Kinesiólogo TR Claudio Torres T.Miembro de la división de kinesiología Intensiva

Especialista en kinesiología RespiratoriaPFCCS Instructor

Kinesiología Respiratoria: Fundamentos y Evidencia

• Ampliamente utilizada en distintos niveles de atención.

• diferentes “tendencias” describen técnicas y fundamentos diferentes.

• evidencia ofrece datos conflictivos en cuanto a su efectividad.

• Escasos “datos duros”

Generalidades

DefinicionesLa Fisioterapia de Tórax (FT) o Kinesiterapia Respiratoria (KTR) es una intervención comúnmente usada en pacientes con enfermedad de las vías aéreas. Su principal objetivo es facilitar el transporte de secreciones y también disminuir la retención de estas en la vía aérea.

Históricamente la FT ha consistido en una combinación de técnicas de espiraciones forzadas (tos dirigida o huff), drenajes posturales, percusiones y/o vibraciones. RESPIRATORY  CARE  •  SEPTEMBER  2007  VOL  52  

NO  9

KTR debe ser ofrecida a pacientes con distintas condiciones respiratoria con el objetivo de manejar y controlar sintomas respiratorios, mejorar o mantener la función y limpiar la via aerea mejorando o aisitiendo la tos. las técnicas incluyen rehabilitación, ejercicios de prueba, prescripción de ejercicios para higiene bronquial, posicionamiento y técnicas de respiración.

Thorax 2009;64(Suppl I):i1–i51. doi:10.1136/thx.2008.110726

C. Lyon. Ann. Kinesither 1995;22:49-57

Gosselink R et Als. Intensive Care Med 2008;34:1188–99

Gouriet A. Revu kiné actualité 2005;20-21

Adasme R, Puppo H. 2011

Consideraciones Anatomo-Funcionales

in the dependent part of the lung during tidal breathingworsens the ventilation-perfusion relationship and is asso-ciated with a reduction in oxygenation and diminishedcarbon monoxide transfer.16,39 Carbon dioxide eliminationappears to be unaffected, despite a slight increase in thedead-space ventilation ratio.40,41

This age-related deterioration in lung function is slowerin those with a long-term habit of exercise, but it is notabated, even in elite athletes.42,43

Exercise and Ventilatory Response

Younger normal individuals are limited in exercise bycirculation, not ventilation.19,44 Because of the changesalready discussed, the ventilatory reserve is compromisedin the elderly, and although not apparent at rest, their

ventilatory limitations may become evident during acuteillness, surgery, or exercise.18 During exercise the elderlytend to use their abdominal muscles to a greater degreeand to use a rapid shallow breathing pattern because of arigid rib cage.19 But, despite these ventilatory changes, theelderly are still usually limited by circulation because ofdeconditioning or from changes in cardiovascular physi-ology.19 During exercise, the incremental increase in tidalvolume to increase minute ventilation is primarily due torecruitment of end-inspiratory lung volume, rather than toreducing end-expiratory lung volume as seen in youngerindividuals.42

With aging, the ventilatory response to hypoxia andhypercarbia is blunted, most likely due to a combination ofa reduced neural output to the respiratory muscles, a de-creased peripheral chemosensitivity, and a lower mechan-ical efficiency and deconditioning.45,46 Minute ventilationresponse to elevated carbon dioxide during hypoxia is re-duced during exercise in the elderly, compared to youngerindividuals.47 Respiratory response to both hypoxemia andhypercarbia is decreased by 40–50% in a healthy 70-year-old.45,46

Clinical Implications

Despite the physiologic and functional changes associ-ated with aging (Table 2), the basal function of most organsystems, including the respiratory system, is relatively un-compromised.63 The healthy elderly individual is asymp-tomatic at rest, but functional reserve and the ability tocompensate for various physiologic stressors is reduced.18

Stressors that might challenge the elderly beyond theirreserve include pneumonia, surgery, and exacerbation of acomorbid condition, such as asthma, chronic obstructivepulmonary disease, or congestive heart failure. Responseof the elderly to specific medications and to combinationsof medications can also be an issue. Lean body mass andtotal body water is decreased while body fat is increased inthe elderly, which alters the volume of distribution andredistribution and the clearance rates of drugs, so drugs arenot eliminated as well as they are in younger patients.64

The aging process is also associated with changes in thecentral nervous system, which increases the sensitivity ofthe elderly patient to many anesthetic agents.65 Elderlypatients are approximately 30 –50% more sensitive topropofol than are younger patients.65,66

A particular respiratory concern is the increased risk ofaspiration and pneumonia.19,67 Anesthetics and muscle re-laxants compromise pharyngeal function and diminish theeffectiveness of the cough mechanism, especially in theelderly.63,67,68 The elderly are also more susceptible todrug interactions that can result in respiratory depression(eg, an analgesic that contains codeine with an antihista-mine or a ! blocker). Because of these issues, the elderly

Fig. 1. Relative changes in lung volume associated with aging.IRV ! inspiratory reserve volume. VC ! vital capacity. TV ! tidalvolume. ERV ! expiratory reserve volume. FRC ! functional re-sidual capacity. RV ! residual volume. (From Reference 19, withpermission.)

Fig. 2. Changes in lung volume over time. (From Reference 15,with permission.)

AIRWAY CLEARANCE IN THE ELDERLY AND PATIENTS WITH NEUROLOGIC COMPROMISE

RESPIRATORY CARE • OCTOBER 2007 VOL 52 NO 10 1365

estado del arte...

inflammation within the airways at an earlystage, even before clinical manifestations.13 14

For this reason, prophylactic chest physio-therapy is often introduced at diagnosis, butthis places a great burden on the family, andadherence to chest physiotherapy in CF isknown to be poor.15 The impact of early inter-vention on the natural history of the disease isunknown.

OTHER CAUSES OF BRONCHIECTASIS

There are a number of paediatric lungconditions that result in bronchiectatic changesand chronic sputum production. Examplesinclude ciliary dyskinesia, postinfective de-struction, and chronic aspiration. Althoughthere are similar clinical features to CF, theunderlying pathogenesis does not necessarilymean that the results of studies evaluating therole of physiotherapy in CF can automaticallybe extrapolated to this group.

A systematic review of randomised control-led trials estimating the magnitude of bronchialhygiene physical therapy (BHPT) interven-tions on patients with bronchiectasis (exclud-ing CF) identified 10 randomised controlledtrials and a total of 153 patients.16 Studies withpositive results involved a total of 67 patients ofall ages but there was no paediatric subgroupanalysis. There was no evidence that lungfunction was improved by BHPT. BeneficialeVects were confined to sputum productionand radio-aerosol clearance. Clinical outcomesconsidering morbidity and mortality are lack-ing and the routine application of BHPT topatients with chronic airways obstruction is notsupported by available evidence.

Primary pneumonia“She was frothing at the nostrils and mouthcorners, a death rattle on respiration andoccasionally a sort of eVort at clearing her throat.Several times each night the nurse compressed thechest and performed artificial respiration. Thechild begged to be left undisturbed, ‘If you’ll onlylet me alone,’ she said. After a month the girl leftthe hospital quite well.”

