sábado, janeiro 24, 2009

Cuidados Intensivos e MFR

Sou confrontado muitas vezes com o mito da "Cinesioterapia Respiratória"- quanto mais melhor nos Cuidados Intensivos...
Penso que a intervenção mais importante por parte da MFR nas UCI, passa por uma avaliação cuidadosa, tendo em mente o diagnóstico e o prognóstico funcional.
A abordagem terapêutica mais importante tem como objectivos o recondicionamento, a mobilidade e verticalização precoce em doentes seleccionados (vide link)...
A Cinesio Respiratória - "Chest Physiotherapy" deverá estar concentrada na progressão efectiva da descontinuação do suporte ventilatório, reeducação ventilatória e drenagem de secreçõs pós extubação (vide artigo)...

Vale a pena perceber o que nos diz este Artigo da Chest , embora com quase 9 anos, constitui uma revisão idónea...
alguns extractos:

1-Riscos da "chest physiotherapy" na UCI

" Significant and at times dramatic increases in heart rate, systolic and mean BP, cardiac output, oxygen consumption, carbon dioxide production, and Paco2 were found during the physiotherapy treatment. The administration of propofol before the treatment decreased or prevented these hemodynamic and metabolic responses. As an example of the metabolic effects seen, oxygen consumption increased by approximately 70% over baseline values during the physiotherapy treatments
A standardized physiotherapy treatment comprising postural drainage and percussion was performed on all patients. All patients had been referred for physiotherapy by a physician, but the specific indications for this treatment were not described. No cardiac arrhythmias were seen for 46 patients (63.9%), minor arrhythmias were seen for 18 patients (25.0%), and major arrhythmias were seen for 8 patients (11.1%)
Multimodality physiotherapy has also been shown to increase intracranial pressure (ICP) significantly, although cerebral perfusion pressure (CPP) is usually maintained at adequate levels


(...)In some hospitals, physiotherapy is performed routinely on all intubated ICU patients receiving mechanical ventilation, with the aim of decreasing the incidence of pulmonary complications (eg, nosocomial pneumonia, bronchopulmonary infection, atelectasis). To my knowledge, the only published report investigating the effectiveness of physiotherapy in preventing pulmonary complications for intubated patients receiving mechanical ventilation is by Ntoumenopoulos
There were no statistically significant differences between the two groups in either the number of patients withdrawn from the study on the suspicion of nosocomial pneumonia or the number of patients with a final diagnosis of pneumonia. Similarly, no significant differences were seen between groups in ABG values, the length of time receiving mechanical ventilation (mean, 6.1 days physiotherapy group; 5.2 days control group), length of ICU stay (mean, 7.4 days physiotherapy group; 6.8 days control group), or mortality rate in the ICU (0 for both groups). As identified by the authors, the small sample size was a limitation of the study that may have led to a type II error.
The management of pulmonary conditions commonly found in intubated ICU patients receiving mechanical ventilation (eg, pneumonia, bronchopulmonary infection, atelectasis, acute exacerbation of chronic pulmonary disease, ARDS) often includes physiotherapy. However, the effect of physiotherapy on the clinical course of such conditions has been studied only for acute lobar atelectasis
With the exception of the study by Ntoumenopoulos et al, as outlined previously, the ability of physiotherapy to facilitate weaning, shorten the length of stay in the ICU or hospital, or decrease morbidity and mortality has not been reported.
Is there sufficient evidence to dictate whether physiotherapists should routinely use respiratory techniques with all intubated patients receiving mechanical ventilation with the intention of preventing complications? An intubated patient in the ICU has many factors that may adversely affect airway clearance, including the presence of an artificial airway, inadequate humidification, medications, underlying pulmonary disease, and mucosal damage as a result of suction.Thus, there are theoretical reasons why physiotherapy may be routinely required. However, the expectation that physiotherapy provided a few times a day (in addition to routine nursing care) will decrease the incidence of pulmonary complications may be unrealistic, given that many of the major causative factors responsible for the high incidence of complications are not addressed (eg, prolonged immobility, microaspiration, reduced host defenses, poor nutritional status, colonization of ventilator circuits, and antibiotic treatment leading to lower-airway colonization and superinfection

Se por um lado parece haver 1 artigo a referir alguma prova (some evidence) de vantagens com a "chest physiotherapy" ... há outro a demonstrar alguma prova de desvantagens (Chest physiotherapy prolongs duration of ventilation in the critically ill ventilated patients)

Um facto interessante é perceber que quem comenta de forma crítica a metodologia do artigo que demonstra desvantagem, é o mesmo autor que publicou o artigo que prova vantagens... uups

3- Intervençõs MFR mais importantes:

Mesmo artigo da Chest:
It has been my observation that in many ICUs, physiotherapists tend to restrict their role to one predominantly involving respiratory assessment and treatment. An additional role that physiotherapists may have in the ICU is the assessment and management of neurologic and musculoskeletal complications. Although this additional role has been previously acknowledged,to my knowledge, there are no published data to support it. Nevertheless, regular neurologic assessment enables the early detection of neurologic deficits, particularly the neuromyopathies often found in critically ill patients, and, less frequently, other lesions involving the peripheral and central nervous systems, all of which may significantly affect the management and outcome of patients. Thorough musculoskeletal assessment ensures that fractures or soft-tissue injuries have not been overlooked (particularly relevant for trauma patients) and enables early detection of the onset of joint stiffness or soft-tissue tightness.

A favor da intervenção no campo musculo esquelético, recondicinomanento ou neurológico:
In a report, published in the Oct. 8 issue of Journal of the American Medical Association (JAMA), Needham says that routinely keeping ICU patients deeply sedated and on bed rest can lead to muscle weakness and that it’s probably best to get patients up and moving shortly after admission to an ICU. The conclusions are based on Needham’s review of recent studies and experience at The Johns Hopkins Hospital medical intensive care unit. A systematic review by Needham and colleagues found that across 24 studies, focused on ICU patients with sepsis, prolonged mechanical ventilation and multiple organ failure, 46 percent of 1,421 patients had neuromuscular dysfunction that was associated with extended use of mechanical ventilation and longer stays in the ICU. Other studies Needham reviewed showed that early physical medicine and rehabilitation therapy, while patients are on life support in the ICU, can safely allow patients to get out of bed and walk more quickly, resulting in shorter time on a ventilator and a shorter stay in the ICU for these critically ill patients.
John Hopkins ICU Mover
notícia no NY Times

Portanto prevenir o descondicionamento Zero G parece ser, em doentes selecionados uma intervenção MFR válida.

4-Será um terreno para disputas entre grupos profissionais?

O mesmo artigo da Chest refere:
An area of considerable controversy that, at times, engenders professional jealousy concerns the delineation of the various roles of ICU staff, in particular between physiotherapists and nursing staff. Although there are comparatively clear delineations for some tasks (eg, delivery of medications and general patient care are usually seen as the sole responsibility of nursing staff, and physiotherapists are usually responsible for providing patients with rehabilitation regimens), many tasks do not fall solely into the lap of either profession.
Similar conflicts may arise in ICUs in which both physiotherapists and respiratory therapists work

5 - Alguns Super Patients:

1 comentário:

Francisco Manuel Martín del Rosario disse...

Siento no saber hablar portugués. Enhorabuena por tu blog y por esta entrada. Es muy buena.
Un saludo desde Canarias.
Francisco Martín del Rosario