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Analysis of Symptoms, Clinical Signs and Oxygen Support in Patients with Bronchiolitis Before and After Chest Physiotherapy During Hospitalization

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Analysis of Symptoms, Clinical Signs and Oxygen Support in Patients with Bronchiolitis Before and After Chest Physiotherapy During Hospitalization Artigo Original Análise dos sintomas, sinais clínicos e suporte de oxigênio em pacientes com bronquiolite antes e após fisioterapia respiratória durante a internação hospitalar Analysis of symptoms, clinical signs and oxygen support in patients with bronchiolitis before and after chest physiotherapy during hospitalization Giselle de Castro1, Renata Remondini2, Adriana Zamprônio dos Santos3, Cristiane do Prado4 RESUMO monar com ruídos adventícios (p<0,001), estertores subcre- pitantes (p=0,017) e sibilos (p=0,010), tiragens de modo Objetivo: Avaliar os efeitos da fisioterapia em pacientes geral (p<0,001), tiragem intercostal (p<0,001) e classificação pediátricos, internados com bronquiolite. da gravidade pelo escore de Downes (p<0,001). Também Métodos: O estudo incluiu 29 pacientes menores de um ano, foi observada melhora significativa em todos os aspectos com diagnóstico médico de bronquiolite aguda, sem cardiopatia avaliados no questionário (p<0,001). congênita não corrigida, neuropatia, doença pulmonar de base Conclusões: A fisioterapia respiratória promoveu uma ou que necessitassem de suporte ventilatório, no período de melhora significante em curto prazo das condições clínicas março a julho de 2009. Foi avaliada, por meio de questionário, dos pacientes com bronquiolite aguda. a opinião dos pais ou responsáveis acerca das condições clínicas do paciente antes e após a primeira sessão de fisioterapia. Foram Palavras-chave: bronquiolite; serviço hospitalar de realizadas manobras de desobstrução brônquica, como drenagem fisioterapia; pediatria. postural, tapotagem, vibração, aceleração de fluxo expiratório e aspiração nasotraqueal. A avaliação foi realizada diariamente por ABSTRACT meio de exame físico antes do atendimento fisioterapêutico e 15 a 45 minutos após, seguindo uma ficha específica. Os desfechos Objective: To evaluate the effects of chest physiotherapy analisados foram: modificações do suporte de oxigênio, sinais in hospitalized patients with bronchiolitis. clínicos (ausculta pulmonar, presença de tiragens, oxigenação Methods: The study included 29 patients younger than e classificação da gravidade pelo escore de Downes) e sintomas one year, diagnosed with acute bronchiolitis, without uncor- (inapetência, hipoatividade, dificuldade para dormir, obstrução rected congenital heart disease, neuropathy, lung pathology nasal e tosse constante). or need of mechanical ventilation, from March to July 2009. Resultados: Dos 29 pacientes avaliados, houve melhora The opinion of the parents or guardians was evaluated using significativa nos seguintes sinais e sintomas: ausculta pul- a questionnaire about the clinical condition of the patient Instituição: Departamento Materno-Infantil do Hospital Israelita Albert Endereço para correspondência: Einstein (HIAE), São Paulo, SP, Brasil Renata Remondini 1Especialista em Fisioterapia Respiratória Pediátrica pelo Instituto da Crian- Rua Inácio, 380 – Vila Zelina ça do Hospital das Clínicas da Faculdade de Medicina da Universidade CEP 03142-000 – São Paulo/SP de São Paulo (USP); Fisioterapeuta do Departamento Materno-Infantil do E-mail: [email protected] HIAE, São Paulo, SP, Brasil 2Especialista em Fisioterapia Cardiorrespiratória pelo Instituto do Coração Conflito de interesse: nada a declarar do Hospital das Clínicas da Faculdade de Medicina da USP; Fisioterapeuta do Departamento Materno-Infantil do HIAE, São Paulo, SP, Brasil Recebido em: 28/9/2010 3Especialista em Fisioterapia Respiratória pela Universidade Adventista Aprovado em: 4/4/2011 de São Paulo (Unasp); Fisioterapeuta do Departamento Materno-Infantil do HIAE, São Paulo, SP, Brasil 4Especialista em Fisioterapia Respiratória e Fisiologia do Exercício pela Universidade Federal de São Paulo (Unifesp); Coordenadora do Serviço de Fisioterapia do Departamento Materno-Infantil do HIAE, São Paulo, SP, Brasil Rev Paul Pediatr 2011;29(4):599-605. Análise dos sintomas, sinais clínicos e suporte de oxigênio em pacientes com bronquiolite antes e após fisioterapia respiratória durante a internação hospitalar before and after the first session of chest physiotherapy. O tratamento da bronquiolite aguda ainda é controverso. Airway clearance techniques, such as postural drainage, A terapêutica inclui hidratação, oxigenação, fisioterapia manual percussion, vibration, acceleration of expiratory flow respiratória e medicamentos, como broncodilatadores, adre- and tracheal suction were applied. The evaluation was per- nalina, mucolíticos e corticoide inalatório(1,6,7). A fisioterapia formed daily by physical examination prior to physiotherapy respiratória tem sido