Northrup WP. In: Paralysis of diaphragm and softpalate. Transactions of the American Pediatric Society1904;16:245–8.

There have been two studies that looked atthe role of physiotherapy in primary pneumo-nia although neither was confined specificallyto the paediatric age group. In a randomisedcontrolled trial, 54 patients with primarypneumonia and no underlying respiratorypathology were allocated to a treatment andnon-treatment group. Chest physiotherapy didnot hasten resolution for a number of outcomemeasures.17 A Swedish study of 171 patientsfound no diVerence between placebo andphysiotherapy treated groups for duration ofhospital stay and improvement in lung func-tion. Patients with pneumonia who had chestphysiotherapy had a longer duration of feverthan those not receiving treatment, an eVectmore pronounced in the younger patients.18

This led to an editorial suggesting that chestphysiotherapy may be harmful in some pa-

tients, especially those who do not produceexcessive sputum.19

In general, it is accepted that application ofmanual techniques in patients with consolida-tion has no beneficial eVect; however, the widerrole that physiotherapy may play should beconsidered in terms of positioning to optimiseventilation and perfusion. Once the consolida-tory phase begins to resolve, chest physio-therapy techniques might have some benefit inmobilising and clearing secretions, especially inthe weak or uncooperative child.

BronchiolitisChest physiotherapy is not uncommonly re-quested in children with acute viral bronchioli-tis. A randomised study of twice daily chestphysiotherapy in addition to standard support-ive measures compared with a no physio-therapy control group found no significant dif-ference for hospital stay, length of illness, ordaily clinical score between the two groups.20

This study was instigated when the authorsfound that chest physiotherapy for childrenwith bronchioloitis had become the rule ratherthan the exception. A further trial has found noclinically discernible benefit of chest physio-therapy in bronchiolitis or impact on the courseof the illness.21

Asthma“Massage is beneficial for asthmatic casesbecause the superficial circulation beingimproved, the congestion of the mucousmembrane of the bronchial tubes is reduced,and probably there is a reflex action on thepulmonary branch of the pneumogastric nerve.”

Ellison MA. A manual for students of massage. London:Bailliere, Tindall and Cox, 1898.

Physiotherapy in acute, severe asthma hasbeen studied in a group of 38 children aged6–13 years.22 The cohort was divided into atreatment group of 19 children who receivedphysiotherapy within 24 hours after admissionand 19 children who had placebo visits. Fourphysiotherapy sessions, preceded by nebulisedsalbutamol, were administered over two days.The two groups were similar in all otherparameters. Lung function at the end of thestudy was similar in both groups and theauthors concluded that chest physiotherapydid not improve lung function in children withacute severe asthma. In the presence ofretained secretions, particularly in the venti-lated asthmatic child, chest physiotherapy maybe beneficial and expedite recovery. However,inappropriate treatment in the presence ofbronchoconstriction might greatly exacerbatethe situation.

The role of breathing exercises and posturein the management of children with morechronic asthma receives intermittent interest.There are psychological benefits in relaxationand controlled breathing exercises in thesechildren.23 Recently, the Buteyko method ofcontrolled breathing in asthma has receivedpositive media attention, but there has as yetbeen no published scientific evaluation.24

394 Wallis, Prasad

Inhaled foreign body“Since the paper at the British MedicalAssociation in 1902, the method of treatingforeign bodies in the air passages has changed.No longer are children held upside down andslapped on the back as some cases are dyingfrom spasm of the glottis. (Now) the trachea isopened and tickled with feathers to dislodge theforeign body. Be prepared to meet any emergencythat may arise. That includes the presence ofplenty of nurses.”

Silver HM. In: Abscess of the lung due to wire nail.

Transactions of the American Pediatric Society1908;20:209–12.

Chest physiotherapy aiming to remove an

impacted object from the main bronchi is gen-

erally regarded as being of no value and as hav-

ing potentially dangerous consequences.25

The

object could be mobilised further into a central

airway causing complete occlusion or, if in the

laryngeal region, it could cause a vagal

response and devastating airway spasm. The

treatment of choice is early bronchoscopic

removal performed under controlled

conditions.26

Acute atelectasis“By causing the child to gag by putting an asepticfinger into the pharynx, you will be astonished tofind that, in a child with interrupted breathing,who is getting worse and worse, with a number ofmoist rales in both sides of the lungs, the lungsclear up and regular breathing is established.

Dr Saunders. In: Disturbances of respiration in the

newborn. Transactions of the American Pediatric Society1903;15:47.

There are a few studies that advocate physio-

therapy to be an eVective treatment in acute

atelectasis, and positioning with vibration does

perhaps aid recovery over hyperinflation and

suctioning alone.27 28

However, frequently these

studies do not specifically consider the paediat-

ric age group, where a child’s inability to coop-

erate with deep inspiration and coughing may

shift the need towards more formal physio-

therapeutic assistance.

Acute lobar atelectasis as a result of mucous

plugging is more commonly encountered in the

intensive care setting and physiotherapy is

often requested to assist in reinflation. Al-

though much of the evidence for the beneficial

eVect of physiotherapy in children is anecdotal,

there are reports of immediate radiological

improvement following intervention.29

In the intubated patient, the endotracheal

tube and mechanical ventilation can cause

mucosal inflammation and increased secre-

tions, but intubation and ventilation are not in

themselves a prescription for physiotherapy.

The rationale for treatment should be based on

excessive secretions, atelectasis, or abnormal

gas exchange. However, airway obstruction and

lung collapse caused by retained bronchial

secretions often complicate the clinical course

and prolong the recovery phase and, therefore,

can impact on long term outcome. In such

situations, chest physiotherapy may facilitate

reinflation of collapsed areas by the removal of

obstructive secretions.

The intubated neonateModern intensive care of very low birthweight

infants often involves prolonged ventilatory

support with all its commensurate problems.

Chest physiotherapy has acquired a role in the

management of these neonates. Some studies

do suggest beneficial eVects of chest physio-

therapy in terms of secretion clearance and

arterial oxygenation30 31

but others, which look

at specific treatment modalities, highlight

potential deterioration in physiological para-

meters such as heart rate, respiratory rate, and

oxygenation.32 33

There are also reports of

hypoxia,34

rib fractures,35

and periosteal

reactions.36

Reports of physiotherapy related

encephaloclastic porencephaly37

have been

contradicted by a similar study in preterm

infants that found no association between

appropriately applied chest physiotherapy and

abnormal neurological outcome.38

The hand-

ling of a sick preterm infant should be minimal.

Chest physiotherapy should only be applied if

it is clearly indicated.

Studies use diVering protocols and popula-

tion groups and comparison of the results is

diYcult. Advances in neonatal ventilation, and

the use of surfactant and antenatal steroids

have changed the patient population since

these early studies. The question remains as to

how eVective the use of chest physiotherapy is

in neonatal intensive care.

