Asociación entre diagnósticos e intervenciones de enfermeras en pacientes sometidos a cirugía torácica o abdominal superior

ObjectiveTo determine associations between respiratory nursing diagnoses and nursing interventions in patients submitted to thoracic or upper abdominal surgery.MethodCross sectional quantitative study. Participants were 312 adult patients within the first 48 hours after thoracic or upper abdominal surgery. Patients were examined by the research team using an instrument with variables related to the respiratory function. The research team established the presence/absence of three nursing diagnoses and proposed interventions using the NANDA-I classification and the Nursing Interventions Classification. Correlations were tested using the chi-square or Fisher's test.ResultsFrom the total 312 examinations, ineffective airway clearance was present in 185 (59.3%) assessments, ineffective breathing pattern in 123 (39.4%), and impaired gas exchange in 141 (45.4%). Significant correlations showed that patients with ineffective airway clearance were more likely to require pain management (or: 2.27), chest physiotherapy (or: 2.96), and positioning (or:1.8), while patients with impaired gas exchange were less likely to require airway management (or: 0.13) and chest physiotherapy (or: 0.28).ConclusionsPatients with ineffective airway clearance had more chances of requiring pain management, chest physiotherapy, and positioning, while the nursing diagnosis impaired gas exchange was related with airway management and chest physiotherapy. The findings provide basis for nurses to develop effective care plans and to minimize postoperative respiratory complications.     

Pediatric airway maintenance and clearance in the acute care setting: how to stay out of trouble

Traditional airway maintenance and clearance therapy and principles of application are similar for neonates, children, and adults. Yet there are distinct differences in physiology and pathology between children and adults that limit the routine application of adult-derived airway-clearance techniques in children. This paper focuses on airway-clearance techniques and airway maintenance in the pediatric patient with acute respiratory disease, specifically, those used in the hospital environment, prevailing lung characteristics that may arise during exacerbations, and the differences in physiologic processes unique to infants and children. One of the staples of respiratory care has been chest physiotherapy and postural drainage. Many new airway clearance and maintenance techniques have evolved, but few have demonstrated true efficacy in the pediatric patient population. Much of this is probably due to the limited ability to assess outcome and/or choose a proper disease-specific or age-specific modality. Airway-clearance techniques consume a substantial amount of time and equipment. Available disease-specific evidence of airway-clearance techniques and airway maintenance will be discussed whenever possible. Unfortunately, more questions than answers remain.     

Mechanical airway clearance using the frequencer electro-acoustical transducer in cystic fibrosis

PURPOSE: Clearance of mucus from airways is the cornerstone of therapy for lung disease in patients with cystic fibrosis (CF). This paper describes the operation of the Frequencer, a novel respiratory physiotherapy device comprised of an electro-acoustical transducer. We hypothesized that the Frequencer would be a safe and effective therapy to help clear secretions from the airways of subjects with CF. METHODS: To verify this hypothesis, 22 individuals with CF were recruited to this study comparing sputum production during conventional chest physiotherapy (CCPT) and Frequencer therapy using a crossover design. The sputum weight was the main outcome measure. RESULTS: Sputum weight was found to be a reproducible measure of the efficacy of chest physiotherapy in individual patients. The Frequencer induced airway clearance in patients with CF that was equivalent to that of CCPT. Furthermore, treatment of a 4% mucin preparation ex vivo with the Frequencer significantly reduced the viscosity of the mucin solution as determined in a capillary rheometer. CONCLUSIONS: These results indicate the Frequencer is safe and as effective as CCPT in inducing airway clearance in patients with CF.     

Finding evidence to support airway clearance techniques in cystic fibrosis

Summary

Chest physiotherapy, aiming to clear bronchopulmonary secretions, has become a mainstay in the respiratory management of cystic fibrosis (CF). Early diagnosis and new therapeutic interventions have dramatically improved the outlook for patients with this disorder and it is no longer a disease of childhood. Along with these changes chest physiotherapy has also progressed, with the development of several treatment modalities that are more effective and can be performed by the patient without assistance. This allows older children and adults with CF to lead more normal and independent lifestyles. Despite this progress questions remain regarding the efficacy and consequences of airway clearance techniques, the scientific evidence available to support the selection of the most appropriate treatment modality and, not least, the problems associated with the treatment-related burden that is placed on patients and their families.     

