Kinesiologa Respiratoria: Fundamentos y Evidencia

Kinesilogo TR Claudio Torres T. Miembro de la divisin de kinesiologa Intensiva Especialista en kinesiologa Respiratoria PFCCS Instructor

Generalidades
Ampliamente utilizada en distintos niveles de
atencin.

diferentes tendencias describen tcnicas y

fundamentos diferentes. efectividad.

evidencia ofrece datos conictivos en cuanto a su Escasos datos duros

Deniciones
La Fisioterapia de Trax (FT) o Kinesiterapia Respiratoria (KTR) es una intervencin comnmente usada en pacientes con enfermedad de las vas areas. Su principal objetivo es facilitar el transporte de secreciones y tambin disminuir la retencin de estas en la va area. Histricamente la FT ha consistido en una combinacin de tcnicas 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 funcin y limpiar la via aerea mejorando o aisitiendo la tos. las tcnicas incluyen rehabilitacin, ejercicios de prueba, prescripcin de ejercicios para higiene bronquial, posicionamiento y tcnicas de respiracin.
Thorax 2009;64(Suppl I):i1i51. doi:10.1136/thx. 2008.110726

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

Gosselink R et Als. Intensive Care Med 2008;34:118899

Gouriet A. Revu kin actualit 2005;20-21

Adasme R, Puppo H. 2011

Consideraciones Anatomo-Funcionales

AIRWAY CLEARANCE

IN THE

ELDERLY

AND

PATIENTS WITH NEUROLOGIC COMPROMISE

ventilatory limitations may become evident during acute illness, surgery, or exercise.18 During exercise the elderly tend to use their abdominal muscles to a greater degree and to use a rapid shallow breathing pattern because of a rigid rib cage.19 But, despite these ventilatory changes, the elderly are still usually limited by circulation because of deconditioning or from changes in cardiovascular physiology.19 During exercise, the incremental increase in tidal volume to increase minute ventilation is primarily due to recruitment of end-inspiratory lung volume, rather than to reducing end-expiratory lung volume as seen in younger individuals.42 With aging, the ventilatory response to hypoxia and hypercarbia is blunted, most likely due to a combination of a reduced neural output to the respiratory muscles, a decreased peripheral chemosensitivity, and a lower mechanical efficiency and deconditioning.45,46 Minute ventilation response to elevated carbon dioxide during hypoxia is reduced during exercise in the elderly, compared to younger individuals.47 Respiratory response to both hypoxemia and

Fig. 1. Relative changes in lung volume associated with aging. IRV inspiratory reserve volume. VC vital capacity. TV tidal volume. ERV expiratory reserve volume. FRC functional residual capacity. RV residual volume. (From Reference 19, with permission.)

estado del arte...

ung cial tion mes ackT to not

at. the

ly ft

soft ciety

d at moally ised mary tory and did ome ents and n of

Asthma Massage is benecial for asthmatic cases because the supercial circulation being improved, the congestion of the mucous membrane of the bronchial tubes is reduced, Chronic lung disease of prematurity and probably there is abe reex action on the in Physiotherapy may recommended pulmonary pneumogastric nerve. chronic lung branch diseaseof ofthe prematurity not only to improve the outcome, but .also to Ellison MA. Aneurological manual for students of massage London: Bailliere, Tindall and and Cox, minimise 1898. maximise recovery the long term pulmonary sequelae. There are no studies of Physiotherapy acute, asthma has suY cient power orin length to severe cater for the large been studied in a group of 38 in children number of confounding variables analysisaged of 22 613 years. The cohort was divided into a the premature infants long term recovery. treatment group 19 children received Physiotherapy in of these childrenwho is usually 44 physiotherapy within 24 hours after admission limited to acute exacerbations. and 19 children who had placebo visits. Four physiotherapy sessions, preceded by nebulised Physiotherapy and surgery Respiratory Unit, salbutamol, were way administered over days. A very pleasant of cleansing the two Great Ormond Street The two were similar in all other thorax: . . groups . after incision of the chest and Hospital for Children resection of the seventh rib, theTrust, child was seated parameters. Lung function at the end of the NHS London in the was bath. similar With every inspiration, the water study in WC1N both 3JH, groups and the UK would run into the opening and, with expiration, authors concluded that chest physiotherapy C Wallis water would return laden with pus, which would did not lung function in children A Prasad sink to improve the bottom. Add warm water from timewith acute the to timesevere until theasthma. expirationIn gives out presence clear uid. of Correspondence to: retained secretions, particularly intreating the ventiThis method also recommends itself in Dr Wallis. lated child, chest physiotherapy may such asthmatic cases in private practice, owing to the ease email: c.wallis@ich.ucl.ac.uk with which it and can be carried out by the childs be benecial expedite recovery. However, parents, as well treatment as by its inexpensiveness. inappropriate in the presence of Adams SS. In: Irrigation by submersion in the treatment bronchoconstriction might greatly exacerbate of empyema. Transactions of the American Pediatric Socithe situation. ety 1898;10:804. The role of breathing exercises and posture in Physiotherapy the management of prescribed children with is often after more ab-

