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TECNICHE DI F

ISIOTERAPIA

RESPIRATORIA

FOCUSING “La riabilitazione respiratoria nuove prospettive”

24° CORSO DI AGGIORNAMENTO

S.I.M.F.E

.R.

G.R. Emilia

Romagna

Riccione 22 Maggio 2013

Lisi Diego Fisioterapista

Policlinico S.Orsola-Malpighi, Bologna

FISIOTERAPIA RESPIRATORIA

•  Patologie primariamente polmonari •  Esiti d Interventi chirurgici maggiori (toraco-

addominali) •  Patologie secondariamente polmonari •  Cardiovascolari •  Neurologiche •  Traumatiche •  Neuromuscolari

PROBLEMATICHE AGGREDIBILI

•  Atelettasie •  Iperaccumulo

secretivo •  Ridotta tolleranza

allo sforzo •  Ostruzione

Bronchiale

•  Restrizione polmonare

•  Ipostenia Muscoli respiratori

•  Dispnea acuta e cronica

Ristagno di secrezioni

Restrizione dei volumi polmonari

Aumento del lavoro respiratorio

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POSTURA E MOBILIZZAZIONE

Recupero della stazione eretta e Mobilizzazione Sono la prima manovra di Fisioterapia respiratoria Influisce su: •  Volumi polmonari •  Rischio di infezioni

•  Lavoro respiratorio

POSTURA E MOBILIZZAZIONE

R. Gosselink et al. Physiotherapy for adult patients with critical illness: Recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients Intensive Care Med (2008) 34:1188–1199

POSTURA E MOBILIZZAZIONE

Hess DR. Patient positioning and ventilator-associated pneumonia. Respir Care. 2005 Jul;50(7):892-8

The available evidence suggests that semi-recumbent position should be used routinely

Engel HJ et al. Physical Therapist-Established Intensive Care Unit Early Mobilization Program: Quality Improvement Project for Critical Care at the University of California San Francisco Medical Center. Phys Ther. 2013 May 16

Admission PT time 3 to 1 day ICU LOT average -2 day Ambulatory patients to home 55% to 77%

FET E ACBT

Unico approccio di esercizi respiratori composto da: •  Respiro Controllato (Breathing Control BC) •  Esercizi di Espansione Toracica (Thoracic Expansion Exercise TEE) •  Tecniche di Espirazione Forzata (Forced Expiration Tecnique FET)

BC

TEE

BC Huff

BC

FET

Es. Broncospasmo⬆BC Subatelettasie, iperreattività delle vie aeree ⬆BC, ⬆TEE

Fink JB. Forced expiratory technique, directed cough, and autogenic drainage. Respir Care. 2007 Sep;52(9):1210-21

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RAZIONALE ACBT

Lewis LK, Williams MT, Olds TS. The active cycle of breathing technique: a systematic review and meta-analysis. Respir Med. 2012 Feb;106(2):155-72

FET E ACBT

Osadnik CR et al. Airway clearance techniques in acute exacerbations of COPD: a survey of Australian physiotherapy practice. Physiotherapy. 2013 Jun;99(2):101-6.

PT prescribed forced expiratory technique (153/189, 81%) and the active cycle of breathing technique (149/189, 79%).

Flores JS et al. Adherence to airway clearance therapies by adult cystic fibrosis patients. Respir Care. 2013 Feb;58(2):279-85.

active cycle of breathing technique (κ=0.40) and autogenic drainage (κ=0.39) each showed moderate agreement

Lewis LK, Williams MT, Olds TS. The active cycle of breathing technique: a systematic review and meta-analysis. Respir Med. 2012 Feb;106(2):155-72

increase in sputum wet weight during and up to 1 h post ACBT compared to conventional physiotherapy (SMD 0.32, 95%CI 0.05-0.59), external oscillatory devices (0.75, 0.48-1.02), and control (0.24, 0.02-0.46).

TOSSE ASSISTITA

•  Più semplice manovra di disostruzione

•  Mimare i meccanismi della tosse efficace spontanea

•  Con/senza Assistenza Manuale

Inspirazione massimale

Chiusura della

glottide

Espirazione Forzata /

FET

TOSSE ASSISTITA

Controindicazioni: RELATIVE •  Possibilità di trasmissione di infezioni tramite droplets •  Elevata PIC o evidenza di Aneurismi cerebrali •  Ridotta perfusione cardiaca •  Trauma acuto non stabilizzato del cranio o colonna vertebrale

Se Assistenza Manuale Attenzione a reflusso/inalazione se paziente non collaborante Patologia Addominale Pneumotorace non drenato Coagulopatie

Respir Care. 1993 May;38(5):495-9. AARC clinical practice guideline. Directed cough. American Association for Respiratory Care.