Early uncomplicated neonatal respiratory

distress syndrome related to surfactant defi-

ciency does not require physiotherapy. Infre-

quent suction alone has been shown to be suf-

ficient in maintaining the airway,39

whereas

routine chest physiotherapy in early respiratory

distress syndrome has been associated with an

increased incidence of intraventricular

haemorrhage.40

PostextubationChest physiotherapy is used widely to prevent

postextubation complications. A systematic

review of the eVects of chest physiotherapy on

neonates being extubated from mechanical

ventilation for neonatal respiratory failure

revealed only three randomised trials over the

last two decades enrolling 138 babies.41

The

numbers were small and there was insuYcient

information to assess short and long term out-

comes other than that there was no significant

reduction in postextubation lobar collapse.

Data on safety were insuYcient and the

conclusion of these authors echoes the re-

sponse heard so often at the end of a systematic

review of physiotherapy: the results of this

review do not give a clear direction for the role

of active chest physiotherapy for babies being

extubated from mechanical ventilation in

today’s neonatal intensive care settings.

In a study of 63 neonates42

who had been

intubated for more than 24 hours, patients

were randomised to receive treatment or no

treatment immediately after extubation. In the

24 hour period after extubation the incidence

of postextubation atelectasis was no diVerent in

the treated and untreated groups. These results

are supported further by a recent retrospective

radiographic study.43

Who needs chest physiotherapy? 395

Chronic lung disease of prematurityPhysiotherapy may be recommended in

chronic lung disease of prematurity not only to

improve the neurological outcome, but also to

maximise recovery and minimise the long term

pulmonary sequelae. There are no studies of

suYcient power or length to cater for the large

number of confounding variables in analysis of

the premature infant’s long term recovery.

Physiotherapy in these children is usually

limited to acute exacerbations.44

Physiotherapy and surgery“A very pleasant way of cleansing thethorax: . . . after incision of the chest andresection of the seventh rib, the child was seatedin the bath. With every inspiration, the waterwould run into the opening and, with expiration,water would return laden with pus, which wouldsink to the bottom. Add warm water from timeto time until the expiration gives out clear fluid.This method also recommends itself in treatingsuch cases in private practice, owing to the easewith which it can be carried out by the child’sparents, as well as by its inexpensiveness.”

Adams SS. In: Irrigation by submersion in the treatment

of empyema. Transactions of the American Pediatric Soci-ety 1898;10:80–4.

Physiotherapy is often prescribed after ab-

dominal or cardiac surgery in an attempt to

counter the negative pathophysiological

changes that occur in the postoperative period.

Adult patients undergoing upper abdominal

surgery show lung function changes after

surgery that may persist for up to two weeks. A

degree of atelectasis is almost invariable. Chil-

dren and neonates are even more predisposed

to postoperative respiratory failure because of

poorly developed intercostal muscles and a

compliant chest wall but less compliant lungs

and poorly established collateral alveolar

ventilation.45

Studies examining the use of physiotherapy

as a prophylactic measure in the prevention of

postoperative pulmonary complications are

contradictory. There is considerable variability

in patient groups, treatment modalities, and

outcome measures that make meta-analysis

impossible for the practitioner keen to tease out

the truth. In some trials patients considered to

be at risk are excluded from the study.46

A

recent randomised controlled trial of prophy-

lactic physiotherapy introduced preoperatively

in adults undergoing major abdominal surgery

in a cohort of 174 treated patients and 192

controls reduced the incidence of postoperative

complications in the treated group.47

Patients

with morbid obesity and those over 50 years

who had smoked presented the highest risk for

complications, a fact which highlights once

again how trials undertaken in adult popula-

tions cannot automatically be extrapolated to

paediatric patient groups. In one of the few

studies in children, negative eVects of routine

chest physiotherapy after cardiac surgery are

documented.48

Postoperative physiotherapy should never be

“routine” but should be used judiciously. Spe-

cific physiotherapy techniques might have

diVerent eVects on oxygen saturation and

haemodynamic stability in diVerent age

groups,49

and careful assessment should ensure

that the intervention is beneficial and eVective

rather than hazardous.

Creating an evidence base forphysiotherapy

“The level of evidence on which treatmentrecommendations are made can be kept simple.NO CLEAR EVIDENCE: opinions based on clinicalexperience, anecdotal studies or descriptivearticles; conflicting evidence from studies orpoorly designed studies, even if randomisedcontrolled trials.SUGGESTIVE EVIDENCE: evidence from cohort,case control, before-and-after studies; evidencefrom non-randomised experimental studies.FIRM EVIDENCE: evidence from at least oneproperly designed randomised controlled trial withadequate sample selection, sample size, andappropriate controls; with double or single blindingand with clear outcomes.”

Feldman W, Rosser W, McGrath P. Primary medical careof children and adolescents. Oxford: Oxford University

Press, 1987.

As we enter the new millennium, the

randomised controlled trial reigns over other

formats as most likely to stand up to scrutiny

and provide the evidence we seek. In creating

an evidence base for paediatric chest physio-

therapy, however, there are problems in study

design and protocols.

There is no placebo that blinds those

involved in a trial of physiotherapy. There is no

standard treatment against which others can be

compared and the “art” of physiotherapy

introduces a number of personal and uncon-

trollable factors. The longitudinal designs

required for chronic pulmonary conditions are

confounded by acute exacerbations, poor

adherence, inconsistency of method, poorly

defined treatment techniques, and the intrinsic

and individual variations of the underlying dis-

ease. CF is the classic example where improve-

ments or declines are inherently diYcult to

attribute to a single treatment factor alone.

Outcome measures need to be defined for

the specific research question and to be both

repeatable and reliable. Current methods of

assessment are often imprecise: radiolabelled

aerosols are aVected by mucociliary clearance

and deposition is aVected by secretions and

bronchial obstruction. Chest x ray changes may

be too crude to pick up subtle diVerences.

Oxygen saturation is an insensitive measure of

pulmonary improvement while pulmonary

function testing excludes a population of

children who, for reasons of their disease or

cooperation, are incapable of performing the

techniques required.

Then there is the thorny issue of sputum

collection. Because clearance of secretions is

the goal of chest physiotherapy in many paedi-

atric chest disorders, should the sputum

produced not be the outcome measure of

choice? Which is the better assessment, sputum

production after a single treatment or over a 24

hour period? Do we measure volume or

weight—accepting that variable amounts of

sputum will be swallowed during the treatment

396 Wallis, Prasad

PERSONAL VIEW

Who needs chest physiotherapy? Moving from

anecdote to evidence

Colin Wallis, Ammani Prasad

“One case which I had was that of a newborn

child with acquired atelectasis, which required

my presence, or that of my assistant, for 24

hours. In such cases there is nothing, I believe, as

eYcacious as flagellation. I usually tell the

attendant to take a rubber band and flip the

soles of the feet whenever the child begins to tire

of breathing.”

Dr Sanders. In: Disturbances of respiration in the new-

born. Transactions of the American Pediatric Society

1903;15:47.

At the beginning of this century, paediatrics

was an art. Skills were learnt from a mentor,

picking up tips and anecdotes while standing at

your master’s side. Now, as practitioners of

child health in the final years of this same cen-

tury, life has changed. Anecdote and word of

mouth have lost credibility and are replaced by

scientific scrutiny and the rigour of evidence

from carefully controlled and suYciently pow-

erful trials. We do our best to find the truth, but

in many areas of care there remains a dearth of

suYcient evidence. Often in the closets of our

own practices, we continue to do what our

teachers taught us and what, over time, we

believe works.