ease 26 in paediatric respiratory disease is to assist in conditions. tio Ea the removal of tracheobronchial secretions. reaso di The intention is to remove airway obstruction, ethic th Wallis, Prasad reduce airway resistance, enhance gas ex- trial Acute atelectasis ha change, reduce the to work of putting breathing. In child Byand causing the child gag by an aseptic th the acute situation, recovery should be hasnger intostability the pharynx, will be age astonished to newl haemodynamic in you diVerent ho 49 nd that, in a child with interrupted breathing, tened and and the child with a chronic invol careful assessment should ensure groups, in who is getting worse and worse, with a number of that the intervention is benecial and e V ective respiratory disorder, the progression of the Publ moist rales both sides of the lungs, the lungs rather hazardous. lungthan disease is in hopefully delayed. di stud clear up and regular breathing is established. Chest physiotherapy can improve a patients inco ci Dr Saunders. In: Disturbances of respiration in the respiratory status and expedite recovery. But in none Creating an evidence base for qu newborn. Transactions of the American Pediatric Society physiotherapy certain situations it may be a useless interven- base c 1903; 15 :47. The level of evidence on which treatment tion or even harmfulperhaps by increasing CFro recommendations are made can be kept simple. bronchospasm, pulmonary hyperThere are a few studies that advocate physio-stand di NO CLEAR EVIDENCE : inducing opinions based on clinical tension, repositioning foreign body, or destaexperience, anecdotal or descriptive therapy to be studies an ea V ective treatment in acutebetw in articles; conicting evidence from studies or bilising a sick infant. What good evidence have atelectasis, and positioning with vibration doesgreat ha poorly designed studies, even if randomised we perhaps accumulated to answer thehyperination question: who aid recovery over andtreat controlled trials. 27 28 needs chest physiotherapy? suctioning alone. However, frequently these Be P SUGGESTIVE EVIDENCE : evidence from cohort, case studies control, before-and-after studies; evidence the paediat-thera do not specically consider C Disorders with chronic sputum from non-randomised experimental studies. ric age group, where a childs inability to coop-techn po FIRM EVIDENCE : evidence from at least one production erate with randomised deep inspiration and coughing mayappr re properly designed controlled trial with Ishift have the goodneed results in these cases from pouring towards more ne adequate sample selection, sample size, and formal physio-spec a therapeutic small quantity of whiskey water into the appropriate controls; with double or and single blinding assistance. ve requ childs throat, some of which passed into the and with clear outcomes. Acute lobar atelectasis as a which result was of mucous Br re trachea and brought on coughing Feldman W, Rosseris W, McGrath P. Primary medical care plugging more commonly encountered in thewith la soon followed by good breathing. of children and adolescents. Oxford: Oxford University intensive care setting and physiotherapy is nu Press, 1987. often requested to assist in reination. Al- in As though we enter theofnew millennium, much the evidence for the benecial co randomised controlled trial reigns over other eVect of physiotherapy in children is anecdotal, re formats as most to stand up to scrutiny there are likely reports of immediate radiological D Arch Dis Child 1999;80:393397 and provide the evidence we seek. In creating improvement following intervention.29 co

Modulacin de los ujos exhalatorios

EF es usada durante la tos o la KTR para permeabilizar VA. punto de igual presin se desplaza de proximal a distal. ujo se mueve en sentido opuesto. punto de estenosis aumenta el ujo. volmenes pulmonares (VP) altos para permeabilizar VA central. VP bajos permeabiliza VA perifrica. Indispensable mantener VP adecuados y estabilidad alveolar. Puede ser pasiva o asistida. En RNPT utilizar apoyo para mantener CRF.
Eur Respir J 2000; 15: 196204

