Ce diaporama a bien été signalé.
Nous utilisons votre profil LinkedIn et vos données d’activité pour vous proposer des publicités personnalisées et pertinentes. Vous pouvez changer vos préférences de publicités à tout moment.

Respiratory Physiotherapy on SLA patients

7 979 vues

Publié le

Il lavoro respiratorio da svolgere nei pazienti portatori di Sla

Publié dans : Santé & Médecine
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (Unlimited) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (Unlimited) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/qURD } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/qURD } ......................................................................................................................... Download doc Ebook here { https://soo.gd/qURD } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici
  • DOWNLOAD THIS BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download Full EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download Full doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download PDF EBOOK here { https://soo.gd/irt2 } ......................................................................................................................... Download EPUB Ebook here { https://soo.gd/irt2 } ......................................................................................................................... Download doc Ebook here { https://soo.gd/irt2 } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book THIS can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer THIS is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story THIS Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money THIS the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths THIS Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Répondre 
    Voulez-vous vraiment ?  Oui  Non
    Votre message apparaîtra ici

Respiratory Physiotherapy on SLA patients

  1. 1. Giornate Marianesi 25 Ottobre 2008 Riabilitazione
respiratoria
 nelle
mala0e
 neuromuscolari
(S.L.A.) Do:.
FtR

Angelo
Longoni Riabilitazione
cardio‐respiratoria
“Paola
Giancola” Mariano
Comense 1
  2. 2. Obie0vi
della
riabilitazione
nelle
SLA 


L’obie0vo
riabilitaHvo
è
vincolato
dalla
storia
 naturale
della
mala0a
che
può
avere
decorso
 lentamente
o
rapidamente
progressivo: Preservare
il
più
a
lungo
possibile
l’autonomia Ritardare
l’evoluzione
dei
sintomi  Prevenire
le
complicanze 1 2 3 2
  3. 3. 
Il
fine
della
riabilitazione 
PrevenHvo 
CuraHvo
(
x
quando
è
possibile) 
CompensaHvo
(uHlizzo
di
ausili) 1 2 3 3
  4. 4. Le
principali
aree
di
intervento 1 - Psicologico 2 - Cognitivo/ Comunicativo 3 - Motorio 
 ‐Mantenimento
della
posizione
seduta 
 ‐Mantenimento
della
stazione
ere:a 
 ‐Locomozione 
 ‐Prensione
e
manipolazione 



‐UHlizzo
di
ausili 4. Funzioni di sopravvivenza:





 
 ‐Funzione
cardiovascolare 





 ‐Alimentazione
 1 2 3 4 










‐ Funzione
respiratoria 4
  5. 5. Funzione
respiratoria
 Il
pz.

deve
fare
a:enzione
ai
primi
segni
di
ipovenHlazione
 che
possono
manifestarsi
con:
 ‐aumento
secrezioni ‐malessere
e
cefalea ‐irritabilità
e
mancanza
di
concentrazione Sintomi

che
in
genere
precedono
la
comparsa
delle
 alterazioni
emogasanaliHche.

Per
questo
sono
 raccomandaH
controlli
periodic
i
basaH
su: ‐Spirometria:
CV
inferiore
a
lt
1
e
MIP
inferiore
a
60
cmH2O
 ‐Emogasanalisi ‐Saturimetria
e
capnometria
durante
il
sonno ‐Polisonnografia ‐Rx
torace 5
  6. 6. 
Disfunzioni
dell’apparato

respiratorio Vie
aeree
superiori
 Disfunzioni

a
livello
dei: ‐
muscoli
facciali ‐
orofaringei ‐
laringei Che
comportano
problemi
di
: ‐
degluHzione ‐
rischio
di
aspirazione 6
  7. 7. 
Disfunzioni
dell’apparato
respiratorio Disfunzioni
delle
vie
inferiori: 
 ‐Debolezza
dei
muscoli
inspiratori 