Reliability and Responsiveness of Patient-Reported Outcome Measures of Neck Disability to Physical Therapy: Comparison of the Copenhagen,Northwick Park,and Neck Bournemouth Questionnaires and the Neck Disability Index

ObjectiveThe purpose of this study was to identify the external and internal reliability and responsiveness of the validated patient-reported outcome measures (PROMs) of neck pain to a standardized regimen of physiotherapy administered acutely after mild whiplash injury using the clinically significant improvement components of the Patient Global Impression of Change (PGIC) as the outcome measure.MethodsEighty-six patients with neck pain alone were referred for physiotherapy within 2 weeks of whiplash injury. They completed the Copenhagen, Northwick Park (NP), and Neck Bournemouth (NBQ) questionnaires and the Neck Disability Index (NDI) before starting and after treatment when they also completed the PGIC. Treatment comprised deep soft tissue massage, myofascial releases, muscle energy techniques, joint articulation and manipulation techniques, and a home exercise program. The duration of treatment was between 3 and 6 weeks. A PGIC of 6 or 7 was considered to be clinically significant improvement.ResultsThe external reliability of the PROMs was >0.7 and internal >0.87. All components of the PROMs contributed to the final score except headache in the Copenhagen and upper-limb dysesthesia in the NP. The most reliable questionnaire was the NBQ, which was significantly more responsive than the Copenhagen (P = .008). The NBQ was slightly more responsive than the NDI and NP. The NBQ and NDI were successfully completed more frequently than the NP and Copenhagen.ConclusionThe NP, NDI, and NBQ are all reliable and responsive measures of change after physiotherapy for neck pain after acute whiplash injury.     

Cardiorespiratory repercussions according to the abdominal circumference measurement of men with obstructive respiratory disorder submitted to respiratory physiotherapy

Purpose: To examine the effect of respiratory physiotherapy among men with obstructive respiratory disorder, in relation to abdominal circumference (AC). Methods: Quasi-experimental study including 26 men split into two groups according to AC(cm): 1) < 102 (AC_risk-free); and 2) ≥ 102 (AC_risk). Heart rate variability (HRV), diastolic blood pressure (DBP), oxygen saturation (SpO₂), FEV₁/FVC, slow vital capacity (SVC), inspiratory capacity (IC), maximal inspiratory pressure (PI_max), thoracoabdominal amplitude (AI) were measured: before (M₁); 5 min after the physiotherapy (i.e. breathing exercises for airway clearance and active kinesiotherapy) (M₂); and at follow-up, 30 min after physiotherapy (M₃). Results: The groups differed in age, body mass index and body fat %. At M₂ IC was different between groups (AC_risk-free< AC_risk). There was an increase in HRV indexes, PI_max, SpO₂, axillary AI, FEV₁/FVC, and reduction in HR for AC_risk-free. There was a decrease in AI and an increase in DBP for AC_risk. Conclusion: In men with obstructive respiratory disorder, increased AC measurement limited the thoracoabdominal expansibility and induced a rise of the DBP. Respiratory physiotherapy promotes an increase of cardiac modulation and inspiratory capacity for men with obstructive respiratory disorder.     

Effects of manually-assisted cough combined with postural drainage,saline instillation and airway suctioning in critically-ill patients during high-frequency oscillatory ventilation: a prospective observational single centre trial