Palv = Ppl + Pel

PIP

Modulacin de los Flujos Exhalatorios

AFE TELPr TEF Huff ELTGOL CAR Drenage autgeno

Indicaciones
Alteraciones del clearence mucociliar Alteraciones de la tos Alteraciones de la reologa del mucus bronquial
Gosselink R et Als. Intensive Care Med 2008;34:11881199 Dennis McCool et Al. Chest 2006;129;250S-259S

Produccin de secreciones >30mL/24 hrs (adultos Atelectasias segmentarias o lobares, abcesos pulmonares y
bronquiectasias
C 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;34:11881199 Dennis McCool et Al. Chest 2006;129;250S-259S

Plaquetas <50000/mm3 Presencia de neumotrax o neumediastino no drenado

Bernard-Narbonne F, et Als. Archives de pdiatrie 2003;10:104347

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

Cambios de Posicin
Decbito Lateral Decbito Prono ELTGOL Drenaje Bronquial

Decbito Lateral

Optimiza la relacin V/Q en las zonas dependientes y provee estabilidad 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

Cambios de posicin - DL
-10
Mayor estabilidad alveolar

-2
Mejor V/Q

Intensive Care Med (2003) 29:787794 DOI 10.1007/s00134-003-1726-y

Inz Frerichs Holger Schiffmann Robert Oehler Taras Dudykevych Gnter Hahn Jos Hinz Gerhard Hellige

tained in infant 2 in different body positions during rapid tidal breathing and deep inspirations. The images originating from tidal breathing periods (top) are all scaled to the same maximum value of end-expiratory-to-end-inspiratory relative impedance change during this form of breathing. The scale of the images showing deep breaths (bottom ) is larger. It corresponds to the maximum Distribution of lung ventilation value of end-expiratory-to-end-inspiratory relative impedance inchange spontaneously breathing neonates lying during large spontaneous inspirations. This approach is more suitable for a visual comparison of ventilation distributions induring different body positions tidal breathing and deep inspirations than if a single scale were used 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 Students paired Objective: t-test. P values <0.05 considered significant. In case Abstract The aim of our were generated during phases of rapid of was multiple comparisons, adjusted significance values were study to determine the effect of tidal breathing and deep breaths. ap789 plied according to the classical Bonferroni test. the irregular spontaneous breathing During tidal breathing, 54.58.3%,

Fig. 2 I Functional EIT images of regional lung ventilation obO RIG NAL

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

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

Fig. 4 Sum of local end-expiratory-to-end-inspiratory relative impedance changes in the right and left lung regions during deep inspirations. To visualise the much larger magnitude of these data in comparison with rapid tidal breathing, fine dotted lines in the lower part of the diagram show the tidal breathing data presented in Fig. 3

tati lun the pro pos dif pro cre rel rev the the ini fer ins

I. Frerichs (u) R. Oehler T. Dudykevych G. Hahn J. Hinz G. Hellige Department of Anaesthesiological Research, Centre of Anaesthesiology, Emergency and Intensive Care Medicine, TL 195, University of Gttingen, Robert-Koch-Strasse 40, 37075 Gttingen, Germany e-mail: isipink@gwdg.de Tel.: +49-551-395919 Fax: +49-551-398676 H. Schiffmann Neonatal and Paediatric Intensive Care Unit, Centre of Paediatrics, University of Gttingen, Robert-Koch-Strasse 40, 37075 Gttingen, Germany

