www.fisiokinesiterapia.biz

Knee extensor

J Appl. Physiol. 1997:82;182-188

TwAP and CMAP were found reduced while CT was found increased in ICU pts when compared to controls. Muscle weakness is common in ICU.

AM J Respir. Care Med 2000:162;240-245

TRIAGE 1TRIAGE 1>20>20

TRIAGE 2TRIAGE 2(16(16--20)20)

TRIAGE 3TRIAGE 3(11(11--15)15)

TRIAGE 4TRIAGE 4(6(6--10)10)

TRIAGE 5TRIAGE 5(0(0--5)5)

PuntiPunti 00 11 22 33 44 PunPuntiti

Pattern Pattern RespiratorioRespiratorio

Pattern Pattern Regolare Regolare

RR 12RR 12--2020

AumentatoAumentato

RR 21RR 21--2525

Dispnea da Dispnea da sforzo, pattern sforzo, pattern irregolare irregolare RR 26RR 26--3030

Riduzione Riduzione Della Della CapacitCapacitààVitale*Vitale*RR 31RR 31--3535

Severo SOB,Severo SOB,uso dei muscoli uso dei muscoli accessoriaccessoriRR>35RR>35

StatoStatoMentaleMentale

Vigile,Vigile,orientato, orientato, collaborantecollaborante

Letargico, Letargico, segue i segue i comandicomandi

Confuso, non Confuso, non segue i segue i comandicomandi

SoporosoSoporoso ComatosoComatoso

Rumori Rumori RespiratoriRespiratori

AuscultazAuscultaz..Chiara Chiara

Ridotti Ridotti unilateralmentunilateralmentee

Ridotti Ridotti bilateralmentbilateralmentee

Crepitii alle Crepitii alle basibasi

Dispnea e/o Dispnea e/o ronchironchi

TosseTosse Spontanea,Spontanea,energica, energica, nonnonproduttivaproduttiva

Energica,Energica,produttivaproduttiva

Debole,Debole,non non produttivaproduttiva

Debole, Debole, produttiva produttiva o debole o debole con ronchicon ronchi

Non tosse Non tosse spontanea o spontanea o necessitnecessitàà di di aspirazioneaspirazione

Livello di Livello di AttivitAttivitàà

DeambulantDeambulantee

Deambulante Deambulante con assistenzacon assistenza

Non Non deambulantedeambulante

ParaplegicoParaplegico TetraplegicoTetraplegico

TRIAGE RIABILITATIVO (ASSESSMENT)

(Stoller JK Respiratory Care 38: 1143-1154.)

SCHEDA DI VALUTAZIONE PER IMPOSTAZIONE FKT

Controllo troncoMovimentiCamminoDispnea da sforzoScore vita premorbidità

0 1 2 3 4

Score totale =

Score trattamento<4 A1 palestra A + all. sforzo arti inf. cycl. + 6 min4-6 A2 palestra gruppo A + 6 min7-9 B1 gruppo B + all. sforzo pedivella + 6 min10-12 B2 gruppo B + deambulaz. + 6 min13-15 I indiv. + deambulaz. + arm> 16 I mobil. Pass. Att. +allin. post.

SCHEDA DI VALUTAZIONE trattamenti complementari

A Stato polmonareB interv. ChirurgiciC tosseD RX torace

0 1 2 3 4

Score totale =

Score trattamento

A >3 ass. tosse o PEPB > 2 threshold e spir. incent.C > 2 ass. tosse + presidio + drenaggioD > 2 stop programma o valut. Indiv.

68%

12%

12%8%

denervazionesevera P iniziale Pnormale

Danni neuromuscolari diagnosticati con tests elettrofisiologiciin 25 pazienti con sospetto clinico su 313 ammessi in UTIR

M. Vitacca Rassegna App. Respiratorio 2004

0.7030.020.0440.700.6930.023P1000005002Normali

10000001003Polineuropatia

iniziale

6733660331003Polineuropatiasevera

76707618418217

Denervazione

Deambulazione alla dimissione

, %

MIP< 45 cmH2O

Aminoglicosidi,%

Steroidi %

Diabete,%

VMin

UTIR, %

N°

M. Vitacca Rassegna App. Respiratorio 2004

Danni neuromuscolari diagnosticati con tests elettrofisiologiciin 25 pazienti con sospetto clinico su 313 ammessi in UTIR

