Riabilitazione in area critica e post-critica

Riabilitazione in area critica e post-critica

www.fisiokinesiterapia.biz

“The 5 year mortality rate in intensive care patientsis over 3 times that of the general population.”

Niskanen M et al. Crit Care Med 1996;24:1962.7.

“However at 2 year survival rates are parallel.”

Impact of Impact of RespiratoryRespiratory ComplicationsComplications on on LenghtLenght of Stay of Stay and Hospital and Hospital CostsCosts in Acute in Acute CervicalCervical InjuryInjury

Winslow C et al, CHEST 2002;121 1548Winslow C et al, CHEST 2002;121 1548--15541554

Sindrome da allettamentoFUNZIONI CARDIOVASCOLARI E COMPOSIZIONE SANGUIGNA•Diminuzione della gittata cardiaca, volume di eiezione e aumento della frequenza a cardiaca sotto sforzo•Rischio di tombosi

MUSCOLI SCHELETRICI•Diminuzione della massa muscolare•Trasformazione delle fibre IIb•Diminuzione del numero e della densità dei mitocondri

SISTEMA NERVOSO CENTRALE•Diminuzione dell’equilibrio in posizione eretta e durante deambulazione•Peggiorata esecuzione di test intellettivi

COMPOSIZIONE CORPOREA•Demineralizzazione ossea•Perdita di proteine•Diminuzione del contenuto corporeo di acqua e sodio•Perdita di peso e aumento della percentuale della massa grassa

FUNZIONI RESPIRATORIE•Diminuzione della CFR•Diminuzione della Compliance polmonare•Ritenzione secrezioni•Atelettasie

Allettamento

DE MATTIA E, PIAGGI G, NAVA S. Rass Pat App Resp 2001 15: 507-514

Sindrome da ImmobilizzazioneCause scatenanti

• Prolungato riposo a letto per il trattamento di una malattia in fase acuta

• Ipocinesia per una malattia primitivamente neurogena e miogena

• Mantenimento continuo di postura seduta o supina, in assenza di patologie rilevanti

• Assenza di gravità

Muscles Weakness in Mechanically Ventilated Patients

with Severe Asthma

JW Leathermann, et al. AJCCM 1996: 153:1686

Critical Illness Myopathy and Neuropathy (n=28)

MUSCULAR FAILURE

22%

61%17%

MiopathyNeuropathyMixed

SURVIVAL

17

7

DeadAlive

Latronico N. et al. Lancet 1996; 347, 1579

GOALS OF PR IN ICU

• Reduce secretions• Favour active mobilization and ADL• Improve muscle strength• Prevent bed-laying and embolism• Improve quality of life

CANDIDATES

Acute respiratory failureand/or monitoring

Weaning process

WHAT TO ASSESS ?Respiratory system

• SatO2• Chest X-ray• Use of respiratory accessory muscle• Signs and symptoms of:

– hypoxia– hypercapnia– right heart failure

SOLUTION 1

CHEST PHYSIOTHERAPY

SOLUTION 2

WEANING PROTOCOLS

WHAT TO ASSESS ?Peripheral muscle system

• Posture• Motility

SOLUTION 1

PASSIVE MOBILITY

SOLUTION 2

ACTIVE MOBILITYMUSCLE RECONDITIONING

ACTIVITIES• POSTURES

- Prone position- Rotational therapy

• CHEST PHYSIOTHERAPY- Drainage (suction, MH)- Percussions and/or vibrations- Rotational therapy

• MUSCULAR ACTIVITY- Respiratory muscles- Peripheral muscles

ACTIVITIES• POSTURES

- Prone position- Rotational therapy

• CHEST PHYSIOTHERAPY- Drainage (suction, MH)- Percussions and/or vibrations- Rotational therapy