pattern and posture on the spatial dis- 55.210.5%, 59.98.4% and tribution of ventilation in neonates 54.28.5% of inspired air (mean valfree from respiratory disease by the ues SD) were directed into the right Results non-invasive imaging method of elec- 790 lung in the supine, right lateral, prone trical impedance tomography (EIT). and repeated supine postures respecScanning of spontaneously breathing tively. During deep inspirations, the All neonates studied exhibited a high irregularity of their neonates is the prerequisite for later right lung ventilation accounted for breathing pattern. Periodic breathing was observed in all routine application of EIT in babies 52.67.9%, 68.58.5%, 55.48.2% subjects. Although respiratory were frequent, with lung pathology undergoing venand pauses 50.56.6% of total ventilation no tilator therapy.phases Design: Prospective respectively. Conclusion: The study apnoeic (i.e. respiratory pauses >10 s) were obstudy. Setting: Neonatal intensive identified the significant effect of served. The selected periods of stable, rapid tidal breathcare unit at a university hospital. breathing pattern and posture on the ing spanned 511 and consecutive breaths. The of mean number Patients: Twelve pre-term term spatial distribution lung ventilation neonates (mean age: 23 days; mean in spontaneously breathing neonates. of breaths analysed was 6.82.0, 6.31.2, 7.31.6 and body weight: in 2,465 g; supine, mean gestatioThe results demonstrate that changes 6.01.7 the right lateral, prone and supine ponal age: 34 weeks; mean birth weight: in regional ventilation can easily be sitions respectively. During the selected tidal breathing 2,040 g). Interventions: Change in determined by EIT and bode well for 1, phases, mean respiratory rate was 70.612.7min body positionthe in the sequence: the future use of this method in paedi1 1 1 supine, right lateral, prone, supine. atric intensive care. 68.316.2min , 70.311.1min and 67.59.3min in Measurements and results: EIT meathe supine, right lateral, and repeated supine surements were performed using theprone Keywords Intensive care unit postures respectively. breathing rate over Gttingen GoeMF I system. The EIT average Paediatric critical care EIT lonscans oftime regional lung ventilation Impedance Ventilation distribution ger intervals, comprising not only the phases of rap- showing the distribution of respired Ventilation monitoring id breathing but also respiratory pauses and sighs, was air in the chest cross-section were

Introduction

of regional lung ventilation obFig. infant 9 in the supine posture. The tracing of relative impedancetained in infant 2 in different body positions during rapid tidal change (top) shows the average data in the chest cross-section.breathing and deep inspirations. The images originating from tidal The large impedance fluctuations are related to ventilation and re-breathing periods (top) are all scaled to the same maximum value flect the changes in pulmonary air content; the small ones, dis-of end-expiratory-to-end-inspiratory relative impedance change cernible during respiratory pauses, are related to cardiac actionduring this form of breathing. The scale of the images showing and lung perfusion and occur at a frequency corresponding to thedeep breaths (bottom) is larger. It corresponds to the maximum heart rate. The enhanced parts of the tracing show those sectionsvalue of end-expiratory-to-end-inspiratory relative impedance

Electrical impedance tomography (EIT) is a relatively lished examination tools. Access to such a novel form new non-invasive radiation-free imaging method providof information may increase the clinical diagnostic ing cross-sectional scans of the body on the basis of the and monitoring possibilities of identifying structural measurement of electrical tissue properties. In recent and functional tissue and organ changes years, intensivists have shown an increasing interest in 2. The method exhibits several advantages over other this method. There are three major reasons explaining imaging techniques. Electrical impedance tomogra2 Functional EIT theElectrical growing attractiveness of EIT for clinicians: (EIT) measurement phy allows frequent at scan ratesimages ap1 impedance tomography inFig. examinations

naturally lower. Neither the number of respiratory cycles selected nor the breathing rate significantly differed with 1. Electrical impedance tomography measures a new tisregard to posture. sue quality that is not being addressed by other estab-

The generated EIT images of regional lung ventilation showed the distribution of lung ventilation in the chest cross-section. Exemplary images obtained in one neonate (infant 2) during periods of rapid tidal breathing and deep inspiration in all postures studied are presented in Fig. 2. Deep inspirations caused no striking differences in the distribution of ventilation in this neonate from that seen during tidal breathing, either in the initial or final observations made in the supine posture. However, in the right lateral position, the right, dependent lung was less ventilated than the left, non-dependent one during tidal breathing, whereas the opposite was true during deep inspiration. In the prone position, an apparent inhomogeneity of ventilation distribution with pronounced ventilation of the right lung was discernible during tidal breathing, which, however, was not present during deep inspiration. The quantitative results are shown in Figs. 3 and 4. During rapid tidal breathing, the sum of end-expiratoryto-end-inspiratory relative impedance changes, represen-

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

lef torap dat ly ing (P< lun pos rig bre

Decbito Prono
Mejora la oxigenacin en la
mayora del os pacientes con enfermedad pulmonar aguda o con SDRA. Optimiza V/Q Aumenta los VP. Reduce WOB reduce edema pulmonar Optimiza el escalador mucocicilar.
Chest 2000;118;1801-1813

Prono

Drenajes Posturales

INDIAN PEDIATRICS VOLUME 42 JUNE 17, 2005

Mtodo

14 pacientes con ATL lobar 2 mtodos de tratamiento propuestos: Intensivo cada una hora (6 horas en total) Grupo 1: vibraciones, posicionamiento (pulmn en zona independiente), succin e hiperinsuacin. Grupo 2: Hiperinsuacin (o respiracin profunda) y succin (o tos asistida) solamente

Conclusin
Fisioterapia es efectiva en la resolucin de ATL.