The central function of chest physiotherapy

in paediatric respiratory disease is to assist in

the removal of tracheobronchial secretions.

The intention is to remove airway obstruction,

reduce airway resistance, enhance gas ex-

change, and reduce the work of breathing. In

the acute situation, recovery should be has-

tened and in the child with a chronic

respiratory disorder, the progression of the

lung disease is hopefully delayed.

Chest physiotherapy can improve a patient’s

respiratory status and expedite recovery. But in

certain situations it may be a useless interven-

tion or even harmful—perhaps by increasing

bronchospasm, inducing pulmonary hyper-

tension, repositioning a foreign body, or desta-

bilising a sick infant. What good evidence have

we accumulated to answer the question: who

needs chest physiotherapy?

Disorders with chronic sputumproduction

“I have good results in these cases from pouring

a small quantity of whiskey and water into the

child’s throat, some of which passed into the

trachea and brought on coughing which was

soon followed by good breathing.”

Dr Booker. In: More timely use of intubation. Transac-

tions of the American Pediatric Society 1905;17:139.

CYSTIC FIBROSIS

Clearing bronchopulmonary secretions has

long been an integral part of cystic fibrosis

(CF) care. Physiotherapy techniques aim to

remove excessive secretions, thereby improving

ventilation in the short term. In the long term,

reduction of elastase mediated damage to the

airways might slow the progressive damage and

impairment of mucociliary clearance.1

A

number of airway clearance techniques have

been developed over the past few decades.

Each hopes to achieve improved clearance for

less eVort and improve compliance, especially

for the older independent child. Common

techniques include a non-specific regimen of

postural drainage and percussion (often

termed “conventional” chest physiotherapy),

the active cycle of breathing techniques,2

autogenic drainage,3

the use of oscillatory

devices such as the flutter4

or high frequency

chest wall oscillator,5

and the application of

positive expiratory pressure.6

But where is the

evidence that physiotherapy improves lung dis-

ease in CF?

Early treatment was based on intuitive

reasoning but its universal acceptance makes it

ethically precarious to attempt the controlled

trial of treatment versus no treatment in the

child with established disease or even in the

newly diagnosed infant. Thus, most trials

involve the comparison of treatment types.7–10

Publications are fraught with the diYculties of

study design in physiotherapy trials and the

inconsistency of findings leave the practitioner

none the wiser in their search for an evidence

base.11

A meta-analysis of randomised trials in

CF comparing the diVering techniques with

standard treatment showed no diVerence

between them but did show significantly

greater sputum expectoration than no

treatment.12

Because no gold standard exists for physio-

therapy in CF and it is unlikely that any one

technique reigns supreme, it would seem

appropriate to select a technique from the

spectrum available that suits the individual’s

requirements.11

Bronchoalveolar lavage studies in infants

with CF indicate the presence of infection and

Arch Dis Child 1999;80:393–397 393

Respiratory Unit,Great Ormond StreetHospital for ChildrenNHS Trust, LondonWC1N 3JH, UKC Wallis

A Prasad

Correspondence to:

Dr Wallis.

email: c.wallis@ich.ucl.ac.uk

Arch Dis Child 1999;80:393–397

Modulación de los flujos exhalatorios

• EF es usada durante la tos o la KTR para permeabilizar VA.

• punto de igual presión se desplaza de proximal a distal.

• flujo se mueve en sentido opuesto.

• punto de estenosis aumenta el flujo.

• volúmenes pulmonares (VP) altos para permeabilizar VA central.

• VP bajos permeabiliza VA periférica.

• Indispensable mantener VP adecuados y estabilidad alveolar.

• Puede ser pasiva o asistida.

• En RNPT utilizar apoyo para mantener CRF.

Eur Respir J 2000; 15: 196±204

Palv = Ppl + Pel

PIP

•AFE

•TELPr

•TEF

•Huff

•ELTGOL

•CAR

•Drenage autógeno

Modulación de los Flujos Exhalatorios

Indicaciones

• Alteraciones del “clearence” mucociliar

• Alteraciones de la tos

• Alteraciones de la reología del mucus bronquialGosselink R et Als. Intensive Care Med 2008;34:1188–1199 Dennis McCool et Al. Chest 2006;129;250S-259S

• Producción de secreciones >30mL/24 hrs (adultos

• Atelectasias segmentarias o lobares, abcesos pulmonares y bronquiectasiasC Lyon. Ann. Kinesither 1995;22:49-57 Wollmer P. Eur J Respir Dis 1985;66:233-9

Contraindicaciones

•Hemoptisis activa

•Fracturas costales •Tiempo de protrombina <50%

Gosselink R et Als. Intensive Care Med 2008;34:1188–1199Dennis McCool et Al. Chest 2006;129;250S-259S

•Plaquetas <50000/mm3 •Presencia de neumotórax o neumediastino no

drenadoBernard-Narbonne F, et Als. Archives de pédiatrie 2003;10:1043–47

A y B bronquios de cerdo de una semana de edad sometidos a Pº intraluminal de +5 y -5 cmH2O respectivamente.

• Decúbito Lateral

• Decúbito Prono

• ELTGOL

• Drenaje Bronquial

Cambios de Posición

Decúbito Lateral

• Optimiza la relación V/Q en las zonas dependientes y provee estabi l idad alveolar hacia zonas no dependientes.

• aumenta Vt, disminuye FR y FC.

• aumenta el clearence mucociliar

• Facilita el drenaje de secreciones favorecido por la gravedad.

Chest 2000;118;1801-1813

-10

-2

Mayor estabilidad alveolar

Mejor V/Q

Cambios de posición - DL

Received: 24 July 2002Accepted: 20 February 2003Published online: 29 March 2003© Springer-Verlag 2003

Abstract Objective: The aim of ourstudy was to determine the effect ofthe irregular spontaneous breathingpattern and posture on the spatial dis-tribution of ventilation in neonatesfree from respiratory disease by thenon-invasive imaging method of elec-trical impedance tomography (EIT).Scanning of spontaneously breathingneonates is the prerequisite for laterroutine application of EIT in babieswith lung pathology undergoing ven-tilator therapy. Design: Prospectivestudy. Setting: Neonatal intensivecare unit at a university hospital. Patients: Twelve pre-term and termneonates (mean age: 23 days; meanbody weight: 2,465 g; mean gestatio-nal age: 34 weeks; mean birth weight:2,040 g). Interventions: Change inbody position in the sequence: supine, right lateral, prone, supine.Measurements and results: EIT mea-surements were performed using theGöttingen GoeMF I system. EITscans of regional lung ventilationshowing the distribution of respiredair in the chest cross-section were

generated during phases of rapid tidal breathing and deep breaths. During tidal breathing, 54.5±8.3%,55.2±10.5%, 59.9±8.4% and54.2±8.5% of inspired air (mean val-ues ± SD) were directed into the rightlung in the supine, right lateral, proneand repeated supine postures respec-tively. During deep inspirations, theright lung ventilation accounted for52.6±7.9%, 68.5±8.5%, 55.4±8.2%and 50.5±6.6% of total ventilation respectively. Conclusion: The studyidentified the significant effect ofbreathing pattern and posture on thespatial distribution of lung ventilationin spontaneously breathing neonates.The results demonstrate that changesin regional ventilation can easily bedetermined by EIT and bode well forthe future use of this method in paedi-atric intensive care.