• MUSCULAR ACTIVITY- Respiratory muscles- Peripheral muscles

Ausili per postura

• Pesi• Rulli• Cubi• Valve rigide• Cuscini • Materassi antidecubito

Effetto della postura del paziente

• 32 pts (24 M, 8 F, età media 55.9 aa)• IRA con PaO2/FiO2: <150 (non causato da ins.cardiaca o atelettasie)• PaO2/FiO2 passa da 103 a 158 in posizione prona dopo 1 h e a 159

dopo 4 hChatte G, Sab JM, Dubois JM, AJCCM 1997; 155: 473

Effect of lateral rotational therapy on the prevalence of VAP in long-term ventilated patients

Kirschenbaum L. et al CCM 2002; 30: 1983-1986

ACTIVITIES• POSTURES

- Prone position- Rotational therapy

• CHEST PHYSIOTHERAPY- Drainage (suction, MH)- Percussions and/or vibrations- Rotational therapy

• MUSCULAR ACTIVITY- Respiratory muscles- Peripheral muscles

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 Manual Hyperinflation (MH) in ICU

Effect of Combined Kinetic Therapy and Percussion Therapy on the Resolution of

actelectasis in Critically Ill Patients

Raoof S. et al CHEST 1999; 115: 1658-1666

ACTIVITIES• POSTURES

- Prone position- Rotational therapy

• CHEST PHYSIOTHERAPY- Drainage (suction, MH)- Percussions and/or vibrations- Rotational therapy

• MUSCULAR ACTIVITY- Respiratory muscles- Peripheral muscles

Effects of controlled inspiratory muscle training in patients with COPD: 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 observational 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 weanedafter 44±43 days

CHEST 2002:122;192-6

Zanotti E at al. Chest 2003; 124: 292-296

PERIPHERAL MUSCLE STRENGTH TRAINING IN BED-BOUND COPD UNDER MVa RCT comparing Active Limb Mobilization (ALM) with ALM + Electrical Stimulation (ES)

PROGRAMMI DI RIABILITAZIONE NEL PAZIENTE VENTILATO INVASIVAMENTE

Terapia FisicaRicondizionamento Muscolatura Generale

Mobilizzazione passiva arti

Mobilizzazione attiva arti

Stazionamentoseduto

Stazionamentoeretto

Deambulazione assistita

Deambulazione autonoma

Dipendenza

Autonomia

Mobilizzazione

• Mobilizzazione passiva• Mobilizzazione passiva forzata• Mobilizzazione attiva

Acquisizione dell’ortostatismo

• Lettino di statica• Standing

PuleggioterapiaErcolina per arti

superiori

Letto di statica

Recupero della motricita’

• Parallele• Deambulatori - walker

- ascellare - articolato- rollator

• Tripodi, quadripodi• Antibrachiali• Bastoni• Scale

Zanotti E at al. Chest 2003; 124: 292-296

PERIPHERAL MUSCLE STRENGTH TRAINING IN BED-BOUND COPD UNDER MVa RCT comparing Active Limb Mobilization (ALM) with ALM + Electrical Stimulation (ES)

ALM/ES significantly ... decreased the number of days needed to transfer from bed to chair(10.75± 2.41 vs 14.33 ± 2.53 days, p 0.001).

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)

Rehabilitation of Patients Admitted to a Respiratory Intensive Care Unit

ns

P<0.0001 P<0.001

P<0.05

Nava S. Arch Phys Med Rehabil 1998; 79, 849-854

Arm training in patientsweaned from MV

Trial profile

Patients included n=66(spontaneous breathing sustained for

at least 48 consecutive hours)

PT + Arm trainingn=32

PT n=34

Pts. evaluablen=25

Pts. evaluablen=25

0

5

10

15

20

25

30

35

40

T0 T10

5

10

15

20

25

30

35

40

T0 T1

0

5

10

15

20

25

30

T0 T10

5

10

15

20

25

30

T0 T1

Group 1 Group 2

Minutes Minutes

Watts Watts

IT

ET