Conrma la efectividad al usar un grupo

control.

Descarta resolucin espontnea

El objetivo de esta revisin fue discutir las mas comunes condiciones para las cuales la sioterapia de trax (FT) ha sido propuesta, discutir la racionalizacin de la terapia en dichos casos y resumir la evidencia clnica que realmente es til para la aplicacin de la FT

Justicacin

Revisin de evidencia disponible Indicacin y principios bsicos similares en nios y adultos. FT habitual no considera diferencias anatmicas y siolgicas FT no considera procesos patolgicos peditricos Conclusiones basadas en escasa evidencia presente

Asma Aguda
38 nios hospitalizados con AB divididos en 2 grupos 6 a 13 aos. B2, corticoides. Con y sin FT 48 hrs. Mejora en la funcin pulmonar. No hubo avances en grupo q recibi FT. no descarta su uso en un selecto grupo de
asmticos que presenten retencin de secreciones que cause ATL o hipoxia

Enfermedad Neuromuscular
Frecuente desarrollo de ATL, NM, Bronquiectasias. FT comnmente usada como mantencin y en reagudizaciones. FT busca mejorar patrn respiratorio, estimular la tos o
reeducarla y permeabilizar VA.

Las publicaciones indicaran que la FT es til en estos pacientes. insufator-exsufator

reagudizaciones disminuye la frecuencia de las

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 mltiples publicaciones que la justican. Pero no existen estudios que justiquen 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 signicativos 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

QUALITY CARE

FOR INFANTS

WITH BRONCHIOLITIS

Costes econmicos tratamiento efectivo tratamiento individualizado objetividad y seguimiento

4. The respiratory therapy recommendations stickers were placed in the chart separately from the orders, so the stickers were not routinely reviewed by the ordering physician. 5. RTs did not receive feedback on how they were performing. A program was developed to address the RTs concerns and to encourage respiratory function assessment, to determine the need for and effect of bronchodilator treatment. 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 recommendation that nasal suctioning and respiratory scoring be done prior to any bronchodilator treatment and that respiratory scoring be done 1530 min following treatment, to determine if the treatment improved the respiratory score. 2. A change in the respiratory score threshold for a recommendation for bronchodilator treatment. Though a recommendation for bronchodilator treatment with a respiratory score of 2 was deemed appropriate for asthma patients, that did not account for the typical presentation of a bronchiolitis patient, which includes increased secretions, increased respiratory rate, and decreased air movement. Therefore, a respiratory score 3 was required to recommend bronchodilator treatment for a guideline-eligible bronchiolitis patient. Patients who warranted a trial bronchodilator therapy typically had elevated respiratory rate, increased use of accessory muscles, decreased air exchange, and mild expiratory wheezes, due to increased secretions and airway inflammation. Figure 1 shows the revised treatment algorithm.

Fig. 1. Infant bronchiolitis treatment algorithm.

RESPIRATORY CARE JUNE 2004 VOL 49the NOphy6 the post-treatment respiratory scoring and advise sician whether the therapy should be continued.

Post- Operados
ATL son frecuentes debido a dolor, alteraciones en la mecnica
respiratoria producto de la anestesia o por aspiracin.

En un estudio prospectivo y randomizado se conrma la

efectividad de la FT.

Los que no reciben FT tiene mayor riesgo de desarrollar severas

atelectasias.

Complicaciones Respiratorias en Parlisis Cerebral

NM frecuentes por alteraciones mecnicas, de la

deglucin u anatmicas.

FT demostr importante disminucin de la

morbilidad en este grupo de pacientes.