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TOSSE ASSISTITA

MODALITA’

Abbinata alle tecniche di Fisioterapia respiratoria e igiene bronchiale (PEP, Incentive Spyrometry, ACBT) Tempi: quando necessaria Autocontenzione del torace/addome Contenzione del FT e assistenza all’espirazione forzata

Respir Care. 1993 May;38(5):495-9. AARC clinical practice guideline. Directed cough. American Association for Respiratory Care.

DRENAGGIO AUTOGENO

Utilizza il flusso espiratorio per mobilizzare le secrezioni 3 fasi, il passaggio da una all’altra avviene quando si percepiscono le secrezioni

Scollamento Raccolta Rimozione ERV FRC IRV

DRENAGGIO AUTOGENO McIlwaine M et al. Long-term comparative trial of two different physiotherapy techniques; postural drainage with percussion and autogenic drainage, in the treatment of cystic fibrosis. Pediatr Pulmonol. 2010 Nov;45(11):1064-9.

10 out of 17 patients who had completed performing AD for the first year refused to change back to PD for the second year

Van Ginderdeuren F et al. Chest physiotherapy in cystic fibrosis: short-term effects of autogenic drainage preceded by wet inhalation of saline versus autogenic drainage preceded by intrapulmonary percussive ventilation with saline. Respiration. 2008;76(2):175-80.

amount of sputum wet weight (primary outcome) was similar

McKoy NA et al Active cycle of breathing technique for cystic fibrosis. Cochrane Database Syst Rev. 2012 Dec 12 patient preference autogenic drainage over ACBT over airway oscillating

devices and HFCWO

TECNICHE A PRESSIONE POSITIVA

PEP Positive

Expiratory Pressure

PAP Positive Airway

Pressure

CPAP Continuos Positive Airway

Pressure

PEEP Positive

End Expiratory Pressure

Dispositivi Oscillanti

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TECNICHE A PRESSIONE POSITIVA

EPAP e PEP

•  Pressione positiva (10-20 cm H2O) nella fase espiratoria •  Inspirazione •  Non richiede un flusso di gas

0

-5

+5

Fisiologico

+10

P

PEP: 10cmH2O

t IN EXP

TECNICHE A PRESSIONE POSITIVA

EPAP e PEP

Sehlin M, Ohberg F, Johansson G, Winsö O. Physiological responses to positive expiratory pressure breathing: a comparison of the PEP bottle and the PEP mask. Respir Care. 2007 Aug;52(8):1000-5.

TECNICHE A PRESSIONE POSITIVA

Mestriner RG, Fernandes RO, Steffen LC, Donadio MV. Optimum design parameters for a therapist-constructed positive-expiratory-pressure therapy bottle device. Respir Care. 2009 Apr;54(4):504-8.

•  Tubo ø>8mm L > 80 cm •  Sfiato >8mm

•  Relativamente costoso •  Richiede un flusso Exp. regolare •  Addestramento e monitoraggio per la

scelta della resistenza

•  Economico (Pep Bottle) •  Indipendente dal flusso (*) •  Addestramento e monitoraggio

per la scelta della resistenza •  ⬆WOB rispetto a PEP a flusso

(a parità di pressioni)

(*)

EZPAP™

Presidio PAP in grado di fornire una pressione positiva nell’intero ciclo respiratorio proporzionale al flusso di aria utilizzato

INDICAZIONI:

•  Prevenzione/trattamento delle Atelettasie

•  Riespansione Polmonare

•  Disostruzione Bronchiale

Il paziente deve avere flussi inspiratori < 30 L/min

•  Pz. Postoperatorio •  COPD •  Pz. Pediatrico •  NMD (!!!)

