XXXI Diada Peumològica • Taula 2: Procediments en el segle XXI, de les “recomanacions” a l’evidència. CLAPPING: NECESSITA AIRE FRESC? Ricard Castro Prat (Universitat de Vic) Sitges, abril 2013 17/04/2013 CLAPPING: NECESSITA AIRE FRESC? “The evidence for passive techniques such as postural drainage and percussion is low.” 17/04/2013 2 CLAPPING: NECESSITA AIRE FRESC? “… routine use […] is not indicated in the treatment of stable outpatients with COPD and moderate amounts of sputm production.” “It seems […] alone is insufficient to evacuate excess mucus.” “Therapists should consider active mucus evacuation techniques instead.” 17/04/2013 3 CLAPPING: NECESSITA AIRE FRESC? “Studies that provide solid evidence of the effectiveness of different airway clearance techniques in patients with COPD are rather scarce” 17/04/2013 4 CLAPPING: NECESSITA AIRE FRESC? 17/04/2013 5 CLAPPING: NECESSITA AIRE FRESC? 17/04/2013 6 CLAPPING: NECESSITA AIRE FRESC? Les percussions thoraciques manuelles (PTM) “Les vibrations appliquées au thorax, et les percussions communément nommées clapping occupent une place anecdotique. Ces techniques ne font pas l'unanimité ....” “Les PTM n'ont fait l'objet d'aucun travail de validation en utilisation isolée alors qu'elles sont largement utilisées et diffusées dans les pays anglo-saxons où elles sont associées avec d'autres techniques sous le vocable de chest physiotherapy, dans la rubrique de la physiothérapie conventionnelle. “… elles ont toutefois des contre-indications locales et générales àrespecter . “ “Si action il y a, les PTM seraient plus efficaces chez les patients ayant des sécrétions volumineuses, proximales.” “Elles semblent également utiles comme moyen de stimuler la toux.“ “…ne peuvent être envisagées comme seul moyen de drainage bronchique. “ “Des études méthodologiquement acceptables sont nécessaires pour apprécier de façon plus précise àla fois les mécanismes d'action et l'efficacité. “ 17/04/2013 7 CLAPPING: NECESSITA AIRE FRESC? “Il nous apparaît que les PTM, lorsqu’elles sont associées au drainage de posture, ont une certaine efficcité chez des grands sécrétants. Par contre, leur effet semble nul voire négatif, chez des sujets peu sécrétants.” “Les PTM seraient un complément aux autres techiniques. Mais l’efficacité en tant techniques isolée reste à démostrer.” “… , utilisées seules, ne semblent pas une technique performante.” 17/04/2013 8 CLAPPING: NECESSITA AIRE FRESC? 17/04/2013 9 CLAPPING: NECESSITA AIRE FRESC? Percussion and vibration PMT and mechanical chest percussion will increase intrathoracic pressure, but the relationship between this increase in pressure and airway clearance is yet to be determined. CAMPBELL and WOLLMER demonstrated an increase in airflow obstruction when chest clapping was included in an airway clearance regimen, but other studies have not shown any increase. Chest clapping has also been shown to cause an increase in hypoxaemia, but, when short periods of chest clapping (<30 s) have been combined with three or four thoracic expansion exercises, no fall in oxygen saturation has been seen. Some patients with severe lung disease demonstrate oxygen desaturation with self chest clapping. This may be due to the work of the additional upper limb activity. 17/04/2013 10 CLAPPING: NECESSITA AIRE FRESC? Percussion and vibration In patients with neuromuscular weakness or paralysis and in those who are intellectually impaired, in addition to in infants and in small children, chest clapping or mechanical percussion may be a useful airway clearance technique; coughing is stimulated, possibly by the mobilization of secretions. GALLON reviewed the literature on manual chest percussion and THOMAS that on mechanical percussors. They concluded that there is a physiological rationale and a place for the use of percussion, but that the clinical evidence is inconclusive. 