Abstract

Background: Chest physiotherapy may aid sputum clearance during conventional ventilation. However, the role of chest physiotherapy during high-frequency oscillatory ventilation (HFOV) is unclear. This study aimed to determine the effects manually-assisted cough (MAC), postural drainage, saline instillation and airway suction during HFOV. Methods: This was an observational study of a chest physiotherapy intervention in adult critically ill patients during HFOV. Measures included gas exchange, HFOV and haemodynamic variables 1?h before, immediately before, and 15?min, 1?h, 6?h and 12?h after intervention. Wet weight of airway secretions was also measured. Linear mixed modelling compared pre-intervention gas exchange, HFOV and haemodynamic variables with the four specified time-points after intervention. Results: Seventeen adults (ten females) with moderate to severe respiratory failure were studied (age, 49 years SD 14; Acute Physiology and Chronic Health Evaluation II score (APACHE II score) 21 SD 6; PaO₂/FiO₂ of 139?mmHg SD 51). There was a statistically, although not clinically significant reduction in PaO₂/FiO₂ for up to 1?h after intervention, but no significant changes in oxygenation index, PaCO₂, pH, or haemodynamic parameters up to 12?h after intervention. A reduction in delta pressure (ΔP_aw) at 15?min (p?<?0.05) and 1?h (p?<?0.05) post intervention was not correlated with sputum wet weight. Conclusions: MAC, postural drainage, saline instillation and airway suctioning during HFOV in critically ill patients was well tolerated with no clinically significant effect on arterial blood gases or haemodynamics. ΔP_aw decreased for up to 1?h after intervention, but was not explained by the weight of sputum removed.     

Control of compensatory stepping reactions: Age-related impairment and the potential for remedial intervention

It is a commonly held assumption that retained airway mucus places the postoperative patient at greater risk of developing clinically significant atelectasis or pneumonia. This assumption is supported by this review of the available literature. However, not all postoperative patients are equally at risk of developing retained mucus. Factors such as the presence of pre-existing diseases, perioperative impairments to normal mucociliary clearance, and relative impairment of cough effectiveness increase the likelihood of retained mucus. As retained mucus can contribute to postoperative atelectasis and pneumonia, this would suggest a role for the promotion of airway clearance techniques in the selected patient. Questions exist, however, as to the efficacy of physiotherapy airway clearance techniques in the postoperative patient.     

The Measurement of Balance Post-Stroke. Part 3: Instrumented Measurement Tools

Abstract

The restoration of balance skills is an important aspect of stroke physiotherapy, but the lack of appropriate outcome measures has been identified as a factor hampering development of the evidence base. In recent years instrumented measurement tools such as those measuring postural sway have become popular for research and clinical use. A systematic review of ways to measure balance using instrumented measurement tools was undertaken. CINAHL, MEDLINE, and EMBASE databases were searched for tests which measured balance post-stroke and could be used in clinical settings. They were assessed for reliability, validity, sensitivity to change, suitability for use in clinical settings and with a wide range of stroke severity. Forty-three papers were identified. For clarity and ease of presentation, these were divided into tests of postural sway, weight distribution, and responses to external perturbations. All had some information about their psychometric properties but none had been comprehensively tested and none fulfilled the criteria for an outcome measure for stroke physiotherapy interventions. Platform measures of postural sway had limited reliability and validity as a measure of balance disability, while responses to external perturbations had been insufficiently tested. Measurement of weight distribution showed more promise however. Here, there was reasonable evidence of reliability and validity, the equipment was simple to use although it could be expensive and difficult to move, but simple 'low-tech' methods (for standing balance) have been suggested which merit further investigation.     

Effectiveness of physiotherapy for lateral epicondylitis: a systematic review

AIM: To evaluate the available evidence of the effectiveness of physiotherapy for lateral epicondylitis of the elbow. METHOD: Randomised controlled trials (RCTs) identified by a highly sensitive search strategy in six databases in combination with reference checking. Two independent reviewers selected RCTs that included a physiotherapy intervention, patients with lateral epicondylitis, and at least one clinically relevant outcome measure. No language restrictions were made. Methodological quality was independently assessed by two blinded reviewers. A best evidence synthesis, including a quantitative and qualitative analysis, was conducted, weighting the studies with respect to their internal validity, statistical significance, clinical relevance, and statistical power. RESULTS: 23 RCTs were included in the review, evaluating the effects of lasertherapy, ultrasound treatment, electrotherapy, and exercises and mobilisation techniques. Fourteen studies satisfied at least 50% of the internal validity criteria. Except for ultrasound, pooling of data from RCTs was not possible because of insufficient data, or clinical or statistical heterogeneity. The pooled estimate of the treatment effects of two studies on ultrasound compared to placebo ultrasound, showed statistically significant and clinically relevant differences in favour of ultrasound. There is insufficient evidence either to demonstrate benefit or lack of effect of lasertherapy, electrotherapy, exercises and mobilisation techniques for lateral epicondylitis. CONCLUSIONS: Despite the large number of studies, there is still insufficient evidence for most physiotherapy interventions for lateral epicondylitis due to contradicting results, insufficient power, and the low number of studies per intervention. Only for ultrasound, weak evidence for efficacy was found. More better designed, conducted and reported RCTs are needed.     

