effectively. Although these techniques are considered to be mainstays in the treatment of bronchiectasis, they have modest effects on increasing sputum volume, and the long-term effectiveness of these interventions is unknown. Chest 2006;129(S):122-131

Recommendation for Bronchiectasis 10. In patients with conditions associated with the hypersecretion of mucus and the inability to expectorate effectively, chest physiotherapy should be used and patients should be monitored for symptom improvement. LevelLevel of evidence, expert opinion; benefit, small/weak; grade of recommendation,, E/C Chest 2006;129(S):122-131

Κυστική ίνωση

Φυσικοθεραπεία και κυστική ίνωση Kάθαρσηάθαρση αεραγωγών Συμβατική φυσικοθεραπεία Θετική Θετική εκπνευστική πίεση Μη Μη επεμβατικός αερισμός Φυσική Φυσική άσκηση

Airway clearance compared with no airway clearance in CF Six randomised,, crossover trials (short-term, term, trials, total of 66 pts) Two trials found no significant difference between airway clearance and no airway clearance in post- treatment TLC and FRC. The long-term effect of no airway clearance is unknown, and short-term term trials provide some evidence of the benefit of airway clearance over no airway clearance in improved mucus transport

Conventional chest physiotherapy (CCPT) compared with other forms of airway clearance in CF Fifteen Fifteen trials of mixed designs (475pts) Mixed Mixed duration (4 short,, 5 1-6mo,, 5 >1yr) Medium- and long-term trials have shown that CCPT is at least as effective as other forms of airway clearance Patients tended to prefer techniques that promoted independence to CCPT

PEP compared with other airway clearance forms in CF Twenty Twenty trials of mixed designs (total( of 429 pts) PEP PEP was compared with several different airway clearance regimens, and a number of trials had numerous comparison groups Single, Single, short and longer term trials show that PEP is at least as effective as other forms of airway clearance

Airway clearance with NIV vs no NIV in CF Three randomised,, crossover trials (62pts( 62pts) No difference was reported in post-treatment treatment spirometry (FEV1, FVC, FEF25 75), respiratory rate was significantly lower during NIV than during ACBT/FET Short-term term trials show that NIV is more effective than other airway clearance regimens in patients with more severe disease, who have difficulty clearing sputum The long-term effect of NIV used for airway clearance is unknown

Physical training compared with no physical training in CF Seven Seven trials using randomised parallel-group design (a total of 231 pts) Short- and longer term trials show some benefit of physical training compared with no physical training There There is no evidence to support or refute the substitution of airway clearance sessions with physical training

Φυσικοθεραπεία και κυστική ίνωση In patients with CF, chest physiotherapy is recommended as an effective technique to increase mucus clearance, but the effects of each treatment are relatively modest and the long-term benefits unproven. LevelLevel of evidence, fair; benefit, small; grade of recommendation,, C Chest 2006;129(S):122-131

Φυσικοθεραπεία και κυστική ίνωση In patients with CF, autogenic drainage should be taught as an adjunct to postural drainage as a method to clear sputum because it has the advantage of being performed without assistance and in one position. LevelLevel of evidence, low; benefit, small; grade of recommendation,, C Chest 2006;129(S):122-131

Φυσικοθεραπεία και κυστική ίνωση In patients with CF, huffing should be taught as an adjunct to other methods of sputum clearance. LevelLevel of evidence, low; benefit, small; grade of recommendation,, C Chest 2006;129(S):122-131

Φυσικοθεραπεία και κυστική ίνωση In patients with CF, PEP is recommended over conventional chest physiotherapy because it is approximately as effective as chest physiotherapy, and is inexpensive, safe, and can be self-administered administered. LevelLevel of evidence, fair; benefit, intermediate; grade of recommendation,, B Chest 2006;129(S):122-131

Φυσικοθεραπεία και κυστική ίνωση In patients with CF, devices designed to oscillate gas in the airway, either directly or by compressing the chest wall, can be considered as an alternative to chest physiotherapy. LevelLevel of evidence, low; benefit, conflicting; grade of recommendation,, I Chest 2006;129(S):122-131