rido:a
espansione
polmonare 



microatele:asie 



alterazione
venHlazione‐perfusione 



ipossiemia
 
‐Debolezza
dei
muscoli
dell’espirazione 



Tosse
scarsa 



Rido:a
eliminazione
delle

secrezioni 



Rischio
di
aspirazione/
e

polmomite 7
  8. 8. IdenHficazione
dei
pazienH
a
rischio
 Segni
generali: ‐Ipostenia
generalizzata ‐Disfagia ‐Disfonia ‐Dispnea
da
sforzo
e
a
riposo Segni
clinici: ‐Respiro
rapido
e
superficiale ‐Tachicardia ‐Tosse
debole ‐Tosse
dopo
degluDzione ‐Uso
dei
muscoli
accessori ‐Respiro
paradosso 8
  9. 9. Valutazione

fisioterapica POMR ( problem oriented medical records) Spirometria Mip-Mep Ega Life shirt 1 2 Febbraio 2009 Ieri 2005 10
  10. 10. Prevenzione
 E’
essenziale
perché
è
più
difficile
 intervenire
quando
i
polmoni
sono
 completamente
ostruiD
dal
catarro.
 Applicare
l’ossigeno
per
combaRere
la


 desaturazione

senza
ripulire
i











 polmoni
significa
non
affrontare
il
 problema
alla

radice. 10
  11. 11. Scopi
della
FKT
respiratoria
 L’eliminazione
dell’eccesso
di
secrezioni
può
ridurre: •
L’ostruzione
bronchiale •Le
infezioni •Le
ateleRasie •Riespandere
le
parD
collassate •Mantenere
adeguaD
livelli
di
ossigenazione •Migliorare
la
funzionalità
respiratoria
e
la
qualità
di
vita Indicazioni:
la
Yt
respiratoria
non
deve
essere
 prescriRa
solamente
in
associazione
a
una
diagnosi
 ma
per
tuRe
quelle
situazioni
che
possono
interferire
 1 con
la
venDlazione
e
la
clearance
delle
vie
aeree. 9
  12. 12. 1 Apertura
vie
aeree

 ostruzione + + + + + + + + Atelettasia + + 1 9
  13. 13. Favorire
la
disostruzione

 2 3 Flusso-volume 9
  14. 14. +flusso + +volumi Canali di Martin + Canali di Lambert + + + + + + +pep + + + + Pori di Kohn + 3 1 9
  15. 15. Tecnica
di
apertura
vie
aeree
 1. Pressione
posiDva
Pep
(resistori):
Pep
 mask,
Vitapep,
Therapep 2. Sistemi
epap
fissi:

Molle
pretarate 


 3.

Sistemi
epap
oscillanD:
Bubble
boRle,
 FluRer,
Cornet,
Acapella 4.

Sistemi
Cpap
imperfec:
Ezpap,
Cpap
di
 Boussignac 5.

Cpap 16
  16. 16. Pep
Mask
 •Danimarca;
anestesista
J.B.
Andersen
Fkt
M.Falk
1980 •Pressione

espiratoria
posiDva •Tecnica
indipendente •PortaDle •Tempo
richiesto:
10‐15
minuD Thera pep Treshold Pep valve Pep mask 18
  17. 17. Epap
 •Pressione

espiratoria
posiDva •Azione
di
sostegno
delle
vie
aeree •Tecnica
dipendente •PortaDle •Tempo
richiesto:
10‐15
minuD Fisso Oscillante 17
  18. 18. Epap
oscillante
 •Scuola
svizzera Flu:er
 •Pressione
posiDva
espiratoria
 •Tecnica
dipendente
(
angolo
di
inclinazione) •PortaDle •Può
non
essere
efficace
a
bassi
volumi •Tempo
richiesto:
10‐15
minuD 




Cornet •Simile
al
fluRer 


 •Tecnica
indipendente
 







Acapella
 19
  19. 19. Ezpap Cpap di Boussignac Sistemi ad alti flussi con O2 o aria . Coanda effect . Venturi principle . Bernoulli theorem
  20. 20. Bpap
  21. 21. Device
available

for
mechanical
venHlaHon
 • 1.
NEGATIVE
PRESSURE
VENTILATORS(problem
of
obstrucDon
upper
airway) • Full

body
venDlator
(iron
lung) • Raincoat
venDlator
(poncho
or
pneumowrap) • Cuirass
venDlator
(chest
shell) • 2.
VENTILATORS
RESULTING
IN
PASSIVE
MOVEMENT
OF
THE
DIAPHRAGM • Pneumobelt • Rocking
bed • 3.