utilizada em pacientes com bronquiolite and 15 to 45 minutes later, following a specific form. The aguda com os objetivos de desobstrução brônquica, desinsu- outcomes observed were: changes of oxygen support, clini- flação pulmonar e recrutamento alveolar, por meio de diversas cal signs (pulmonary auscultation, presence of retractions, técnicas, como posicionamento, aumento do fluxo expirató- oxygenation and severity classification by Downes score) and rio (AFE), vibração manual, tapotagem e aspiração das vias symptoms (difficulty in sleeping and in feeding, decreased aéreas(8,9). Em três estudos foram relatados efeitos benéficos activities, nasal obstruction and constant cough). dessas técnicas em pacientes com bronquiolite aguda(1,2). Results: Among the 29 patients evaluated, a significant Crianças hospitalizadas por bronquiolite apresentam um improvement was noticed in the following signs and symp- risco elevado de sequela pulmonar, caracterizada principal- toms: pulmonary auscultation with adventitious sounds – mente por tosse e sibilância recorrente, podendo acarretar general (p<0.001), rales (p=0.017) and wheezes (p=0.010); um maior número de visitas em pronto-atendimento e, até retractions – general (p<0.001) and intercostal retraction mesmo, reinternações(4). Alguns autores não indicam a fisiote- (p<0.001); severity of Downes Score (p<0.001). A significant rapia respiratória na fase aguda da bronquiolite devido ao fato improvement was also noted in all aspects evaluated in the de as manobras de higiene brônquica causarem agitação na questionnaire (p<0.001). criança, aumentando, assim, a hipoxemia e, eventualmente, Conclusions: Chest physiotherapy lead to a significant o broncoespasmo(10,11). Há até relato de fratura de costelas short term improvement in infants with bronchiolitis. devido à intensidade das manobras de higiene brônquica(12). Já outros autores acreditam que a fisioterapia respiratória seja Key-words: bronchiolitis; physical therapy department, benéfica por promover diminuição do tempo de internação hospital; pediatrics. hospitalar e evitar a necessidade de suporte ventilatório(2,7). É importante analisar a intervenção fisioterapêutica em Introdução lactentes com bronquiolite, utilizando técnicas adequadas de acordo com a idade e a colaboração do paciente durante o atendi- A bronquiolite aguda é uma das doenças mais frequentes mento. As orientações são fundamentais para uma boa evolução do sistema ventilatório e acomete neonatos, lactentes e crian- durante a instalação do quadro em relação ao posicionamento ças até os três anos de idade, com predominância nos seis adequado e estimulação para eliminar as secreções. Dessa forma, primeiros meses de vida, afetando mais os recém-nascidos faz-se necessário investigar os efeitos da fisioterapia respiratória prematuros, e leva, em muitos casos, à necessidade de in- em pacientes com bronquiolite aguda. O presente estudo teve ternação hospitalar. Possui característica sazonal, ocorrendo como objetivo avaliar os efeitos da fisioterapia respiratória em epidemicamente nos meses de outono e inverno. As infecções recém-nascidos e lactentes com diagnóstico de bronquiolite respiratórias agudas são importantes causas de morbimorta- aguda durante a internação hospitalar antes e após a intervenção lidade, particularmente nos países em desenvolvimento(1-3). fisioterapêutica de AFE, tapotagem, vibração manual, aspiração A bronquiolite aguda pode ser caracterizada por diversas nasotraqueal e posicionamento. Os desfechos analisados foram manifestações clínicas, como coriza, febre, tosse e sibilância(4). as modificações dos parâmetros cardiorrespiratórios (suporte de A radiografia de tórax é caracterizada por hiperinsuflação, in- oxigênio, ausculta pulmonar, presença de tiragens, saturação filtrados grosseiros e preenchimento peribrônquico(1). Algumas periférica de oxigênio e escore de Downes) e identificação das escalas podem avaliar a gravidade da bronquiolite apor meio opiniões dos pais ou responsáveis quanto à fisioterapia. da análise de variáveis clínicas, como a escala Wood-Downes modificada por Ferres, a qual caracteriza a doença em leve (1 a Método 3 pontos), moderada (4 a 7 pontos) ou grave (8 a 14 pontos). Os itens analisados (sibilos, tiragem, frequência respiratória, fre- Neste estudo, foram avaliados recém-nascidos e lactentes quência cardíaca, ventilação e cianose) recebem pontuações de 0 com diagnóstico de bronquiolite aguda, internados na ala a 3, dependendo da presença e da intensidade dos mesmos(5). pediátrica, semi-intensiva pediátrica e Unidade de Terapia 600 Rev Paul Pediatr 2011;29(4):599-605. Giselle de Castro et al Intensiva Pediátrica (UTIP) de um hospital particular, no pe- comparação entre sinais e sintomas nos instantes pré e pós ríodo de março a julho de 2009. Foram selecionados pacientes foi realizada utilizando modelos de equações de estimação com idade até um ano, de ambos os sexos e com diagnóstico
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