Νευρομυικά νοσήματα

Respiratory Muscle Strength Training In patients with neuromuscular weakness and impaired cough, expiratory muscle training is recommended to improve peak expiratory pressure, which may have a beneficial effect on cough. Level of evidence, expert opinion; benefit, small; grade of recommendation,, E/C Chest 2006;129(S):122-131

Electrical Stimulation of the Expiratory Muscles In patients with neuromuscular disease with impaired cough, mechanical cough assist devices are recommended to prevent respiratory complications. Level of evidence, low; benefit, intermediate; grade of recommendation,, C Chest 2006;129(S):122-131

Χειρουργικοί ασθενείς

Προεγχειρητικά Chest physiotherapy does not improve the outcome in laparoscopic fundoplication and vertical-banded gastroplasty. (Fagevik, Surg Endosc. 1999) Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery (Fagevik,, Br J Surg 1997) Oxygen saturation on postoperative days 1-3 was significantly greater in the treatment group. Postoperative pulmonary complications occurred in 6 per cent of patients in the treatment group and in 27 per cent of controls (P < 0.001).

Prevention of respiratory complications after abdominal surgery: : a randomised clinical trial Most postoperative respiratory complications were due to atelectasis: less than 1% of the patients developed pneumonia An American Society of Anesthesia classification >1 and an age >/=60 years is a simple way of defining patients at high risk of respiratory complications and other adverse events after abdominal surgery A regimen consisting of deep breathing exercises (low risk patients) and incentive spirometry (high risk patients) is an efficient way of providing prophylaxis against respiratory complications after abdominal surgery Hall, BMJ, 1996

Prophylactic respiratory physiotherapy after cardiac surgery 18 trials (1457 patients) were identified. 13 tested physical therapy, 8 incentive spirometry, 5 CPAP, and 3 intermittent positive pressure breathing. The maximum follow up was six days. Four trials only had a no intervention control; none showed any significant benefit of physiotherapy. No intervention showed superiority for any end point. For the most labour intensive intervention, continuous positive airway pressure, the average cost of labour for each patient day was 27 ( 19; $32). Pasquina, BMJ, 2003

Pasquina, BMJ, 2003

Ανεπιθύμητες ενέργειες-kόστος Gastric distension in 2-10% of patients and nausea in 0-12% of patients. Inconvenience of the mask was reported in 43% of patients receiving continuous positive airway pressure. During physical therapy,, 4% of patients had a percutaneous capillary oxygen saturation of less than 90% and 1% of patients had tachycardia. Pasquina, BMJ, 2003

Αποκατάσταση

Αποκατάσταση Chest 1997;112:1363-96

Αποκατάσταση και φυσικοθεραπεία Individual physiotherapy advice to patients with sputum production is an appropriate component of rehabilitation when this has not been addressed previously. The physiotherapist also has a role in providing advice about relaxation and breathing retraining techniques. The true value of these techniques has not yet been established, although they may be popular with patients. Clinical trials of diaphragmatic breathing retraining or pursed lip breathing have not been shown to be effective. BTS statement on Pulmonary Rehabilitation, Thorax 2001;56:827-834

Chest therapy consists of bronchial, or postural, drainage, which is done by placing the patient in a position that allows drainage of the mucus from the lungs. At the same time, the chest or back is clapped (percussed) and vibrated to dislodge the mucus and help it move out of the airways. This process is repeated over different parts of the chest and back to loosen the mucus in different areas of each lung. This procedure has to be done for children by family members but older patients can learn to do it by themselves. Mechanical aids that help chest physical therapy are available commercially. BTS statement on Pulmonary Rehabilitation, Thorax 2001;56:827-834

Φυσικοθεραπεία: πρόκληση πτυέλων 75% of centres reported using physiotherapy techniques for sputum induction procedure Randomised, crossover trial 59 pts referred for sputum induction for suspected pulmonary infection with Mycob or PCP Elkins, ERJ 2005;26:904-908