POSITIVE
PRESSURE
VENTILATORS • External:
Smartvest
oscillator • Internal:IPPV • 
4.
POSITIVE
PRESSURE
VENTILATORS • Invasive



 iron lung pneumowrap Cuirass
  22. 22. Rocking
bed • Rocking
bed,
a
motorized
bed
that
moves
 conDnuously
in
the
longitudinal
plane.
When
 the
head
is
higher
than
the
rest
of
the
body,
 the
diaphragm
is
pulled
down
and
inhalaDon
 is
assisted.
When
the
head
is
lower,
the
 abdominal
contents
are
pulled
down
and
 expiraDon
is
assisted.

  23. 23. Pneumobelt • Pneumobelt,
also
known
as
the
intermiRent
 abdominal
pressure
venDlator
(IAPV)
‐
a
 motorized,
inflatable
bladder
that
is
secured
over
 the
abdomen.
The
bladder
alternately
expands
 and
contracts
(as
air
is
forced
into
and
released
 from
it),
which
intermiRently
compresses
the
 abdomen,
causing
the
diaphragm
to
move
 upwards
and
augment
expiraDon.
Since
 inhalaDon
with
the
pneumobelt
is
largely
passive
 and
dependent
on
gravity,
the
device
is
only
 useful
in
the
sicng
or
standing
posiDon
as
an
 alternaDve
to
tracheostomy‐dependent
means
of
 venDlatory
support

  24. 24. Nuovi sistemi Vibrapap Vibrapap
  25. 25. Pressione
+:
HFCWO
(
Smartwest
)
 •Applica
un
alta
frequenza
oscillatoria
al
torace •Uso
indipendente •Tecnica
indipendente •PortaDle
 •Tempo:
15‐30
minuD
 28
  26. 26. 29
  27. 27. IPV‐PERCUSSIONAIRE
 La
 venDlazione
 intrapolmonare
 percussiva
 
 è
 un
 disposiDvo
 a
 pressione
 posiDva
 vibratoria
 intermiRente
 per
 il
 traRamento
 delle
 patologie
 restricve
 e
 ostrucve.
 Favorisce
 gli
 scambi
 alveolari,migliora
 la
 compliance
 toracica,
 e
 aRraverso
 effec
 peristalDci
 indoc
 sDmola
 
 la
 circolazione
polmonare.
 30
  28. 28. 
Tosse
 •Risposta
naturale
(
espulsi
circa
2,5
lt
di
 
 aria
a
velocità
tra
6
e20
lt/sec) •Può
essere
soppressa
dal
paziente •Inefficace
(se
soRo
i
160lt/min) •Può
indurre
un
afflosciamento
delle
vie
 aeree 40
  29. 29. La
tosse
 Nei
pazienD
neuromuscolari
una
scarsa
 efficacia
della
tosse
comporta
gravi
 complicanze
come
la
chiusura
di
territori
 polmonari
per
la
formazione
di
tappi
di
muco
 (ateleRasie).
Nei
soggec
con
difficoltà
di
 degluDzione
con
facilità
di
inalazione
di
 materiale
alimentare
è
fondamentale
per
la
 sua
rimozione. 41
  30. 30. Tosse
inefficace
per:
 1 Debolezza
dei
 RidoRo
 muscoli
inspiratori volume
 pretussivo RidoRa
compliance
 2 toraco‐polmonare RidoRo
 Debolezza
dei
 3 flusso
 muscoli
espiratori espiratorio 42
  31. 31. Tosse
inefficace
 CV<
1500
ml Mep
<
40
cmH20 PCF
<
3
l/sec
(160‐270
l/min) MISURE
STRUMENTALI VALORI
CRITICI 
Spirometria 
Capacità
vitale
<
di
1
lt Picco
di
flusso PCF
<
160
lt/min Ossimetria SatO2
<90% Capnometria PaCo2
>
45
mmHg 43
  32. 32. MISURATORE DI “ PCF “ 
 Come si misura 270 il PEF/PCF FET _______ 160 PCF 
270

