prevenzione o trattamento - ARIR Associazione riabilitatori della

PREVENZIONE O TRATTAMENTO:
QUANDO, COME, PERCHÉ?
Emilia Privitera
Fondazione Ca’ Granda Ospedale Maggiore Policlinico
COMPLICANZE
FATTORI
• dipendenti dal paziente
(identificabili con esami preoperatori)
• dipendenti dall'atto chirurgico e dall'anestesia
Gruppi ASA
(American Society of Anaesthesia)
Gruppo 1
Paziente in buona salute
Gruppo2
Malattia sistemica senza limitazioni funzionali
Gruppo 3
Grave malattia sistemica con limitazioni
funzionali
Gruppo 4
Gravi malattie sistemiche con costante
pericolo per la vita
Gruppo 5
Paziente moribondo che non può sopravvivere
per 24 ore con o senza intervento.
RISCHIO CHIRURGICO NEL PAZIENTE CANDITATO A RESEZIONE
POLMONARE
Basso rischio
FEV1 >2 lt o >60%
DLCO >60%
Elevato rischio
FEV1 <2 L o <60%
DLCO < 60%
Inoperabile
FEV1 <0.8 l
<40% del teorico
DLCO < 40%
prova da sforzo
cardio-polmonare
ANAMNESI E ESAME FISICO SONO LA PARTE PIÙ
IMPORTANTE DELLA VALUTAZIONE DI RISCHIO
PREOPERATIVE CLINICAL EVALUATION
careful history taking and physical examination
are the most important parts of preoperative pulmonary
risk assessment. One should seek a history of
exercise intolerance,chronic cough, or unexplained
dyspnea. The physical examination may identify findings suggestive of
unrecognized pulmonary disease.
Gerald W.Smetana
VALUTAZIONE PRE-OPERATORIA
Anamnesi e storia clinica:
–
–
–
–
Malattie respiratorie pregresse
Interventi chirurgici precedenti
Traumi
Farmaci utilizzati
Esame clinico
•atteggiamento posturale
•mobilità della gabbia toracica
•pattern respiratorio
•uso muscolatura accessoria
•tosse/escreato
•capacità di comprensione: limitazioni sensoriali o psichiche
•aderenza del paziente alle cure
•tono della parete addominale
Patologie associate :
–
–
–
Apparato cardio-respiratorio
Apparato muscolo-scheletrico
Altro
•Esami strumentali
Fattori di rischio
• Età
• Fumo
• Stato nutrizionale : malnutrizione/ obesità
(BMI > 25)
• Compromissione della funzione respiratoria
e/o degli scambi gassosi
FATTORE PREDITTIVO DI RISCHIO DI
COMPLICANZE
Incapacita’ a sostenere un
esercizio fisico lieve - moderato
Gerson 1990
VALUTAZIONE POLMONARE PREOPERATORIA INTERVENTI RESETTIVI
COMPLICANZE
•
•
•
•
•
STRATEGIE
di prevenzione del rischio di complicanze respiratorie
postoperatorie
di ottimizzazione dello stato clinico
anestesiologiche
chirurgiche
postoperatorie
PREOPERATORIO
• EDUCAZIONE
•CORREZIONE FATTORI RISCHIO
•OTTIMIZZAZIONE TERAPIA PNEUMOLOGICA
•ATTIVITÀ FISICA
PREOPERATIVE EXERCISE THERAPY FOR ELECTIVE MAJOR ABDOMINAL SURGERY: A SYSTEMATIC
REVIEW.
Pouwels S1, Stokmans RA2, Willigendael EM3, Nienhuijs SW4, Rosman C5, van Ramshorst B6, Teijink JA7.
Author information
Abstract
OBJECTIVES:
The impact of postoperative complications after Major Abdominal Surgery (MAS) is substantial, especially when
socio-economical aspects are taken into account. This systematic review focuses on the effects of preoperative
exercise therapy (PEXT) on physical fitness prior to MAS, length of hospital admission and postoperative
complications in patients eligible for MAS, and on what is known about the most effective kind of exercise regime.
METHODS:
A systematic search identified randomised controlled trials on exercise therapy and pulmonary physiotherapy prior
to MAS. The methodological quality of the included studies was rated using the 'Delphi List For Quality Assessment
of Randomised Clinical Trials'. The level of agreement between the two reviewers was estimated with Cohen's kappa.
RESULTS:
A total of 6 studies were included, whose methodological quality ranged from moderate to good. Cohen's kappa was
0.90. Three studies reported on improving physical fitness prior to MAS with the aid of PEXT. Two studies reported
on the effect of training on postoperative complications, showing contradictory results. Three studies focused on the
effect of preoperative chest physiotherapy on postoperative lung function parameters after MAS. While the effects
seem positive, the optimal training regime is still unclear.
CONCLUSION:
Preoperative exercise therapy might be effective in improving the physical fitness of patients prior to major
abdominal surgery, and preoperative chest physiotherapy seems effective in reducing pulmonary complications.
However consensus on training method is lacking. Future research should focus on the method and effect of PEXT
before high-risk surgical procedures.
PREOPERATIVE PHYSICAL THERAPY FOR ELECTIVE CARDIAC SURGERY PATIENTS
Hulzebos EH1, Smit Y, Helders PP, van Meeteren NL.
