Fisioterapia respiratoria con cinturones de vibración en el paciente crítico COVID-19 en posición de prono

Sancho, P.T.; Gandarias, P.A.; González, R.S.; Gurumeta, A.A.
doi:10.1016/j.redar.2020.06.014
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">La situaci&#243;n actual de la pandemia ha incrementado exponencialmente la necesidad de ventilaci&#243;n mec&#225;nica invasiva en los pacientes que presentan un s&#237;ndrome de distr&#233;s respiratorio agudo&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Cuando los objetivos de protecci&#243;n pulmonar y oxigenaci&#243;n no se consiguen&#44; se ventila al paciente en dec&#250;bito prono<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> para mejorar la ventilaci&#243;n&#47;perfusi&#243;n de los alveolos&#46; El da&#241;o pulmonar y del epitelio alveolar provocados por la infecci&#243;n&#44; junto a la reacci&#243;n inmunol&#243;gica y la tormenta de citoquinas&#44; aumentan las secreciones alveolares impidiendo un correcto intercambio gaseoso en los alveolos no da&#241;ados&#46; Existe un riesgo incrementado de atelectasias severas secundarias a la producci&#243;n de tapones de moco que obstruyen por completo la luz bronquial&#46; En la literatura&#44; se describen diferentes t&#233;cnicas de fisioterapia respiratoria manual que pueden ser empleadas en casos de distr&#233;s respiratorio&#46; En el caso de la pandemia por COVID-19 se debe garantizar el mejor tratamiento para el paciente minimizando los riesgos de exposici&#243;n y contacto con los pacientes en las zonas contaminadas&#44; reduciendo el n&#250;mero de personas que atienden al enfermo al m&#237;nimo imprescindible&#46; Con este objetivo&#44; presentamos una serie de casos de pacientes con neumon&#237;a y ventilaci&#243;n mec&#225;nica invasiva sometidos a movilizaci&#243;n de secreciones con un sistema de cintur&#243;n vibratorio aut&#243;nomo&#44; durante posici&#243;n de prono&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Nuestro objetivo era conocer si pudiese existir una mejor&#237;a en la relaci&#243;n de la presi&#243;n arterial de ox&#237;geno&#44; con la fracci&#243;n inspirada de ox&#237;geno aportada por el respirador &#40;PAO<span class="elsevierStyleInf">2</span>&#47;FIO<span class="elsevierStyleInf">2</span>&#41;&#46; Se realizaron tres mediciones de PAO<span class="elsevierStyleInf">2</span>&#47;FIO<span class="elsevierStyleInf">2</span>&#58; PAO<span class="elsevierStyleInf">2</span>&#47;FIO<span class="elsevierStyleInf">2</span> en supino&#44; PAO<span class="elsevierStyleInf">2</span>&#47;FIO<span class="elsevierStyleInf">2</span> tras dos horas en prono y PAO<span class="elsevierStyleInf">2</span>&#47;FIO<span class="elsevierStyleInf">2</span> en prono tras la realizaci&#243;n de fisioterapia respiratoria con cintur&#243;n vibratorio aut&#243;nomo&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Se autoriz&#243; uso compasivo por parte de la Comisi&#243;n de Investigaci&#243;n del hospital&#44; y se obtuvo la autorizaci&#243;n y consentimiento informado de la familia de forma verbal y telef&#243;nica&#46; Se utiliz&#243; un cintur&#243;n vibratorio est&#225;ndar &#40;Innovagoods&#44; modelo Sauna effect&#44; 2019&#44; Valencia&#44; Espa&#241;a&#41;&#44; que dispone de varias velocidades de frecuencias vibratorias&#44; siendo la utilizada la de menor frecuencia &#40;equivalente a 8 hz&#41; y sin calor&#46; Esta vibraci&#243;n m&#237;nima es similar a la de los cinturones de torso completos<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#44;3</span></a> que se utilizan ya desde hace a&#241;os&#46; El cintur&#243;n de fisioterapia se coloc&#243; en la parte posterior e inferior del t&#243;rax&#44; para favorecer la movilizaci&#243;n de secreciones de las zonas de mayor dec&#250;bito&#44; donde se acumulan con mayor frecuencia<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4&#44;5</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">El cintur&#243;n adem&#225;s dispone de dos extensiones laterales de tela que permiten su fijaci&#243;n para que no se mueva durante su utilizaci&#243;n&#46; Las extensiones de tela se utilizan s&#243;lo para sujetar el cintur&#243;n sin realizar tensi&#243;n sobre el paciente&#44; para evitar lesiones por presi&#243;n&#46; Se procedi&#243; a la colocaci&#243;n del dispositivo en