L/min PCEF 
160

L/min ! (Bach‐1996)
  33. 33. Elettronico Manuale MIP Inspirazione MIP - MEP MEP Espirazione Misuratore 1 MIP-MEP
  34. 34. Protocollo
di
Bach
 Il
protocollo
messo
a
punto
da
John
Bach
si
basa
sull’osservazione
 che
“nei
pazienD
neuromuscolari
l’I.R.A.
consegue
più
spesso
a
 infezioni
delle
vie
aeree”
e
che
“
durante
quesD
episodi,
la
già
severa
 disfunzione
polmonare
è
ulteriormente
compromessa
dall’accumulo
 di
secrezioni
e
dall’indebolimento
dei
muscoli
in‐espiratori”.
Tali
 episodi
“possono
esitare
facilmente
in
polmoniD
con
 ospedalizzazione,intubazione,
tracheotomia
o
decesso”. Assistenza
inspiratoria Assistenza
espiratoria Tecniche
manuali
strumentali
x
tosse
assisDta VenDlazione
meccanica 




Espirazione























Inspirazione 




Niv






















Invasiva 
abdominal
thrust















Air
stacking 


























in‐exsufflator 46
  35. 35. Tecniche
di
assistenza
alla
tosse
 Assistenza


















Assistenza



 
 Inspiratoria
















Espiratoria ‐Air
stacking ‐Compressioni








 
 ‐Respiro
glossofaringeo addominali ‐InExsufflator 47
  36. 36. Air
Stacking
 Assunzione
consecuDva
di
due
o
più
 insufflazioni
d’aria,
traRenute
mediante
 chiusura
della
glocde.
Il
metodo
si
basa
sul

 faRo
che
il
flusso
espiratorio
è
funzione
del
 volume
massimale
inspirato
precedentemente. Condizioni: ‐Buon
funzionamento
della
glocde ‐Buona
collaborazione
del
paziente ‐Vantaggi:
uDle
come
esercizio
di
espansione
e
 mantenimento
dell’elasDcità
della
gabbia
 toracica. 48
  37. 37. Assistenza
inspiratoria



 Air
stacking
 Pallone
ambu:
necessaria
assistenza VenDlatore.
Il
paziente
è
autonomo 49
  38. 38. Air
Stacking
con
ambu
 L’operatore
al
termine
di
una
inspirazione
 insuffla
il
paziente
con
un
dato
volume
d’aria
 che
andrà
ad
aggiungersi
a
quello
inalato.
 Sucessivamente
verrà
chiesto
al
paziente
di
 tossire
con
eventuale
assistenza
alla
tosse. 50
  39. 39. Air
Stacking
mediante
venHlatore
 La
metodica
è
basata
sulla
possibilità
di
 insufflare
progressivamente
il
paziente
col
 venDlatore
volumetrico
che
permeRe
più
 insufflazioni
della
medesima
enDtà. 51
  40. 40. Assistenza
inspiratoria
 G.P.B.
(Frog
breathing) E’n
una
tecnica
non
invasiva.
 Richiede
l’integrità
della
muscolatura
 glossofaringea
e
laringea. E’
una
forma
di
respirazione
a
pressione
 posiDva
intermiRente. Può
migliorare
l’efficacia
della
tosse. Migliora
o
manDene
la
compliance
polmonare. E’
un
uDle
tecnica
di
stretching. Previene
le
microateleRasie Aumenta
la
sensazione
di
indipendenza. (Chest
1998) 53
  41. 41. G.P.B. GULP=
singolo
movimento
linguale
capace
di
far
 ingoiare
nei
polmoni
50‐150
ml
di
aria
per
volta: 5‐10
GULPS