Keywords Intensive care unit · Paediatric critical care · EIT · Impedance · Ventilation distribution ·Ventilation monitoring

Intensive Care Med (2003) 29:787–794DOI 10.1007/s00134-003-1726-y O R I G I N A L

Inéz FrerichsHolger SchiffmannRobert OehlerTaras DudykevychGünter HahnJosé HinzGerhard Hellige

Distribution of lung ventilation in spontaneously breathing neonates lying in different body positions

Introduction

Electrical impedance tomography (EIT) is a relativelynew non-invasive radiation-free imaging method provid-ing cross-sectional scans of the body on the basis of themeasurement of electrical tissue properties. In recentyears, intensivists have shown an increasing interest inthis method. There are three major reasons explainingthe growing attractiveness of EIT for clinicians:

1. Electrical impedance tomography measures a new tis-sue quality that is not being addressed by other estab-lished examination tools. Access to such a novel formof information may increase the clinical diagnosticand monitoring possibilities of identifying structuraland functional tissue and organ changes

2. The method exhibits several advantages over otherimaging techniques. Electrical impedance tomogra-phy allows frequent examinations at scan rates ap-

I. Frerichs (!) · R. OehlerT. Dudykevych · G. Hahn · J. HinzG. HelligeDepartment of Anaesthesiological Research, Centre of Anaesthesiology,Emergency and Intensive Care Medicine,TL 195, University of Göttingen,Robert-Koch-Strasse 40, 37075 Göttingen, Germanye-mail: isipink@gwdg.deTel.: +49-551-395919Fax: +49-551-398676

H. SchiffmannNeonatal and Paediatric Intensive Care Unit, Centre of Paediatrics, University of Göttingen,Robert-Koch-Strasse 40, 37075 Göttingen, Germany

injections of small alternating electrical currents. Both the voltagemeasurements and current injections take place between pairs ofconventional self-adhesive surface electrodes of a 16-electrode ar-ray attached on the chest circumference. Electrical impedance to-mography scans are generated from the collected potential differ-ences and the known excitation currents using weighted back-pro-jection (see, e.g. [10]) in a 32!32 pixel matrix. Each pixel of thescan shows the instantaneous local relative impedance changewith respect to a reference state of local impedance. Further de-tails on EIT basics can be found in multiple publications (e.g. [2,11, 12]). Electrical impedance tomography scans are circular withthe following orientation: the ventral area is at the top and theright side of the body is on the left of the image.

In our study, EIT measurements were carried out using theGöttingen high-performance EIT tomograph GoeMF I [1], operat-ing with excitation currents of 5 mArms and 50 kHz. The acquisi-tion of EIT scans was performed periodically. During each scan-ning period, 1,000 scans were acquired at a rate of 25 scans persecond.

Protocol

All neonates were studied immediately after having been fed. Theexamination lasted approximately 50 to 60 min. At first, 16 ECGelectrodes (Blue Sensor BR-50-K, Medicotest A/S, Ølstykke,Denmark) were applied on the chest circumference and connectedto the EIT device. The newborns were positioned in the supineposture and after a few minutes they usually fell asleep. Thereaf-ter, the first EIT data were acquired during two to three scanningperiods. The posture was then changed to right lateral, then toprone with the head rotated to one side and finally back to the su-pine position. In each body position, EIT scanning was repeatedlyperformed during two to three separate scanning periods.

Off-line data analysis

The respiratory breathing pattern of pre-term but also term new-borns is irregular [13, 14]. Often, periodic breathing with respira-tory and even apnoeic pauses is observed. The aim of our studywas to determine the magnitude and distribution of local lung ven-tilation and the irregularity of the neonatal breathing pattern gaveus the opportunity to quantitatively characterise these parametersduring two characteristic periods of breathing:

1. Stable, low tidal volume (VT) breathing at rapid respiratoryrates

2. Spontaneous large inspirations, typically occurring in the formof sighs

Therefore, the initial step in the off-line data analysis was the iso-lation of sequences of EIT scans from the original long series of1,000 scans that were collected during such periods of tidalbreathing and deep inspiration. The following criteria for the se-lection of tidal breathing phases were used:

1. Duration of more than five breaths2. Regular breathing rate >50·min–1

3. Stable tidal volume and end-expiratory lung volume4. Rejection of the first breath if a respiratory pause preceded the

tidal breathing period

In each posture, the EIT data from one tidal breathing period andone deep breath were used for quantitative evaluation and genera-tion of derived functional EIT images. Usually, the irregularity ofthe breathing pattern did not allow repetitive identification of suchphases.

In the next data evaluation step, the magnitude of the local airvolume changes occurring during tidal or deep breaths was quanti-

fied using the following procedure. At first, the end-expiratory andend-inspiratory data points were identified in the selected series ofEIT data obtained during tidal breathing. The individual breath-by-breath differences between the corresponding values were thencalculated in each pixel of the EIT chest scans and, afterwards, thelocal average tidal end-expiratory-to-end-inspiratory relative im-pedance changes were determined from all breaths analysed. Lo-cal end-expiratory-to-end-inspiratory relative impedance changeswere also calculated during deep inspirations by subtracting theminimum from the maximum value of relative impedance changein the selected series of EIT data (see Fig. 1, top). Thereafter, newEIT images, showing the cross-sectional distribution of the calcu-lated local end-expiratory-to-end-inspiratory relative impedancechanges using a grey tone scale, were generated from each tidalbreathing and deep breath period (Fig. 1, bottom). The lighter anarea, the larger the local end-expiratory-to-end-inspiratory relativeimpedance change. These images were previously termed by us“functional EIT images of regional lung ventilation” [6, 8]. Theycharacterise the magnitude of local ventilation in the chest cross-section and visualise the ventilated lung regions. Finally, the sumof all pixel values of end-expiratory-to-end-inspiratory relativeimpedance change, lying within the right and left lung regions,was calculated. This quantitative parameter was used to determine

789

Fig. 1 Electrical impedance tomography (EIT) measurement ininfant 9 in the supine posture. The tracing of relative impedancechange (top) shows the average data in the chest cross-section.The large impedance fluctuations are related to ventilation and re-flect the changes in pulmonary air content; the small ones, dis-cernible during respiratory pauses, are related to cardiac actionand lung perfusion and occur at a frequency corresponding to theheart rate. The enhanced parts of the tracing show those sectionsof the measurement that were used to determine the magnitude oflocal end-expiratory-to-end-inspiratory impedance change duringtidal breathing and deep inspiration, and to generate functionalEIT images of regional lung ventilation. The arrows show the av-erage difference between the end-expiratory and end-inspiratorydata points. The EIT images clearly visualise the lower air volumechanges occurring during tidal breathing compared with the largebreath. The larger the local air volume change, the lighter the areain the functional EIT image appears to be the fractional distribution of ventilation between the right and left

lung regions in different postures.The results in the text and figures are presented as mean values

± SD. The statistical analysis was performed using the Student’spaired t-test. P values <0.05 were considered significant. In caseof multiple comparisons, adjusted significance values were ap-plied according to the classical Bonferroni test.