Use of questionnaire-based outcomes for the measurement of activities and participation in the physiotherapy management of hip osteoarthritis: a review

Abstract

Physiotherapy is an important management option in hip osteoarthritis. Its effectiveness can be evaluated with the use of valid and reliable outcome measures in research and clinical practice. Numerous outcome measures for use in hip osteoarthritis are available and the ICF classification can be used to guide decision making to ensure that all aspects of human functioning are represented. The activity and participation components of ICF are a vital part of assessment, but are traditionally under-utilised in physiotherapy. A number of questionnaire-based outcomes that measure activity and participation can be used in clinical or research practice with hip osteoarthritis patients such as The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lequense Index of Severity, Harris Hip Score (HHS), Arthritis Impact Measurement Scale (AIMS), Short Form-36 (SF-36) and European Quality of Life scale (Euroqol). These are discussed with particular reference to their psychometric properties of reliability, validity and responsiveness. To date, the WOMAC has undergone the most psychometric testing of the disease-specific measures, whilst the SF-36 is the most widely tested generic measure. Both of these measures are recommended for use in hip osteoarthritis. Further psychometric testing is required of the other measures which will enable clinicians and researchers to decide which is the most appropriate measure for use in hip osteoarthritis.     

Airway clearance: physiology, pharmacology, techniques, and practice

Clinicians and their patients are troubled by respiratory secretions, and standard practice calls for efforts to clear secretions from the lungs. On one hand, mucus production and cough are important for airway defense and protection of the lower respiratory tract against inhaled irritations. On the other hand, excessive mucus obstructs airways and excessive cough has been associated with a number of complications. The objective of this conference was to review the scientific basis and clinical evidence for the use of airway clearance therapy to guide the most appropriate approach to airway clearance. An international group of clinicians and scientists addressed the physiology of mucus production and cough, pharmacologic approaches to airway clearance, and the variety of techniques available for airway clearance. Specific issues related to airway clearance in critically ill patients, children, and the elderly were discussed. Outcome measures related to evaluating mucus clearance therapy were also presented. One of the themes repeated consistently throughout this conference was the dearth of high-level evidence related to airway clearance techniques. Appropriately powered and methodologically sound research is desperately needed in this area.     

Responsiveness of selected outcome measures of participation restriction and quality of life in patients with multiple sclerosis

Purpose: To evaluate the responsiveness of two outcome measures of participation restriction [as measured by the Community Integration Questionnaire (CIQ)] and quality of life [as measured by the Multiple Sclerosis Quality of Life (MSQOL)] following a physiotherapy intervention in patients with multiple sclerosis (MS). Method: A sample of 265 patients completed both instruments first at the time of initial visit and then after 4–6 weeks physiotherapy. In addition, patients were asked to complete the 7-point global rating scale as an external criterion of change at the post-intervention time. The responsiveness was evaluated using the receiver operating characteristics (ROC) method and the correlation analysis. Two useful statistics were area under the ROC curve (AUC) and the minimally clinically important difference (MCID). The AUC and correlation coefficient greater than 0.70 were considered as acceptable responsiveness. Results: The CIQ achieved the acceptable responsiveness with an AUC of 0.81. However, the AUCs of 0.61 and 0.66 were obtained for the MSQOL physical and mental, respectively. Moreover, good correlation coefficient was obtained for the CIQ (Gamma?=?0.76) while fair correlations of 0.28 and 0.33 were obtained for the MSQOL physical and mental, respectively. The MCIDs were approximately 0.50, 1.5 and 2.5 points for the CIQ, MSQOL physical and mental, respectively. Conclusions: In contrast to the MSQOL, the CIQ was responsive outcome measure in detecting changes in participation restriction of patients with MS. Moreover, the MCID values obtained in this study will help the clinicians and researchers to determine if a patient with MS has experienced a true change following physiotherapy intervention.

