Nezavisle, ale synergisticke systemy!!

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1 Mechanical insufflation/exsufflation (MI/E) Michal Rosicky, MD., Anestesi och Intensivvårdavdelning Kungälv Sjukhus Sverige

2 Transportni mechanizmy sekretu z DC Mukociliarni aparat Mobilizace sekretu z distalnich DC COPD, nikotinismus, CF, Kasel Mobilizace sekretu ci cizich predmetu ze sliznice DC, prevazujici vyznam predevsim od urovne strednich DC NMD, SCI, trauma, kachexie, Nezavisle, ale synergisticke systemy!!

3 Kasel: (pato)fyziologicke aspekty Iniciovan volne i mimovolne Za fyziologickych podminek neni nezbytny pro efektivni clearance DC (mukociliarni clearance) Nezbytny za patologickych podminek Podminky pro efektivni kasel: Funkcni glottis Intaktni CNS centra (medulla oblongata) Pruchodne DC Inspiracni objem 2,5l (TLC) Intaktni expiracni svaly Vysoke intrathorakalni tlaky (max. az 200cm H2O!!) Normalni CPF 6-12l/sec ( l/min) 620l/min)

4 Kasel: fyziologicke faze (adapted from

5 Priciny neefektivniho/abnormalniho cyklu kasle Neschopnost dostatecne hlubokeho nadechu Snizena schopnost (vykonnost) interkostalnich/abdominalnich abdominalnich svalu dosahnout pozadovaneho intrathorakalniho tlaku Nedostatecna funkce (ovladani, koordinace) glottis Centralni priciny Klinicke stavy (onemocneni): Hrudni, plicni trauma, pooperacni stavy (bolest) SCI (poraneni krcni michy/patere) Vrozene deformity Restriktivni, obstruktivni poruchy Neuromuskularni onemocneni Tracheostomie

6 Klinicke strategie pri potizich s mobilizaci sekretu z DC Adekvatni bilance tekutin Nutricni podpora, prevence kachexie, Fyzicka aktivita Kineziterapie, dechova gymnastika, Radne zvlhceni Mukolytika CPAP? Asistovany kasel CoughAssist "... chest vibration techniques, no matter how effective in mobilizing peripheral secretions, will not result in their expulsion without an effective cough flow." - Bach JR. Eur Respir J. 2003; 21:

7 Mechanical in/exsufflation Mechanical in/exsufflation MI/E Assisted coughing CoughAssist (Respironics, Philips) Lung Volume recruitment with CoughAssist Hostapparat??

8 Mechanical in/exsufflation, (CoughAssist ) Princip: prohloubene asistovane inspirium k docileni optimalni expanze plic nasledovane rychlym expiriem pri asistovanem podtlaku pro zvyseni a prodlouzeni expiracniho peak-flow

9 Mechanical in/exsufflation, (CoughAssist ): terminologie 1 cyklus (cykle): insuflace/exsuflace 1 aplikace (treatment): 3-5 cyklu (cykles) 1 serie (session): 3-5 aplikaci (treatments)

10 Indikace MI/E (CoughAssist ) Indikace Redukovany Peak Cough Flow (pcf) <270 lpm nezbytny k optimalni bronchialni toalete za ruznych patologickych (fyziologickych) podminek Maximalni vyvinuty expiracni tlak <60 cm H20 Klinicke efekty CoughAssist Uvolnuje sekret z distalnich casti plice Redukuje vyskyt plicnich infekci Bezpecna metoda, noninvazivni, doplnek (alternativa) k odsavani Dobra compliance pacienta Jednoducha aplikace pro zdravotnicky personal (laiky)

11 Indikace MI/E (CoughAssist ) Pacienti s infekci dolnich cest dychacich Restriktivni poruchy Obstruktivni poruchy Pooperacni stavy cetnosti odsavani dyskomfortu u odsavani cetnosti TS u pacientu s NIV Neuromuskularni poruchy ALS,SMA, GB, MS, Muskularni dystrofie Poraneni michy Myastenia gravis respiracnich infektu rehospitalizace cetnosti TS u pacientu s NIV kvality zivota