La fisioterapia

L’umidificazione delle vie aeree

La terapia rotazionale

Tecniche di disostruzione

0

100

200

300

400

0 3 7 14

TESTCONTROL

0102030405060708090

100

TEST CONTROL

Raoof S. CHEST 1999

% of atelectasisresolution

PaO2/FiO2

# days

CONTROL (n=7)

KT with P(n=17)

p value

intubated, % 29 47 NS

entire lung atelectasis, % 14 29 NS

lobar lung atelectasis, % 86 59 NS

bronchoscopy, % 43 0 0.02

0102030405060708090

100

UK Australia HK UK2

% of MH

L Denehy Eur Respir. J 1999

01020304050607080

secr

etio

ns

ATE

L:

FiO

2

coug

h

LV

CO

M.

ausc

ulta

tion

% of R

% of responders during MH in ICU

Design: prospective controlled trial setting: ICUpatients:60 intubated pts under MVInterventions: CP (24) vs sham (36)CP: twice daily: drainage, positioning, expiratory vibrations, suctioning, coughing when extubatedsham: nurse positioning and suction

Results: VAP occurred in 8% of CP vs 39% of sham (OR 0.14)after adjustment for Apache II, MV gg, trach., GCS (OR 0.16)

Design: prospective randomized controlled trial Setting: RICUPatients: 27 COPD with exacerbationInterventions: group A : PEP mask plus ass. coughgoup B cough alone

Results: Amount of sputum was stat. higher and weaning time lower

Mortality and ETI were not.

Short term effects of expiration under positive pressure in patients with acute exacerbation of COPD and

mild acidosis requiring NPPV

Bellone et al (Intenive Care Med 2002;28 (5):581-5)

Design: prospective randomized controlled trial setting: ICU

patients: 236 intubated pts under MV (EI) after cardiac surgical operation Interventions: FKT under EI vs FKT only after extubation

Results:EI duration, ICU stay, hospital stay, spirometric valuespulmonary complications between groups were similar.

Fisioterapia dopo cardiochirurgia: è necessaria duranteil periodo di intubazione ?

Patman S et al (Aust J Physiother 2001; 47:7-16)

Design: prospective randomized controlled trial Setting: ICUPatients: 46 trauma patients under MV Interventions:group A: physiotherapygroup B: control

Results: % of weaning %, ICU time, MV time and pneumonia were notstatistically different

The effect of manual lung hyperinflation and postural drainage on pulmonary complications in

mecahnically ventilated trauma patients

Ntoumenopoulos (Anaesth Intensive Care 1998; 26:492-6)

La misura della MIP e MEP

Per svezzare indice di outcome

per decannulare

MIP and MEP measurements

Cuffed cannula mouth with cuffed cannula

phonetic cannula mouth with closed stoma

Effects of controlled inspiratory muscle training in patients withCOPD: a meta-analysis

F Lotters et al (2002; 20:570-576)

BerryGoldesteinLarsontotal pimax > 60DekhuijzenWeankeWeinertotal Pimax < 60

-2 -1 0 1 2 3 Favours favourscontrol treatment

BerryGoldestein

total pimax > 60Dekhuijzen

Weinertotal Pimax < 60

-2 -1 0 1 2 3 Favours favourscontrol treatment

IMS EC

Design: prospective trial setting: ICUpatients: 10 pts who had failed to wean from MV with 2.1±3.4 h of SB.Interventions: IMST of 4 sets of 6 breaths with threshold with anintensity to yield an exertion rating of 6 to 8.

Results: IMST pressure from 7±3 cmH20 to 18±7; 9 out 10 weaned after 44±43 days

CHEST 2002:122;192-6

L’allenamento allo sforzo

L’allenamento allo sforzo

Design: prospective randomized controlled trial Setting: RICUPatients: COPD recovering from ARF Interventions: early PRP vs Standard MT alone;

step 1: 2/d 30-45 min postural position, sitting in bed or chair, lower extremities training, postural drainage, coughstep 2: rolling , walk , step 3: muscle training, lower extremity training, cycling, climbingstep 4: treadmill sessions

Results: Effort tolerance, MIP, dyspnoea were better for PRP group

Rehabilitation of patients admitted to a respiratory intensive care unit

Nava S. (Arch Phys Med Rehabil 1998; 79:849-854)

PRP plus

SAEX :15 daily supervised consecutive sessions of actual 20minutes of upper arm cycling with an arm ergometer.