la parte inferior y posterior del t&#243;rax con paciente en dec&#250;bito prono&#44; habiendo transcurrido dos horas desde el inicio del prono&#46; Se realizaron tres sesiones de fisioterapia pulmonar de 15 minutos&#44; cada una con el cintur&#243;n vibratorio al m&#237;nimo nivel de vibraci&#243;n y sin calor local&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Cada sesi&#243;n de fisioterapia de 15 minutos era separada de las siguiente por una hora de descanso&#46; Tras finalizar las tres sesiones y transcurridas cuatro horas desde el inicio de la fisioterapia respiratoria&#44; se realiz&#243; la medici&#243;n de PAO<span class="elsevierStyleInf">2</span>&#47;FIO<span class="elsevierStyleInf">2</span>&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Fueron estudiados 10 pacientes coincidiendo con el inicio de la posici&#243;n en prono&#44; en un total de 15 pronaciones&#44; observando mejor&#237;a en 12 de las mismas &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; La PAO<span class="elsevierStyleInf">2</span>&#47;FIO<span class="elsevierStyleInf">2</span> media en supino fue de 114&#46;86 &#40;17&#44;25&#41;&#44; en prono de 144&#46;73 &#40;36&#44;04&#41; y en prono m&#225;s fisioterapia de 162&#46;66 &#40;35&#44;57&#41;&#46; Se observ&#243; una mejor&#237;a de la PAO<span class="elsevierStyleInf">2</span>&#47;FIO<span class="elsevierStyleInf">2</span> en la mayor&#237;a de las intervenciones de fisioterapia respiratoria&#44; especialmente en aquellos pacientes con respuesta a la posici&#243;n de prono&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">El cambio de posici&#243;n de supino a prono puede facilitar una mejor&#237;a en la PAO<span class="elsevierStyleInf">2</span>&#47;FIO<span class="elsevierStyleInf">2</span> por el cambio de la ventilaci&#243;n perfusi&#243;n pulmonar y la movilizaci&#243;n de las secreciones&#46; Facilitar la movilizaci&#243;n y expulsi&#243;n de secreciones con sistemas mec&#225;nicos podr&#237;a disminuir las atelectasias pulmonares&#44; facilitar la ventilaci&#243;n de los alveolos&#44; evitando la obstrucci&#243;n de los bronquiolos por tapones de moco y mejorando la PAO<span class="elsevierStyleInf">2</span>&#47;FIO<span class="elsevierStyleInf">2</span>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Se precisan m&#225;s estudios para poder confirmar las ventajas del uso de fisioterapia respiratoria con cinturones de vibraci&#243;n aut&#243;nomos en el paciente cr&#237;tico con infecci&#243;n COVID-19 con ventilaci&#243;n mec&#225;nica en posici&#243;n de prono &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span>"
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          "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Aspecto de la colocaci&#243;n definitiva del cintur&#243;n vibratorio aut&#243;nomo en los pacientes cr&#237;ticos con infecci&#243;n por COVID-19 en dec&#250;bito prono&#46;</p>"
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paciente 7 prono 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">130&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">136&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">109&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paciente 8 prono 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">104&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">132&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paciente 9 prono 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">178&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">148&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paciente 9 prono 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">149&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">175&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Paciente 10 prono 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">146&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">182&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Media PAO<span class="elsevierStyleInf">2</span>&#47;FIO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">114&#46;86 &#40;17&#44;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">144&#46;73 &#40;36&#44;04&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">162&#46;66 &#40;35&#44;57&#41;&nbsp;\t\t\t\t\t\t\n
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