• Implications for Rehabilitation

• The results provide valuable information regarding to the ability of two outcome measures (i.e. the CIQ and MSQOL) to detect treatment effects in patients with MS.

• In contrast to the MSQOL, the CIQ is a responsive measure to changes in participation restriction due to physiotherapy.

• A patient with MS had to change at least 0.50 point on the CIQ, 1.5 points on the MSQOL physical and 2.5 points on the MSQOL mental to be judged as having clinically changed.

     

Respiratory exacerbations in children with cystic fibrosis: Physiotherapy treatment outcomes

Treatment efficacy is crucial in cystic fibrosis (CF) as it impacts directly upon life expectancy, with its evaluation contributing to the evidence base for physiotherapy practice. This study assesses whether respiratory outcomes changed at the Royal Children's Hospital, Brisbane (RCH) over a period when physiotherapy airways clearance techniques altered. All 1998 and 2000 admissions of children over two years of age to RCH for CF related respiratory exacerbations were included, totalling 248 admissions, 125 in 1998 and123 in 2000. Data for respiratory effort, cough quality, sputum volume/weight, sputum colour and sputum stickiness were analysed. Respiratory function test (RFT) results included: forced expiratory volume in one second (FEV₁), forced vital capacity (FVC) and forced expiratory flow (FEF_25–75%) and % of predicted values.

Repeated measures ANOVA and appropriate post hoc tests evaluated changes occurring during the admissions. Independent-samples t-tests allowed comparison of the improvement in the two years. During hospital admission in both 1998 and 2000, a significant improvement in RFT results occurred. Similar improvements in 1998 and 2000 suggested no change in treatment efficacy had occurred. Significant changes during hospitalisation, in cough quality, sputum volume/weight, and sputum colour suggest that these variables are appropriate and simple physiotherapy outcome measures.     

Emergency Endotracheal Intubation With a Rigid Stylet of an Infant With Severe Subglottic Stenosis

BackgroundSubglottic stenosis is a frequent complication of endotracheal intubation in children and can create a difficult airway situation for subsequent respiratory illnesses. Difficult airway algorithms are an essential aid when dealing with respiratory failure in clinical situations where ventilation or intubation is unsuccessful.Case ReportA 4-month-old infant with a history of previous endotracheal intubation required endotracheal intubation for stridor and respiratory failure due to croup. There was difficulty intubating the trachea due to severe subglottic stenosis that developed following the previous episode of endotracheal intubation. Successful intubation was facilitated by the use of a rigid endotracheal tube stylet to facilitate passage of an endotracheal tube through the stenotic segment.Why Should an Emergency Physician Be Aware of This?Difficult airway algorithms recommend the use of invasive airway access only as a last resort and noninvasive airway access should be explored prior to their use. The use of a readily available rigid stylet as an alternative method for tracheal intubation should be considered only after more conventional techniques and potential complications have been considered.     

An outcome audit for musculoskeletal patients in primary care

Use of accepted validated measures by physiotherapists to monitor the outcomes of their treatment interventions is not widespread. There is limited published data on the outcomes of physiotherapy intervention or the length of treatment episodes in physiotherapy. One objective of this study was to audit outcome measures at the beginning and end of an episode of physiotherapy care for musculoskeletal patients. A second objective was to evaluate the effectives of the introduction of evidence-based guidelines for the management of musculoskeletal problems. A retrospective review of 1,713 consecutive patients with a range of spinal and extremity problems was used. These patients were referred by General Practitioners (GPs) and seen in primary care. An audit was conducted during normal clinical practice using the Roland-Morris back function questionnaire, the Neck Disability Index, the Croft Shoulder scale, and the Lower Extremity Functional Scale as outcome tools. Patients who were unable to complete the outcome tools were excluded from this study, as were patients with elbow and hand conditions, as no suitable outcome tool for these patients was found. At the start of an episode of physiotherapy the patient was asked to complete a self-report measure of pain (0-10) and function (%). At discharge the patient was asked to complete the same measures. Changes in pain and function were documented as a record of outcome. Before and after data on pain and/or function was available for 914 (53.4%) patients. They had predominantly back (37.7%), neck (22.7%), shoulder (14%), and knee (13%) problems. Most patients' (75%) problems were managed with exercise and advice in an average of four sessions. There was a mean improvement of 3.2 on the pain visual analogue scale and a 20% improvement in function. Audit of outcome using valid and reliable tools is feasible in clinical practice, but substantial subject attrition occurred. Most patients achieved significant and clinically important improvements in pain and function with relatively few treatment episodes.     