17/04/2013 11 CLAPPING: NECESSITA AIRE FRESC? 17/04/2013 12 CLAPPING: NECESSITA AIRE FRESC? 34 estudis. Curta durada. Pocs pacients. Qualitat metod. pobre. CPT on Sputum Mass. CPT on FEV1 CPT on Radio. Aeros. CPT on Atelectasis. CPT on Hospital Stay Ch Per on Sputum Mass 17/04/2013 13 CLAPPING: NECESSITA AIRE FRESC? The effect of percussion was reported in 10 studies. Because of the poor methodological quality of these studies and the failure of most to report a treatment, it is concluded that there is insufficient evidence to support a benefit from the use of percussion as a technique to improve secretion clearance. Moreover, there is no benefit from the use of mechanical percussion versus manual percussion. 17/04/2013 14 CLAPPING: NECESSITA AIRE FRESC? There is no role for routine use of CPT in hospitalized patients. The effect of CPT on long-term outcomes and quality of life in patients with chronic diseases such as CF is unknown. There is little evidence of benefit from chest percussion and vibration, compared to postural drainage alone. The evidence for improved secretion clearance with postural drainage is weak; there is insufficient evidence to support or not support the use of this therapy. CPT has the potential to harm some patients under some conditions. 17/04/2013 15 CLAPPING: NECESSITA AIRE FRESC? 17/04/2013 16 CLAPPING: NECESSITA AIRE FRESC? 17/04/2013 17 CLAPPING: NECESSITA AIRE FRESC? Chest Percussion Chest Clapping physiotherapy Chest wall oscillation 17/04/2013 18 CLAPPING: NECESSITA AIRE FRESC? 1 17/04/2013 19 CLAPPING: NECESSITA AIRE FRESC? 1 17/04/2013 20 CLAPPING: NECESSITA AIRE FRESC? 17/04/2013 21 CLAPPING: NECESSITA AIRE FRESC? 17 17/04/2013 22 CLAPPING: NECESSITA AIRE FRESC? 12 5 17/04/2013 23 CLAPPING: NECESSITA AIRE FRESC? 2 0 17/04/2013 24 CLAPPING: NECESSITA AIRE FRESC? 4 1 17/04/2013 25 CLAPPING: NECESSITA AIRE FRESC? 17/04/2013 26 CLAPPING: NECESSITA AIRE FRESC? 3 1 17/04/2013 27 CLAPPING: NECESSITA AIRE FRESC? 3 0 17/04/2013 28 CLAPPING: NECESSITA AIRE FRESC? 17/04/2013 29 CLAPPING: NECESSITA AIRE FRESC? 5 2 17/04/2013 30 CLAPPING: NECESSITA AIRE FRESC? 3 17/04/2013 31 CLAPPING: NECESSITA AIRE FRESC? 7 0 17/04/2013 32 CLAPPING: NECESSITA AIRE FRESC? 1 0 17/04/2013 33 CLAPPING: NECESSITA AIRE FRESC? 56 28 Bhowmik, A., Chahal, K., Austin, G., & Chakravorty, I. (2009). Improving mucociliary clearance in chronic obstructive pulmonary disease. 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WITHDRAWN: Bronchopulmonary hygiene physical therapy for chronic obstructive pulmonary disease and bronchiectasis. Cochrane Database of Systematic Reviews (Online), (7) 17/04/2013 34 CLAPPING: NECESSITA AIRE FRESC? Langer, D., Hendriks, E., Burtin, C., Probst, V., van der Schans, C., Paterson, W., . Troosters, T. (2009). A clinical practice guideline for physiotherapists treating patients with chronic obstructive pulmonary disease based on a systematic review of available evidence. Clinical Rehabilitation, 23(5), 445-462. Lewis, L. K., Williams, M. T., & Olds, T. S. (2012). The active cycle of breathing technique: A systematic review and meta-analysis. Respiratory Medicine, 106(2), 155-172. doi:10.1016/j.rmed.2011.10.014 Main, E., Prasad, A., & Schans, C. (2005). Conventional chest physiotherapy compared to other airway clearance techniques for cystic fibrosis. Cochrane Database of Systematic Reviews (Online), (1) Marks, J. H. (2007). Airway clearance devices in cystic fibrosis. 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