MODALITA’: •  Boccaglio •  Maschera •  Connessione a cannula tracheostomica

MATERIALE’: •  Sorgente di aria compressa/Ossigeno •  Manometro

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EZPAP™

Protocollo Clinico Pratico per l’utilizzo del presidio EzPap™ - Smiths Medical, a cura di Arir – Associazione Riabilitatori dell’insufficienza Respiratoria, 2013

Obiettivo Disostruzione Riespansione

Pressione (cm H2O) 5-15 15-20

Tempi 2’ – FET/tosse 10’ – FET/tosse >10’ se monitoraggio

Cicli ≈4 cicli x 4-6 sedute/

die Ogni 2h

EZPAP®

MONITORAGGIO:

⬇ RR ⬆

⬇ Dispnea ⬆

⬆ Volumi polmonari ⬇

⬇ Distress Respiratorio ⬆

⬆ SpO2 ⬇

⬇ HR ⬆

⬇ Agitazione ⬆ Distensione Gastrica ⬆

Protocollo Clinico Pratico per l’utilizzo del presidio EzPap™ - Smiths Medical, a cura di Arir – Associazione Riabilitatori dell’insufficienza Respiratoria, 2013

TECNICHE A PRESSIONE POSITIVA

CPAP

•  Pressione positiva costante nelle vie aeree (5-20 cm H2O) in entrambe le fasi in-espiratorie

•  Richiede un flusso di gas per poter compensare il flusso aereo durante l’inspirazione

0

-5

+5

Fisiologico

+10

P

CPAP: 5cmH2O

t

TECNICHE A PRESSIONE POSITIVA

OSAS e Stroke Johnson KG, Johnson DC. Frequency of sleep apnea in stroke and TIA patients: a meta-analysis. J Clin Sleep Med. 2010 Apr 15;6(2):131-7.

Nobili L. - Atti del 2nd International Conference on Respiratory Physiotherapy. Genova, 2013

Martínez et al. Continuous positive airway pressure treatment reduces mortality in patients with ischemic stroke and obstructive sleep apnea: a 5-year follow-up study. Am J Respir Crit Care Med. 2009 Jul 1;180(1):36-41

•  SDB in up to 72% of stroke and TIA, 38% >20 AHI

•  only 7% of central apneas

Higher risk in AHI>20 non- tolerating CPAP AHI>20 + CPAP ≈ AHI<20

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TECNICHE A PRESSIONE POSITIVA

Osadnik CR, McDonald CF, Jones AP, Holland AE. Airway clearance techniques for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Mar 14;3

TECNICHE A PRESSIONE POSITIVA

Osadnik CR, McDonald CF, Jones AP, Holland AE. Airway clearance techniques for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Mar 14;3

TECNICHE A PRESSIONE POSITIVA

Osadnik CR, McDonald CF, Jones AP, Holland AE. Airway clearance techniques for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012 Mar 14;3

INCENTIVATORI DI VOLUME/FLUSSO

•  Stimolare l’esecuzione di respiri lunghi, lenti e profondi

•  Feedback visivo •  Flusso/volume predeterminato

•  Ampiamente utilizzati •  Letteratura quasi esclusivamente sul trattamento

del paziente pre-post chirurgico •  Diffusione Vs Scarse prove di efficacia

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INCENTIVATORI DI VOLUME/FLUSSO

Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Freitas ER, Soares BG, Cardoso JR, Atallah ÁN. Cochrane Database Syst Rev. 2012 Sep 12;9

Incentive spirometry in major surgeries: a systematic review. Carvalho CR, Paisani DM, Lunardi AC. Rev Bras Fisioter. 2011 Sep-Oct;15(5):343-50.

Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Guimarães MM, El Dib R, Smith AF, Matos D. Cochrane Database Syst Rev. 2009 Jul 8;(3)

widely used without standardization in clinical practice

urgent need to conduct well-designed trials in this field

No evidence regarding the effectiveness

Patients treated with IS had worse pulmonary function and arterial oxygenation compared with positive pressure breathing (CPAP, BiPAP, IPPB)

INCENTIVATORI DI VOLUME/FLUSSO

Parreira VF, Tomich GM, Britto RR, Sampaio RF. Assessment of tidal volume and thoracoabdominal motion using volume and flow-oriented incentive spirometers in healthy subjects. Braz J Med Biol Res. 2005 Jul;38(7):1105-12.

Weindler J, Kiefer RT. The efficacy of postoperative incentive spirometry is influenced by the device-specific imposed work of breathing. Chest. 2001 Jun;119(6):1858-64.

Yamaguti WP, Sakamoto ET, Panazzolo D, Peixoto Cda C, Cerri GG, Albuquerque AL. Diaphragmatic mobility in healthy subjects during incentive spirometry with a flow-oriented device and with a volume-oriented device. J Bras Pneumol. 2010 Nov-Dec;36(6):738-45.

