Intensive physiotherapic respiratory care in critically ill patients with tracheostomy after cardiac surgery

Abstract

IntroduzioneNella nostra esperienza, in Riabilitazione Cardiologica, il paziente cardioperato è sempre più anziano e portatore di comorbilità neurologiche, vascolari, ortopediche e, soprattutto, respiratorie.La degenza in Terapia Intensiva Post Chirurgica (TIPO) a seguito dell'intervento cardiochirurgico è costellata da numerose complicanze e caratterizzata da prolungato uso di ventilazione meccanica con necessità di confezionamento di tracheostomia percutanea.La gestione in Riabilitazione Cardiologica del paziente cardioperato, pluricomplicato, tracheostomizzato comporta un continuo adeguamento dell'approccio riabilitativo.In letteratura sono presenti numerosi lavori riguardanti l'intervento riabilitativo respiratorio in pazienti postchirurgici [1][2][3][4][5] e numerosi studi descrivono il quadro del paziente portatore di cannula tracheostomica [6-9] ma scarsi sono i lavori che incrociano i due argomenti.Di fronte all'obiettivo, quindi, di riportare il paziente al più alto livello possibile di capacità funzionale in considerazione della sua situazione globale, si evidenzia la necessità di trovare un approccio riabilitativo più specifico e personalizzato. Intervento riabilitativo fisioterapico intensivo in pazienti cardioperati pluricomplicati tracheostomizzatiIntensive physiotherapic respiratory care in critically ill patients with tracheostomy after cardiac surgery Most of these patients, when transferred to our Intensive Cardiac Rehabilitation Unit, still have a percutaneous tracheostomy due to respiratory mechanical dysfunction.The aim of our work is to present new rehabilitative care strategies in such compromised patients.Methods and materials. We studied 27 elderly critically ill tracheostomized patients who were split into 2 Groups (A = 11 and B = 16). The Groups were homogeneous for age and for left ventricular ejection fraction.Group A received a standard treatment including cautious mobilisation and respiratory unspecific physiotherapy.Group B received an earlier and more aggressive treatment with a specific respiratory physiotherapy including Positive Expiration Pressure (PEP) directly connected to the tracheostomy cannula.A protocol for tracheostomy decannulation by assessment of the Peak Expiratory Flow during cough (PCEF≥ 180 L/min.) has been defined in order to verify the patients ability to develop a mechanically effective cough to obtain weaning from tracheostomy. Besides, in the patients of Group B, we carried out a screening of the swallowing dysfunction.Results. Four patients of Group A deceased while in Group B there were no deaths. Furthermore patients of Group B showed a statistically significant improvement of mobility and respiratory indexes.In Group B only one patient was discharged with tracheostomy cannula in site because he did not reach standard criteria for decannulation and his PCEF value was not satisfactory. This patient underwent percutaneous gastrostomy.Conclusions. A precocious and intensive rehabilitation, based on specific respiratory physiotherapy, significantly improves...