Author information
Abstract
BACKGROUND:
After cardiac surgery, physical therapy is a routine procedure delivered with the aim of preventing postoperative pulmonary complications.
OBJECTIVES:
To determine if preoperative physical therapy with an exercise component can prevent postoperative pulmonary complications in cardiac surgery patients,
and to evaluate which type of patient benefits and which type of physical therapy is most effective.
SEARCH METHODS:
Searches were run on the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library (2011, Issue 12 );
MEDLINE (1966 to 12 December 2011); EMBASE (1980 to week 49, 2011); the Physical Therapy Evidence Database (PEDro) (to 12 December 2011)
and CINAHL (1982 to 12 December 2011).
SELECTION CRITERIA:
Randomised controlled trials or quasi-randomised trials comparing preoperative physical therapy with no preoperative physical therapy or sham therapy
in adult patients undergoing elective cardiac surgery.
DATA COLLECTION AND ANALYSIS:
Data were collected on the type of study, participants, treatments used, primary outcomes (postoperative pulmonary complications grade 2 to 4: atelectasis,
pneumonia, pneumothorax, mechanical ventilation > 48 hours, all-cause death, adverse events) and secondary outcomes (length of hospital stay, physical
function measures, health-related quality of life, respiratory death, costs). Data were extracted by one review author and checked by a second review author.
Review Manager 5.1 software was used for the analysis.
MAIN RESULTS:
Eight randomised controlled trials with 856 patients were included. Three studies used a mixed intervention (including either aerobic exercises or
breathing exercises); five studies used inspiratory muscle training. Only one study used sham training in the controls. Patients that received preoperative
physical therapy had a reduced risk of postoperative atelectasis (four studies including 379 participants, relative risk (RR) 0.52; 95% CI 0.32 to 0.87; P = 0.01)
and pneumonia (five studies including 448 participants, RR 0.45; 95% CI 0.24 to 0.83; P = 0.01) but not of pneumothorax (one study with 45 participants,
RR 0.12; 95% CI 0.01 to 2.11; P = 0.15) or mechanical ventilation for > 48 hours after surgery (two studies with 306 participants, RR 0.55; 95% CI 0.03 to 9.20;
P = 0.68). Postoperative death from all causes did not differ between groups (three studies with 552 participants, RR 0.66; 95% CI 0.02 to 18.48; P = 0.81).
Adverse events were not detected in the three studies that reported on them. The length of postoperative hospital stay was significantly shorter in experimental
patients versus controls (three studies with 347 participants, mean difference -3.21 days; 95% CI -5.73 to -0.69; P = 0.01). One study reported a reduced physical
function measure on the six-minute walking test in experimental patients compared to controls. One other study reported a better health-related quality of life in
experimental patients compared to controls. Postoperative death from respiratory causes did not differ between groups (one study with 276 participants,
RR 0.14; 95% CI 0.01 to 2.70; P = 0.19). Cost data were not reported on.
AUTHORS' CONCLUSIONS:
Evidence derived from small trials suggests that preoperative physical therapy reduces postoperative pulmonary complications (atelectasis and pneumonia)
and length of hospital stay in patients undergoing elective cardiac surgery. There is a lack of evidence that preoperative physical therapy reduces postoperative
pneumothorax, prolonged mechanical ventilation or all-cause deaths.
COMPLICANZE
•
•
•
•
•
STRATEGIE
di prevenzione del rischio di complicanze respiratorie
postoperatorie
di ottimizzazione dello stato clinico
anestesiologiche
chirurgiche
postoperatorie
FISIOTERAPIA RESPIRATORIA
POSTOPERATORIA
45
40
35
30
25
20
15
10
5
0
Thoren L. 1953;107: 193-205
PHYSIOTHERAPY AFTER CORONARY SURGERY: ARE BREATHING
ESERCISES NECESSARY?
110 pz sesso maschile razza bianca omogenei per eta’, peso, altezza,
funzionalita’ polmonare, abitudine al fumo
EX. ALTA
INTENSITA’
EX. MEDIA
INTENSITA’
EX. ALTA
INTENSITA’
EX. BASSA
INTENSITA’
FET/TOSSE
EX Arti Superiori e Inferiori
Respiri Profondi Percussioni Vibrazioni
Spirometria Incentivante
FET/TOSSE
EX Arti Superiori e Inferiori
Respiri Profondi Percussioni Vibrazioni
FET/Tosse
Precoce Mobilizzazione
Jenkins SC Thorax 1989; 44:634-639
L'ANALISI COMPARATA DELL'EFFICACIA DEI DIVERSI
TRATTAMENTI DI FISIOTERAPIA RESPIRATORIA
non ha permesso di osservare una reale superiorità
di questi nei confronti :
• della mobilizzazione precoce
• huffing/tosse assistita
per la prevenzione delle complicanze respiratorie
postoperatorie
• Hall JC Lancet 1991; 337:953-956
•Gosselink R Crit Care Med 2000;28:679-83
•Overend TJ Chest 2001; 120:971-78
•Pasquina P BMJ 2003; 327:1379-84
POST INTERVENTO
• mobilizzazione precoce
•corretta gestione della terapia analgesica
•Tosse/FET
A SCOPO PREVENTIVO……..
MANOVRE MIRATE DI
RIESPANSIONE/DISOSTRUZIONE POLMONARE
IS
10 cc/Kg
SEZIONE PEP
NO
SI
SEZIONE I.S.