the load was increased by 2,5 Watt/session according to Borg D and Funtil the 70% of W max reached baseline

PRP: 45 minutes/daily sessions (6 days/week)

chest physiotherapypassive and active lower and upper-limb mobilisationreinforcement tecniques for head and trunk control sitting and standing balanceassisted deambulation

according to clinical triage (every 3° day)

All patients

Only Study group

0

5

10

15

20

25

T0 T1

Wat

t

0

5

10

15

20

25

T0 T1

Min

utes

IT ET

p=0.0029p=0.021

Incremental and endurance variation after training

Study groupcontrols

§

#

§

#

20

30

40

50

60

70

T0 T1

cmH

2O

MIP variation

p= 0.002

Study groupcontrols

p=0.08

p= 0.02

PSV and effort tolerance with armergometer in tracheostomized patientPSV and effort tolerance with arm

ergometer in tracheostomized patient

Fondazione S. Maugeri IRCCS Gussago (unpublished data 2004)

7.18±4.5010±6.12

Max load SBMax load MV

1.01±0.290.66±0.41

1.67±0.841.0±0.63

1.20±0.60.61±0.3

WOBes (J/L) SBWOBes (J/L) MV

0.62±1.060.8±1.13

2.25±3.21.87±1.55

0.25±0.701.12±0.64

PEEPi-dyn (cmH2O) SBPEEPi-dyn (cmH2O) MV

0.16±0.050.04±0.03

0.32±0.240.19±0.20

0.17±0.080.08±0.06

Pes/Pesmax SBPes/Pesmax MV

24±717±5

27±525±6

23±818±7

f (a/min) SBf (a/min) MV

0.5±0.91.2±1.06

4.8±34.1±2.2

0.4±10.6±1

Borg F SBBorg F MV

1.8±1.771.3±1

6.2±2.45.2±2.3

1.9±1.31±0.8

Borg D SBBorg D MV

RecoveryIsowattBaseline

Fondazione S. Maugeri IRCCS Gussago (unpublished data 2004)

Time (hours)

Pro

babi

lity

to re

mai

n un

der M

V

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

0 100 200 300 400 500 600 700 800 900 1000 1100

p<0.0001

Vitacca M. Am J Respir Crit Care Med 2001; 164: 225-230

0102030405060708090

100

0 1 3 5 15 25

control (151pts)intervention(149 pts)

Ely N. Engl J Med 1996

Duration of MV after a succesfull weaning test

% of ptson MV

Days

Self extubation, reintubation,tracheostomy

0102030405060708090

100

tosse dren. ric. diafr. PEP

0102030405060708090

mobili. bronco posture NIV Bellone Rassegna Pat. App. Respir. 2001

%

%

Lavorano in UTIR 54%lavorano in UTIR solo 1 volta/die 53%lavorano il sabato mattina 53%usano indici di outcome 63%

Rapporto paz/FDR5/1

RECCOMENDATIONS FOR FKT IN ICU

• Evidence A in acute lobaratelectasis.

• prone position > Oxygenationin ARDS

• side lying > Oxygen inunilateral lung disease

• Haemodinamic monitoringis mandatory.

• Sedation before FKT preventshaemodynamic effects

• Preox. sedation are necessarybefore suction

• Rotation therapy< Pulmonary complications

K. Stiller CHEST 2000

• FKT has short beneficialeffects on respir. function

• MH with monitoring has short beneficial effects on respir. function

• ICP and CPP should bemonitored during FKT

K. Stiller CHEST 2000

RECCOMENDATIONS FOR FKT IN ICU

• FKT+ nursing < complicationsin ICU

• FKT is effective to improvepulmonary derangement

• FKT < weaning, stay in ICU and hospital, mortality, morbility

• Positioning + lung FKT are effective

• limb exercises prevent loss of joint range or > muscle strenghtand function.

K. Stiller CHEST 2000

RECCOMENDATIONS FOR FKT IN ICU

Conclusions: Pulmonary R. in ICU

controlled studies ?controlled studies ?

RationalisationRationalisation of programs:of programs:assessmentassessmenttriagetriageexclusion criteriaexclusion criteriaspecific programs specific programs respiratory musclesrespiratory musclesperipheral muscles peripheral muscles timing timing intensityintensityspecificity for diseasesspecificity for diseases

The futureThe future !!