A Systematic Review of Methods to Measure Balance and Walking Post-Stroke. Part 1: Ordinal Scales

Abstract

The rehabilitation of balance and walking is a cornerstone of stroke physiotherapy and our main interest is to assess the effectiveness of physiotherapy interventions. We therefore reviewed the literature to seek outcome measures which would be suitable for such a purpose. This article is limited to ordinal scales. CINAHL, Medline and Embase databases were searched for measurement tools which measured balance and/or walking post-stroke and could be used in clinical settings. They were assessed for reliability, validity, sensitivity to change, scale development, suitability for use in clinical settings and with a wide range of stroke severity. Twenty-six measurement tools were identified. All had some information about their psychometric properties but few had been rigorously tested. They were generally reliable and valid, but sensitivity to change was poor or untested and few showed a true hierarchy. None of the measurement tools fulfilled all the assessment criteria.     

After-hours respiratory physiotherapy for intubated and mechanically ventilated patients with community-acquired pneumonia: An Australian perspective.

Introduction

Community acquired pneumonia (CAP) is a common reason for admission to an intensive care unit for intubation and mechanical ventilation, and results in high morbidity and mortality. The primary aim of the study was to investigate availability and provision of respiratory physiotherapy, outside of normal business hours, for intubated and mechanically ventilated adults with CAP in Australian hospitals.

The effect of core stability training with ball and balloon exercise on respiratory variables in chronic non-specific low back pain: An experimental study

BackgroundStudies have shown the involvement of respiratory characteristics and their relationship with impairments in non-specific low back pain (NS-LBP). The effects of core stability with a combined ball and balloon exercise (CBB) on respiratory variables had not been investigated.ObjectiveTo evaluate the effectiveness of CBB on respiratory variables among NS-LBP patients.Study designpre- and post-experimental study.ParticipantsForty participants were assigned to an experimental group (EG) [n = 20] and control group (CG) [n = 20] based on the study criteria.InterventionsThe EG received CBB together with routine physiotherapy and the CG received routine physiotherapy over a period of 8 weeks. Participants were instructed to carry out the exercises for 3 days per week. The training was evaluated once a week and the exercises progressed based on the level of pain. Outcome measures: Primary outcomes were maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP) and maximum voluntary ventilation (MVV). The secondary outcomes were measured in the numeric rating scale (NRS), total faulty breathing scale (TFBS), cloth tape measure (CTM) and lumbo-pelvic stability. Results: The MIP increased significantly among the EG when compared with that in the CG (p > 0.05).The EG showed a significant increase in MVV (p = 0.04) when compared to the CG (p = 0.0001). There was a significant reduction in pain for both groups. The MEP, TFBS, chest expansion and core stability showed no changes in either group. Conclusion: CBB was effective in improving respiratory variables among NS-LBP patients.     

Ineffective airway clearance in adult patients after thoracic and upper abdominal surgery

AimThe aim of this study is to analyze the accuracy of the defining characteristics of ineffective airway clearance (IAC) in patients after thoracic and upper abdominal surgery.BackgroundAlthough numerous studies have described the most prevalent respiratory NANDA-I diagnoses, only few investigates the precision of nursing assessments.MethodsA cross-sectional study was conducted with 192 patients in a surgical clinic. Accuracy measures were obtained by the latent class analysis method.ResultsIAC was present in 46.73% of the sample. The defining characteristics with better predictive capacity were changes in respiratory rate and changes in respiratory rhythm. However, other defining characteristics also had high specificity, such as restlessness, cyanosis, excessive sputum, wide-eyed, orthopnea, adventitious breathing sounds, ineffective cough, and difficulty vocalizing.ConclusionResults can contribute to the improvement of nursing assessments by providing information about the key clinical indicators of IAC.