Results

All neonates studied exhibited a high irregularity of theirbreathing pattern. Periodic breathing was observed in allsubjects. Although respiratory pauses were frequent, noapnoeic phases (i.e. respiratory pauses >10 s) were ob-served. The selected periods of stable, rapid tidal breath-ing spanned 5–11 consecutive breaths. The mean numberof breaths analysed was 6.8±2.0, 6.3±1.2, 7.3±1.6 and6.0±1.7 in the supine, right lateral, prone and supine po-sitions respectively. During the selected tidal breathingphases, the mean respiratory rate was 70.6±12.7·min–1,68.3±16.2·min–1, 70.3±11.1·min–1 and 67.5±9.3·min–1 inthe supine, right lateral, prone and repeated supine pos-tures respectively. The average breathing rate over lon-ger time intervals, comprising not only the phases of rap-id breathing but also respiratory pauses and sighs, wasnaturally lower. Neither the number of respiratory cyclesselected nor the breathing rate significantly differed withregard to posture.

The generated EIT images of regional lung ventilationshowed the distribution of lung ventilation in the chestcross-section. Exemplary images obtained in one neo-nate (infant 2) during periods of rapid tidal breathing anddeep inspiration in all postures studied are presented inFig. 2. Deep inspirations caused no striking differencesin the distribution of ventilation in this neonate from thatseen during tidal breathing, either in the initial or finalobservations made in the supine posture. However, in theright lateral position, the right, dependent lung was lessventilated than the left, non-dependent one during tidalbreathing, whereas the opposite was true during deep in-spiration. In the prone position, an apparent inhomoge-neity of ventilation distribution with pronounced ventila-tion of the right lung was discernible during tidal breath-ing, which, however, was not present during deep inspi-ration.

The quantitative results are shown in Figs. 3 and 4.During rapid tidal breathing, the sum of end-expiratory-to-end-inspiratory relative impedance changes, represen-

790

Fig. 2 Functional EIT images of regional lung ventilation ob-tained in infant 2 in different body positions during rapid tidalbreathing and deep inspirations. The images originating from tidalbreathing periods (top) are all scaled to the same maximum valueof end-expiratory-to-end-inspiratory relative impedance changeduring this form of breathing. The scale of the images showingdeep breaths (bottom) is larger. It corresponds to the maximumvalue of end-expiratory-to-end-inspiratory relative impedancechange during large spontaneous inspirations. This approach ismore suitable for a visual comparison of ventilation distributionsduring tidal breathing and deep inspirations than if a single scalewere used

Fig. 3 Sum of local end-expiratory-to-end-inspiratory relative im-pedance changes in the right and left lung regions during rapid tid-al breathing. Z impedance, s supine, r right lateral, p prone posture

the fractional distribution of ventilation between the right and leftlung regions in different postures.

The results in the text and figures are presented as mean values± SD. The statistical analysis was performed using the Student’spaired t-test. P values <0.05 were considered significant. In caseof multiple comparisons, adjusted significance values were ap-plied according to the classical Bonferroni test.

Results

All neonates studied exhibited a high irregularity of theirbreathing pattern. Periodic breathing was observed in allsubjects. Although respiratory pauses were frequent, noapnoeic phases (i.e. respiratory pauses >10 s) were ob-served. The selected periods of stable, rapid tidal breath-ing spanned 5–11 consecutive breaths. The mean numberof breaths analysed was 6.8±2.0, 6.3±1.2, 7.3±1.6 and6.0±1.7 in the supine, right lateral, prone and supine po-sitions respectively. During the selected tidal breathingphases, the mean respiratory rate was 70.6±12.7·min–1,68.3±16.2·min–1, 70.3±11.1·min–1 and 67.5±9.3·min–1 inthe supine, right lateral, prone and repeated supine pos-tures respectively. The average breathing rate over lon-ger time intervals, comprising not only the phases of rap-id breathing but also respiratory pauses and sighs, wasnaturally lower. Neither the number of respiratory cyclesselected nor the breathing rate significantly differed withregard to posture.

The generated EIT images of regional lung ventilationshowed the distribution of lung ventilation in the chestcross-section. Exemplary images obtained in one neo-nate (infant 2) during periods of rapid tidal breathing anddeep inspiration in all postures studied are presented inFig. 2. Deep inspirations caused no striking differencesin the distribution of ventilation in this neonate from thatseen during tidal breathing, either in the initial or finalobservations made in the supine posture. However, in theright lateral position, the right, dependent lung was lessventilated than the left, non-dependent one during tidalbreathing, whereas the opposite was true during deep in-spiration. In the prone position, an apparent inhomoge-neity of ventilation distribution with pronounced ventila-tion of the right lung was discernible during tidal breath-ing, which, however, was not present during deep inspi-ration.

The quantitative results are shown in Figs. 3 and 4.During rapid tidal breathing, the sum of end-expiratory-to-end-inspiratory relative impedance changes, represen-

790

Fig. 2 Functional EIT images of regional lung ventilation ob-tained in infant 2 in different body positions during rapid tidalbreathing and deep inspirations. The images originating from tidalbreathing periods (top) are all scaled to the same maximum valueof end-expiratory-to-end-inspiratory relative impedance changeduring this form of breathing. The scale of the images showingdeep breaths (bottom) is larger. It corresponds to the maximumvalue of end-expiratory-to-end-inspiratory relative impedancechange during large spontaneous inspirations. This approach ismore suitable for a visual comparison of ventilation distributionsduring tidal breathing and deep inspirations than if a single scalewere used

Fig. 3 Sum of local end-expiratory-to-end-inspiratory relative im-pedance changes in the right and left lung regions during rapid tid-al breathing. Z impedance, s supine, r right lateral, p prone posture

Fig. 4 Sum of local end-expiratory-to-end-inspiratory relative im-pedance changes in the right and left lung regions during deep in-spirations. To visualise the much larger magnitude of these data incomparison with rapid tidal breathing, fine dotted lines in the low-er part of the diagram show the tidal breathing data presented inFig. 3

Fig. 5 Contribution of the right and left lungs to the total sum ofend-expiratory-to-end-inspiratory relative impedance changes(left), and the proportion of the right and left lungs on the ventilat-ed lung area (right) during rapid tidal breathing (top) and sponta-neous deep inspirations (bottom)

791

tative of the magnitude of ventilation in the right and leftlung regions, was significantly reduced in both lungs inthe right lateral posture and in the left lung region in theprone posture when compared with the initial supineposture (Fig. 3). This parameter exhibited a significantdifference between the right and left lung regions in theprone position. During deep inspirations, a significant in-crease of the sum of end-expiratory-to-end-inspiratoryrelative impedance changes in the right lung region wasrevealed in the right lateral posture in comparison withthe first supine data, whereas a decrease was observed inthe left lung region (Fig. 4). The data obtained during theinitial and final supine postures did not significantly dif-fer from each other either during tidal breathing or deepinspirations.