12 MI/E, CoughAssist : Clinical references American Thoracic Society (ATS) clinical practice guidelines strongly recommend CoughAssist to prevent respiratory complications in patients with neuromuscular disease. - Bach JR. Eur Respir J. 2003; 21: Cough augmentation with mechanical insufflation/exsufflation produces a significant increase in peak cough flow and facilitates airway secretion clearance in neuromuscular disorders. It has been reported to be successful in avoiding hospitalizations, pneumonias, episodes of respiratory failure, and tracheotomy for patients with Duchenne muscular dystrophy, spinal muscular atrophy, and ALS." - Winck JC, et al. Chest. 2004;126: "In addition to the medical benefits of enhanced airway clearance, the importance of the psychological benefits to patients with NMD should be considered as well." - Miske LJ, et al. Chest. 2004; 125:

13 Mechanical in/exsufflation Kontraindikace Pneumothorax Pokrocila faze COPD, bulozni emfysem, Barotrauma ICP ARDS/ALI Akutni plicni edem Porucha vedomi, neschopnost efektivni komunikace, Warning: Pacienti se znamou obehovou (kardialni) insuficienci: vhodna monitorace behem aplikace MI/E (SpO2, EKG) Jakakoli bolest na hrudniku ci dyspnoe: prerusit MI/E, klinicka diagnostika a prehodnoceni indikace MI/E, CF, bronchiektazie: muze provokovat kolaps ochable, patologicky zmenene steny DC,

14 MI/E, CoughAssist : klinicka aplikace Provedeni: Volba interface Volba rezimu Volba ( kalibrace ) pracovnich tlaku Automaticky rezim: nastaveni T- in/exsufl., T-pause Aplikace MI/E cyklu Odstraneni viditelneho sekretu Pauza cca 30-60sec. Volba rezimu T-insuflace T-exsuflace T-pause On/Off Manometr Manualni ovladani in/exsuflace P-insuflace Flow-insuflace Nastaveni P-in/exsuflace Typicke nastaveni: P-insufl cm H2O, T-insufl. 2-3sec P-exsufl cm H2O, T-exsufl. 2-3sec

15 MI/E, CoughAssist : interface

16 MI/E, CoughAssist : klinicke tipy a triky Priprava pacienta Dostatek casu pri prvni aplikaci, vysvetlit metodu, zkouska masky (interface) pacientem (personalem) Opora pro pacientovu hlavu Smluvit si signaly, komunikaci behem aplikace, Zkouska na necisto (reakce na vzduch, pretlak, podtlak) Interface Kvalitni maska, zkouska tesnosti Tracheostomie: nafoukla tesnici manzeta, adapter pro kolekci sekretu, Naustek: nosni klip, Provedeni Inicialne zkusit co nejnizsi tlak (15cm H2O), nicmene vetsina pacientu vyzaduje 30-40cm H2O, OBS: prilis nizke pracovni tlaky snizuji efektivitu Udrzet max. nadech cca 1-2sec. Manualni rezim pri zahajeni terapie Manualni komprese hrudniku pri vydechu (exsuflaci) Recruitment po ukonceni aplikace LungmedKlin/CoughAssist%20kliniska%20tips.doc

17 MI/E, CoughAssist Souhrn: Bezpecna noninvazivni metoda, vhodna pro home- care Dobra compliance pacienta i personalu User-friendly pristroj Optimalni mobilizace sekretu z distalnich casti DC Doplnuje (i zcela nahrazuje) klasicke odsavani u nekterych onemocneni Prokazana efektivita: kvality zivota, rehospitalizace, pneumonie, (NMD) Cost-effective (USA, Sverige)

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