Φυσικοθεραπεία: δεν βοηθάει στην πρόκληση πτυέλων Intervention: : manualm percussion and vibration of the chest wall during deep breathing and huffing and coughing, interspersed with periods of relaxed diaphragmatic breathing Control:breaths slightly more deeply than usual, occasionally two to three deep breaths, and cough at least every 5 min and whenever they felt secretions in their airways Elkins, ERJ 2005;26:904-908

Φυσικοθεραπεία και ΜΑ Ο ακριβής ρόλος του φυσιοθεραπευτή στη ΜΕΘ ποικίλει σε μεγάλο βαθμό και εξαρτάται από παράγοντες όπως Η παράδοση Η στελέχωση Το μόνιμο ή εναλασσόμενο προσωπικό Εκπαίδευση Εμπειρία Τρόπος επιλογής των περιστατικών

Φυσικοθεραπεία στη ΜΕΘ Norenberg, ICM, 2000;26:988-994

Τοποθέτηση H τοποθέτηση μπορεί να χρησιμοποιηθεί σαν θεραπευτική τεχνική με σκοπό τη βελτίωση της σχέσης αερισμού αιμάτωσης,, την αύξηση των πνευμονικών όγκων και της βλεννοκροσσωτής κάθαρσης και τη μείωση του έργου της αναπνοής. Ειδικά παραδείγματα η τοποθέτηση σε ημικαθιστική θέση κατά τον απογαλακτισμό, στο πλάι σε ασθενείς με ετερόπλευρη πνευμονική βλάβη, ή σε πρηνή θέση σε ασθενείς με ARDS.

Norenberg, ICM, 2000;26:988-994

Chest physiotherapy for the prevention of ventilator-associated associated pneumonia 60 pts ventilated for at least 48 h (physio 36-control 24) There were no differences in the duration of mechanical ventilation, length of stay in ICU or mortality. VAP was assessed daily by combined clinical assessment and the clinical pulmonary infection score (CPIS). VAP occurred in 39% (14/36) of the control group and 8% (2/24) of the intervention group (P=0.02). Ntoumenopoulos,, ICM, 2002

Weaning Recommendation 8: Weaning/discontinuation protocols that are designed for nonphysician health-care professionals (HCPs) should be developed and implemented by ICUs. Protocols aimed at optimizing sedation also should be developed and implemented. Evidence-Based Guidelines for Weaning and Discontinuing Ventilatory Support. Chest. 2001;120:375S-396S 396S

Rationale ThereThere is clear evidence that nonphysician HCPs (eg, respiratory therapists) can execute protocols that enhance clinical outcomes and reduce costs for critically ill patients. TheThe reproducibility of benefit for using various protocols in different ICUs and institutions suggests that it is the use of a standardized approach to management that improves outcomes. Ely, AJRCCM, 1999 Kollef, CCM, 1997 Stoller, AJRCCM, 1998

Κινητοποίηση Δεν υπάρχουν κλινικές μελέτες που αξιολογούν την επίπτωση της κινητοποίησης στους μηχανικά αεριζόμε- νους ασθενείς όσον αφορά Την πνευμονική λειτουργία Τη διαδικασία του απογαλακτισμού Τη διάρκεια του μηχανικού αερισμού Τη διάρκεια νοσηλείας στη ΜΕΘ

Clini & Ambrosino. Physiotherapy in the respiratory intensive care unit. Resp Med 2005;99:1096-1104

Quality of evidence The effect of nonpharmacologic airway clearance techniques on long-term outcomes such as health- related quality of life and rates of exacerbations, hospitalizations, and mortality is not known at this time. The committee recommends that future investigations measure these outcomes in patients with CF, bronchiectasis,, COPD, and neuromuscular diseases. Level of evidence, expert opinion; benefit, substantial; grade of recommendation,, E/A