Figure 5 (left) shows the contribution of the right andleft lung to the calculated overall sum of end-expiratory-to-end-inspiratory relative impedance changes duringrapid tidal breathing and deep inspiration. This form ofdata presentation also revealed the small, but significant-ly higher ventilation of the right lung during tidal breath-ing in the prone posture, as well as the highly significant(P<0.01) difference in ventilation of the right and leftlung regions during deep inspirations in the right lateralposture. Figure 5 (right) shows the relative area of theright and left lung regions by end-inspiration during tidalbreathing and deep inspirations in all postures studied.

Decúbito Prono• Mejora la oxigenación en la

mayoría del os pacientes con enfermedad pulmonar aguda o con SDRA.

Optimiza V/QAumenta los VP.Reduce WOBreduce edema pulmonarOptimiza el escalador mucocicilar.

Chest 2000;118;1801-1813

Prono

Drenajes Posturales

INDIAN PEDIATRICS VOLUME 42 JUNE 17, 2005

• 14 pacientes con ATL lobar

• 2 métodos de tratamiento propuestos:

• Intensivo cada una hora (6 horas en total)

• Grupo 1: vibraciones, posicionamiento (pulmón en zona independiente), succión e hiperinsuflación.

• Grupo 2: Hiperinsuflación (o respiración profunda) y succión (o tos asistida) solamente

Método

Conclusión

• Fisioterapia es efectiva en la resolución de ATL.

•Confirma la efectividad al usar un grupo control.

•Descarta resolución espontánea

El objetivo de esta revisión fue discutir las mas comunes condiciones para las cuales la fisioterapia de tórax (FT) ha sido propuesta, discutir la racionalización de la terapia en dichos casos y resumir la evidencia clínica que realmente es útil para la aplicación de la FT

Justificación

• Revisión de evidencia disponible

• Indicación y principios básicos similares en niños y adultos.

• FT habitual no considera diferencias anatómicas y fisiológicas

• FT no considera procesos patológicos pediátricos

• Conclusiones basadas en escasa evidencia presente

Asma Aguda•38 niños hospitalizados con AB divididos en 2 grupos

•6 a 13 años.

•B2, corticoides.

•Con y sin FT

•48 hrs. Mejora en la función pulmonar.

•No hubo avances en grupo q recibió FT.

•no descarta su uso en un selecto grupo de asmáticos que presenten retención de secreciones que cause ATL o hipoxia

Enfermedad Neuromuscular

•Frecuente desarrollo de ATL, NM, Bronquiectasias.

•FT comúnmente usada como mantención y en reagudizaciones.

•FT busca mejorar patrón respiratorio, estimular la tos o reeducarla y permeabilizar VA.

•Las publicaciones indicarían que la FT es útil en estos pacientes.

•insufflator-exsufflator disminuye la frecuencia de las reagudizaciones

FQ y otras causas de BQ

•FT es uno de los pilares fundamentales en el manejo de FQ.

•FT mejora la adherencia al tratamiento

•Basado en múltiples publicaciones que la justifican.

•Pero no existen estudios que justifiquen su uso rutinario para permeabilizar VA comenzando en la primera infancia.

Bronquiolitis Aguda

Una revision de Cochrane de 3 ensayos clinicos en FT de rutina en pacientes hospitalizados con bronquiolitis no encontro avances significativos en disminuir la duracion de la hospitalizacion ni duracion de la enfermedad, ademas fracturas costales han sido reportadas en pacientes con bronquiolitis que recibieron FT

•Costes económicos

•tratamiento efectivo

•tratamiento individualizado

•objetividad y seguimiento

4. The respiratory therapy recommendations stickerswere placed in the chart separately from the orders, so thestickers were not routinely reviewed by the ordering phy-sician.5. RTs did not receive feedback on how they were per-

forming.A program was developed to address the RTs’ concerns

and to encourage respiratory function assessment, to de-termine the need for and effect of bronchodilator treat-ment. The program was implemented on January 14, 2002.It included:1. A revised respiratory assessment form (see Appendix

2). The revised form reflected the guideline recommenda-tion that nasal suctioning and respiratory scoring be doneprior to any bronchodilator treatment and that respiratoryscoring be done 15–30 min following treatment, to deter-mine if the treatment improved the respiratory score.2. A change in the respiratory score threshold for a

recommendation for bronchodilator treatment. Though arecommendation for bronchodilator treatment with a re-spiratory score of ! 2 was deemed appropriate for asthmapatients, that did not account for the typical presentation ofa bronchiolitis patient, which includes increased secre-tions, increased respiratory rate, and decreased air move-ment. Therefore, a respiratory score ! 3 was required torecommend bronchodilator treatment for a guideline-eli-gible bronchiolitis patient. Patients who warranted a trialbronchodilator therapy typically had elevated respiratoryrate, increased use of accessory muscles, decreased airexchange, and mild expiratory wheezes, due to increasedsecretions and airway inflammation. Figure 1 shows therevised treatment algorithm.3. Multidisciplinary rounds. When possible an RT ac-

companied the physician on morning rounds. Attendingphysicians familiar with the evidence encouraged the res-idents to listen to the RTs’ recommendations. The educa-tion coordinator for Health Policy and Clinical Effective-ness attended rounds 1 day each week, with each of the 3physician teams responsible for treating bronchiolitis pa-tients. She tracked eligible patients and reinforced use ofthe new respiratory assessment form and treatment recom-mendations.4. Improved effective, data-based communication be-

tween the RTs and physicians. The chart sticker (that sum-marized the RT’s recommendations) was discontinued andreplaced by the RTs making their recommendations ver-bally to the physician. Specifically, when an order waswritten for a bronchodilator treatment, the RT would dothe nasal suctioning and before-and-after-treatment scor-ing. If the post-suctioning score was ! 3, the RT wouldpage the physician who wrote the order and advise thatbronchodilator was unwarranted. If the post-suctioningscore was ! 3, the RT would conduct the treatment and

the post-treatment respiratory scoring and advise the phy-sician whether the therapy should be continued.5. Better-informed RTs. The respiratory therapy educa-

tion coordinator (author EC) reviewed the charts of allbronchiolitis patients daily and conducted biweekly meet-ings to increase communication among the RTs, to receivetheir opinions on what was and was not working, and toshare the data being regularly collected. Two RTs, onefrom the day shift and one from the night shift, becameguideline champions on the floor. Therapists were givenwatches with timers to remind them to conduct the fol-low-up respiratory scoring 15–30 min following broncho-dilator treatment.

Study Population

Guideline-eligible patients were infants " 1 year oldand admitted to the hospital with a first-time episode ofuncomplicated bronchiolitis.35,36 All guideline-eligible pa-tients were included in the study, except for infants whohad histories of cystic fibrosis, immunodeficiency, con-genital heart disease, bronchopulmonary dysplasia, con-genital airway disease, or any other comorbid condition

Fig. 1. Infant bronchiolitis treatment algorithm.

QUALITY CARE FOR INFANTS WITH BRONCHIOLITIS

RESPIRATORY CARE • JUNE 2004 VOL 49 NO 6 591

RESPIRATORY CARE • JUNE 2004 VOL 49 NO 6

Post- Operados•ATL son frecuentes debido a dolor, alteraciones en la mecánica

respiratoria producto de la anestesia o por aspiración.

•En un estudio prospectivo y randomizado se confirma la efectividad de la FT.