A favor...
Lactantes con bronquiolitis sin soporte mecnico 15 repeticiones de ELPR + NBZ hipertnica Score de Wang (sibilancias, FR, retracciones, condicion general) SpO2 y FC a 0, 30 min y 120 min ELPR mejora todos los ndices evaluados.
Postiaux G. Respir Care 2011;56(7):98994 Postiaux G. Kinesither Rev 200 6;(55):35-41

20 nios en VM (PCV) Cohorte prospectiva SpO2, TpCO2, Vti y Vte basal y 1 hora despus SET v/s AFE Cambios signicativos en SpO2 y Vts
Bernard-Narbonne F. Archives de pdiatrie 2003;10:10437

Benecio slo si TMFE son lentas

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

Dolor e inestabilidad hemodinmica

Gosselink R et Als. Intensive Care Med 2008;34:11881199 Dennis McCool et Al. Chest 2006;129;250S-259S

Se sugiere monitorizacin vital bsica

Efectos no Deseados
Neonatos
16% de lesin cerebral con AFE (92% previas)
Demont B et Als. Physiotherapy 2007;93:126

En va area inestable

Compresin dinmica puede causar colapso y cese del ujo areo

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

Fracturas costales en pacientes peditricos con

bronquiolitis o neumona (1 en 1000)
Chalumeau & Cols. Pediatr Radiol (2002) 32: 644647 van der Schans C. Respir Care 2007;52(9):1150 6

Vmitos

Que tcnica elegir?

Se deben considerar preferencias
Respir Care. 2001; 46: 1276-1293. 2001;56(6):438444 Sivasothy P & Cols. Thorax

del paciente y del Kinesilogo. Hess D.

Kinesilogo trabaja con la familia y el paciente para determinar la mejor terapia y educa en su administracin y dosicacin.

Se deben considerar diferencias

anatomofuncionales

Lester M & Col. Respir Care 2009;54(6):733750

Recomendaciones
Intevenciones para aumentar el volumen inspiratorio se
deberan considerar si este contribuye a mejorar una espiracin forzada no efectiva (B)
Gosselink R & Cols. Intensive Care Med 2008;34:118899

Las TMFE se deben utilizar para asistir la remocin de

secreciones si la tos es inefectiva (B)
Gosselink R & Cols. Intensive Care Med 2008;34:118899

Las intervenciones para aumentar el ujo espiratorio en no

intubados se sugiere en pacientes con dicultad para acelerar el ujo por ellos mismos (B)
Sivasothy P et Als. Thorax 2001;56:438444

Recomendaciones (2)
En pacientes con Enfermedades neuromusculares,
Dennis F & Cols. Chest 2006;129;250S-259S

EPOC y FQ, la TEF debe ser realizado en conjunto con otros mtodos de Clearence mucociliar (C)

En pacientes con Enfermedades neuromusculares,

EPOC y FQ, la TEF (hufng) tiene evidencia en retencin de secreciones (C)
Dennis F & Cols. Chest 2006;129;250S-259S

Buena Moderada Mala

A B E

B B E

C C E

D D E

Tabla III. Significado de los grados de recomendacin (USPSTF) Grado de recomendacin A B C D I

(7)

Significado Extremadamente recomendable (buena evidencia de que la medida es eficaz y los beneficios superan ampliamente a los perjuicios). Recomendable (al menos moderada evidencia de que la medida es eficaz y los beneficios superan a los perjuicios). 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 recomendacin general). Desaconsejable (al menos moderada evidencia de que la medida es ineficaz o de que los perjuicios superan a los beneficios). Evidencia insuficiente, de mala calidad o contradictoria, y el balance entre beneficios y perjuicios no puede ser determinado.

Tabla IV. Niveles de evidencia (SIGN) Nivel de evidencia 1++ 1+ 12++

(9)

Tipo de estudio Meta-anlisis de gran calidad, revisiones sistemticas de ensayos clnicos aleatorizados o ensayos clnicos aleatorizados con muy bajo riesgo de sesgos. Meta-anlisis bien realizados, revisiones sistemticas de ensayos clnicos aleatorizados o ensayos clnicos aleatorizados con bajo riesgo de sesgos. Meta-anlisis, revisiones sistemticas de ensayos clnicos aleatorizados o ensayos clnicos aleatorizados con alto riesgo de sesgos. Revisiones sistemticas 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 confusin, sesgos o azar y una alta probabilidad de que la relacin sea causal.

Consideraciones
A menor edad del paciente, se requieren fuerzas de menor magnitud para provocar colapso de la va area. Se hace imprescindible el asegurar volumen pulmonar para evitar el cierre de la va area. La intervencin por kinesilogo debe ser individualizada y priorizar objetivos de educacin y prevencin. La falta de evidencia...no es sinnimo de falta inefectividad La FT no es la nica intervencin relevante que puede ser realizada por el kinesilogo.