WOB imposed by the flow-oriented device was twice the one imposed by the volume-oriented device

higher WOB is observed during the use of this type of device [flow-oriented]

abdominal motion was larger during the use of volume-oriented

INCENTIVATORI DI VOLUME/FLUSSO

•  Paziente con CV>10 ml/Kg o IC>30% pred.

POSOLOGIA •  10 atti/h oppure 5 X 10 atti/giorno oppure 15 atti ogni 4h •  Stimolare autotrattamento

Usare in combinazione con: Deep Breathing tec., Tosse Assistita, Mobilizzazione precoce,

Analgesia

ASSISTENZA ALLA TOSSE

IN-Essufflazione Meccanica

Indicazione prioritaria nelle Patologie Neuromuscolari

Joint BTS/ACPRC Guidelines, Thorax, 2009 ACCP Evidence based clinical practice guidelines, Chest, 2006

Sostituisce l’atto della tosse Obiettivo: Mantenere ROM e Compliance del sistema toracopolmonare Evitare complicanze (atelettasie, polmoniti…) Insufflazione a pressione positiva – pausa – Rapida Essufflazione a pressione negativa

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ASSISTENZA ALLA TOSSE

Gómez-Merino, Bach JR. et al. Mechanical insufflation-exsufflation: pressure, volume, and flow relationships and the adequacy of the manufacturer's guidelines. Am J Phys Med Rehabil. 2002 Aug;81(8):579-83

Kang SW, Bach JR. Maximum insufflation capacity: vital capacity and cough flows in neuromuscular disease. Am J Phys Med Rehabil. 2000 May-Jun;79(3):222-7. Tosse efficace: PCEF > 180l/min,

> 270l/min se NMD Correlato con VC > 1500 ml o > 50% predetto

Pressioni di IN ≥ 40 cm H2O

IN-Essufflazione Meccanica

ASSISTENZA ALLA TOSSE IN-Essufflazione Meccanica

Trebbia G. et al. Cough determinants in patients with neuromuscular disease. Respiratory Physiology & Neurobiology 146 (2005) 291–300

VC and PCF were higher during MI plus MAC than during MAC or MI alone (p < 0.01).

ASSISTENZA ALLA TOSSE

IN-Essufflazione Meccanica

Vitacca M, Gonçalves MR. et al At home and on demand mechanical cough assistance program for patients with amyotrophic lateral sclerosis. Am J Phys Med Rehabil. 2010 May;89(5):401-6.

A Domicilio

Bento J, Gonçalves M et al. Indications and compliance of home mechanical insufflation-exsufflation in patients with neuromuscular diseases. Arch Bronconeumol. 2010 Aug;46(8):420-5.

Trained non professional caregiver 8/21 avoided hospitalization

MIE on demand 30/39 avoided hospitalization Mean monthly cost is 59% less than for continuous MI-E rental

HFCWO (HIGH FREQUENCY CHEST WALL OSCILLATION)

Compressioni toraciche a frequenza impostabile (5-25 Hz) mediante corpetto gonfiabile 10’-30’ a frequenze crescenti

Razionale: ⬆ interazione aria-muco ⬆ attività ciliare ⬇ Viscoelasticità del muco

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HFCWO (HIGH FREQUENCY CHEST WALL OSCILLATION)

Bott J et al. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. Thorax. 2009 May;64

Grade A in airway clearance in stable CF

MA…

HFCWO (HIGH FREQUENCY CHEST WALL OSCILLATION)

McIlwaine MP et al. Long-term multicentre randomised controlled study of high frequency chest wall oscillation versus positive expiratory pressure mask in cystic fibrosis.Thorax. 2013

Outcome measure: PFT, Sputum W. VS Pulmonary exacerbation

PEs per participant in the PEP group was 1.14 compared with 2.0 in the HFCWO group (p=0.007)). PEs requiring intravenous antibiotics in the HFCWO three times the PEP group

CONCLUSIONI

chest physiotherapy “classica”

(ACBT, DA, FET, Tosse assistita)

Poche evidenze certe, necessità di indicatori di outcome adeguati a breve e lungo termine

attenzione a caratteristiche tecniche = WOB

Scelta della tecnica adeguata

Incentivatori e presidi PAP

MOBILIZZAZIONE PRECOCE Disallettamento Mantenimento di un adeguato livello di attività Riallenamento allo sforzo

VALUTAZIONE GRAZIE PER L’A

TTENZIONE