•Los que no reciben FT tiene mayor riesgo de desarrollar severas atelectasias.

Complicaciones Respiratorias en Parálisis Cerebral

•NM frecuentes por alteraciones mecánicas, de la deglución u anatómicas.

•FT demostró importante disminución de la morbilidad en este grupo de pacientes.

A favor...Lactantes con bronquiolitis sin soporte mecánico

15 repeticiones de ELPR + NBZ hipertónicaScore de Wang (sibilancias, FR, retracciones, condicion general)SpO2 y FC a 0, 30 min y 120 minELPR mejora todos los índices evaluados.

Postiaux G. Respir Care 2011;56(7):989–94Postiaux G. Kinesither Rev 200 6;(55):35-41

20 niños en VM (PCV)Cohorte prospectiva SpO2, TpCO2, Vti y Vte basal y 1 hora despuésSET v/s AFE Cambios significativos en SpO2 y Vt’s

Bernard-Narbonne F. Archives de pédiatrie 2003;10:1043–7

Beneficio sólo si TMFE son lentas

Precauciones

•Uso B2 agonistas ante la presencia de broncoespasmo Barnabé V et Als.Physiotherapy 2003;89(12):714-9

•Dolor e inestabilidad hemodinámicaGosselink R et Als. Intensive Care Med 2008;34:1188–1199Dennis McCool et Al. Chest 2006;129;250S-259S

•Se sugiere monitorización vital básica

Efectos no Deseados

•Neonatos 16% de lesión cerebral con AFE (92% previas)Demont B et Als. Physiotherapy 2007;93:12–6

•En vía aérea inestable Compresión dinámica puede causar colapso y cese del flujo aéreo

Fink J. Respir Care 2007;52(9):1210 –1221Hasani A & Cols. Respiratory Medicine 1991;85(s1):23-26

•Fracturas costales en pacientes pediátricos con bronquiolitis o neumonía (1 en 1000)

Chalumeau & Cols. Pediatr Radiol (2002) 32: 644–647

•Vómitosvan der Schans C. Respir Care 2007;52(9):1150 –6

• Se deben considerar preferencias del paciente y del Kinesiólogo. Hess D. Respir Care. 2001; 46: 1276-1293. Sivasothy P & Cols. Thorax 2001;56(6):438–444

• Kinesiólogo trabaja con la familia y el paciente para determinar la mejor terapia y educa en su administración y dosificación.

• Se deben considerar diferencias anatomofuncionales

¿Que técnica elegir?

Lester M & Col. Respir Care 2009;54(6):733–750

• Intevenciones para aumentar el volumen inspiratorio se deberían considerar si este contribuye a mejorar una espiración forzada no efectiva (B)

Gosselink R & Cols. Intensive Care Med 2008;34:1188–99

• Las TMFE se deben utilizar para asistir la remoción de secreciones si la tos es inefectiva (B)

Gosselink R & Cols. Intensive Care Med 2008;34:1188–99

•Las intervenciones para aumentar el flujo espiratorio en no intubados se sugiere en pacientes con dificultad para acelerar el flujo por ellos mismos (B)

Sivasothy P et Als. Thorax 2001;56:438–444

Recomendaciones

Recomendaciones (2)

• En pacientes con Enfermedades neuromusculares, EPOC y FQ, la TEF debe ser realizado en conjunto con otros métodos de “Clearence” mucociliar (C)

Dennis F & Cols. Chest 2006;129;250S-259S

• En pacientes con Enfermedades neuromusculares, EPOC y FQ, la TEF (huffing) tiene evidencia en retención de secreciones (C)

Dennis F & Cols. Chest 2006;129;250S-259S

40 • Enfermedad Inflamatoria Intestinal al día - Vol. 2 - Nº. 2 - 2003

Tabla III. Significado de los grados de recomendación (USPSTF) (7)

Grado derecomendación Significado

A Extremadamente recomendable (buena evidencia de que la medida es eficaz y los beneficios superan ampliamente a los perjuicios).

B Recomendable (al menos moderada evidencia de que la medida es eficaz y los beneficios superan a los perjuicios).C Ni recomendable ni desaconsejable (al menos moderada evidencia de que la medida es eficaz, pero los beneficios son muy

similares a los perjuicios y no puede justificarse una recomendación general).D Desaconsejable (al menos moderada evidencia de que la medida es ineficaz o de que los perjuicios superan a los

beneficios).I Evidencia insuficiente, de mala calidad o contradictoria, y el balance entre beneficios y perjuicios no puede ser determinado.

Tabla IV. Niveles de evidencia (SIGN) (9)

Nivel deevidencia Tipo de estudio

1++ Meta-análisis de gran calidad, revisiones sistemáticas de ensayos clínicos aleatorizados o ensayos clínicos aleatorizados con muy bajo riesgo de sesgos.

1+ Meta-análisis bien realizados, revisiones sistemáticas de ensayos clínicos aleatorizados o ensayos clínicos aleatorizados con bajo riesgo de sesgos.

1- Meta-análisis, revisiones sistemáticas de ensayos clínicos aleatorizados o ensayos clínicos aleatorizados con alto riesgo de sesgos.2++ Revisiones sistemáticas de alta calidad de estudios de cohortes o de casos y controles, o

Estudios de cohortes o de casos y controles de alta calidad, con muy bajo riesgo de confusión, sesgos o azar y una alta probabilidad de que la relación sea causal.

2+ Estudios de cohortes o de casos y controles bien realizados, con bajo riesgo de confusión, sesgos o azar y una moderada probabilidad de que la relación sea causal.

2- Estudios de cohortes o de casos y controles con alto riesgo de confusión, sesgos o azar y una significante probabilidad de que la relación no sea causal.

3 Estudios no analíticos (observaciones clínicas y series de casos).4 Opiniones de expertos.

Tabla II. Establecimiento de las recomendaciones (USPSTF) (7)

Calidad de la Beneficio neto Beneficio neto Beneficio neto Beneficio netoevidencia sustancial moderado pequeño nulo o negativo

Buena A B C DModerada B B C D

Mala E E E E

Tabla I. Jerarquía de los estudios por el tipo de diseño (USPSTF) (7)

Nivel deevidencia Tipo de estudio

I Al menos un ensayo clínico controlado y aleatorizado diseñado de forma apropiada.II-1 Ensayos clínicos controlados bien diseñados, pero no aleatorizados.II-2 Estudios de cohortes o de casos y controles bien diseñados, preferentemente multicéntricos.II-3 Múltiples series comparadas en el tiempo, con o sin intervención, y resultados sorprendentes en experiencias no controladas.III Opiniones basadas en experiencias clínicas, estudios descriptivos, observaciones clínicas o informes de comités de expertos.

ConsideracionesA menor edad del paciente, se requieren fuerzas de menor magnitud para provocar colapso de la vía aérea.

Se hace imprescindible el asegurar volumen pulmonar para evitar el cierre de la vía aérea.

La intervención por kinesiólogo debe ser individualizada y priorizar objetivos de educación y prevención.

La falta de evidencia...no es sinónimo de falta inefectividad

La FT no es la única intervención relevante que puede ser realizada por el kinesiólogo.