Volume
corrente
di
600
ml 54
  42. 42. Assistenza
espiratoria Abdominal
Thrust
 E’
una
manovra
di
rapida
compressione
 manuale
dell’addome
con
direzione
e
spinta
 verso
l’alto
eseguita
in
fase
espiratoria
e
in
 sincronia
con
la
tosse
del
paziente.
In
soggec
 con
MEP
>
50
cm/H2O
il
PCF
non
varierà
molto
 con
questa
assistenza. 56
  43. 43. Abdominal
Thrust
 Assistenza
alla
tosse
 57
  44. 44. Assistenza
meccanica
alla
 tosse In-Exsufflator Pegaso 32
  45. 45. InExsufflator
 L'In‐Exsufflator
è
un
venDlatore
a
pressione
 posiDva/negaDva

per
la
disostruzione
delle
alte
 vie
aeree.
Esso
garanDsce
un'insufflazione
di
 ampiezza
variabile
aRraverso
un
boccaglio,
una
 maschera

oro‐nasale
o

aRraverso
un
tubo
 endotracheale.
Tale
aRo
è
seguito
 dall'applicazione
di
una
pressione
 negaDva
che
assicura
una espirazione
meccanica
forzata. 32
  46. 46. In‐exsufflator
 •Crea
una
tosse
meccanica
aRraverso
l’uso
 
 di
pressione
posiDva
e
negaDva •Uso
indipendente
o
con
assistenza •Tecnica
indipendente •Tempo.
10
minuD 33
  47. 47. Modalità ‐Il
traRamento
abituale
consiste
di
5
serie
di
in‐ 
 essuflazioni‐pause
da
ripetere
4/5
volte. ‐Posizione:
supina‐seduta
col
capo
iperesteso. ‐Può
essere
usato
anche
per
la
ginnasDca
 respiratoria
usando
la
pressione
posiDva. ‐Può
essere
usato
come
percussionaire
 alternando
velocemente
le
pressioni
posiDve
e
 negaDve. Regolazioni
 ‐Inspirazione:

+30
‐
+40

cmH2O
for
2‐3
sec. ‐Espirazione:



‐30
‐
‐40


cmH2O
for
2‐3
sec. ‐Pausa:




1‐2
sec. 34
  48. 48. In‐exsufflator 35
  49. 49. Effe0
negaHvi
 ‐Distensione
dell’addome
(si
elimina
riducendo
la
 pressione). ‐SDramento
dei
muscoli
della
gabbia
toracica. Controindicazioni
 ‐Pneumotorace
non
traRato. ‐Enfisema
bolloso. ‐RecenD
intervenD
chirurgici. 36
  50. 50. IN‐ESSUFFLAZIONE
meccanica
(
MI‐E
) Apparecchio
“
In‐Exsufflator
“ •Efficacia
su
modelli
clinici
e
animali (Bickerman
HA‐1954) •Nessun
effeRo
collaterale (Barach
AL‐1955)
(Colebatch
HJH‐1961) •Metodo
efficace
e
sicuro
vs
tecniche
di
assistenza
 manuale (Bach
JR‐1993) •Confort
ed
efficcacia
vs
broncoaspirazione.
 (Barach
AL‐1951) •Facile
uDlizzo
domiciliare‐ambulatoriale
  51. 51. IN‐EXSUFFLATOR Assistenza
alla
tosse Aspirazione
tradizionale
  52. 52. 39
  53. 53. Riassumendo AD DMD 27aa BP DMD 34aa 500 350 450 400 300 350 250 300 Spontaneo l/min 250 200 Spontaneo AMBU 1 mandata l/min 200 AMBU 1 mandata 150 150 AMBU 2 mandate 100 100 50 0 50 PEF PCF PCF A 0 PEF PCF PCF A Capacità Vitale 1600 1400 Capacità Vitale 1200 1000 1200 ml 800 1000 600 400 800 200 ml 600 0 Spontaneo AMBU 1 mandata 400 Modalità 200 0 Spontaneo AMBU 1 mandata AMBU 2 mandate Modalità 39
  54. 54. paediatric patients Mechanical insufflation/exsufflation produces a greater increase in peak cough flow than other standard cough adult patients augmentation techniques in adults and children with neuromuscular disease. UAC: unassisted cough; PAC: physiotherapy-assisted cough; NVAC: noninvasive ventilator-assisted cough; EAC: exsufflation-assisted cough; 39 IEAC: insufflation/exsufflation-assisted cough.
  55. 55. 39
  56. 56. Grazie..
 
 









per
l’a:enzione 59

×