5. Mobilisasi dini dan aktivitas fisik
Mobilisasi dini: mengatasi deconditioning
syndrome
Asesmen :
• Kerjasama pasien
• Kardiorespirasi
• Kekuatan otot
• Mobilitas sendi
• Status fungsional
(sebelumnya)
4
6. Mobilisasi dini dan aktivitas fisik
• Prinsip
– Segera (pasif bila belum stabil)
– Bertahap
– Aktif + agresif u/ Px stabil
(hemodinamik, neurologis, metabolik, respirasi)
• Pemberian modalitas (peresepan) disesuaikan
dengan kondisi pasien
1. Kondisi kritis – akut, non kooperatif
2. Kondisi stabil dan ko-operatif, ETT [+]
5
7. Mobilisasi dini dan aktivitas fisik
1. Kondisi kritis – akut, non kooperatif
– Proper positioning
– Upright position & roll over q2h (mika-miki)
– PROM exercise
– Muscle stretching
– Passive cycling
– Stimulasi elektrik (NMES)
• (kontraksi otot involunter beban kardiorespirasi minimal)
2. Kondisi stabil dan kooperatif, ETT [+]
– Mobilisasi di samping tempat tidur – kursi
– AROM exercise (AA, A, R)
– Active cycling (bed/chair cycle)
– Walk w/wo assistance
6
10. PROM exc + Stretching
Menjaga ROM
Mencegah atrofi (Str.) + DVT
Mencegah drop foot
Passive cycling
Early application of daily bedside (initially passive) leg cycling in critically ill
patients showed improved functional status, muscle function and exercise
performance at hospital discharge compared to patients receiving standard
therapeutic exercise without leg cycling. RCT.
Burtin C, Clerckx B, Robbeets C, Ferdinande P, Langer D, Troosters T, et al.
Early exercise in critically ill patients enhances short-term functional recovery.
Crit Care Med 2009;37:2499-505.
9
11. MOBILISASI TAHAP MOBILISASI
Memperbaiki 1. Transfer di tempat tidur
(MiKa-MiKi,
• ventilasi/perfusi geser ↑↓, duduk
sentral – perifer, bertahap)
• sirkulasi, 2. duduk ongkang-ongkang
• metabolisme 3. berpindah dari tempat
tidur ke kursi
• Alertness
4. Dst …. (bangsal)
Alat bantu
Standing - Tilting tables
Mobilisasi dini mengurangi lama perawatan di ICU dan LOS di RS
1. Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, et al.
Early intensive care unit mobility therapy in the treatment of acute respiratory failure. Crit Care Med 2008;36:2238-43.
2. Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, et al.
Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet
2009;373:1874-82. 10
14. Kondisi Pernafasan
Chest–PT gol:
1. membersihkan sekresi jalan nafas
– mengurangi kerja otot pernafasan
2. meningkatkan kekuatan otot inspirasi
– peningkatan kapasitas paru
– mempercepat pernafasan spontan
• Terapi latihan otot inspirasi pre op <i angka
komplikasi pasca operasi pasca bedah thorak
• Mobilisasi dini + posisi tegak
>>> volume paru & mencegah komplikasi pasca
bedah abdomen 13
15. N =60 (36 control :24 interv.)
Durasi pemasangan ventilator
minimal 48 jam
14
16. Chest therapy : WEANING fokus
1. kontrol pernapasan
2. penguatan otot inspirasi
3. latihan batuk efektif
Latihan diberikan small-frequent
(beban ringan, waktu pendek, jangan
sampai lelah)
→ umumnya 5-10 menit; 2-4 sesi latihan/hari
17. Weaning
Inspiratory muscle training (IMT) + Threshold
loading kekuatan otot inspirasi
mempercepat weaning
“IMT 2x5’ 30% PImax PImax &
durasi weaning”
Cader SA, Vale RG, Castro JC, Bacelar SC, Biehl C, Gomes MC, et al.
Inspiratory muscle training improves maximal inspiratory pressure and
may assist weaning in older intubated patients: a randomised trial. J
Physiother 2010;56:171-7.
16
18. Bila sudah lepas ETT, dapat diberikan peresepan latihan
mandiri dengan :
incentive spirometry
flutter / acapella (oscillating)
“MENCEGAH RE-INTUBASI”
19. PATHWAYS AND TREATMENT MODALITIES FOR INCREASING AIRWAY
CLEARANCE.
PEP=positive expiratory pressure
CPAP=continuous positive airway pressure
HFO=high frequency oscillation
IPV=intrapulmonary percussive ventilation
NIV=non- invasive ventilation
18
21. Take Home Message
• Penanganan tim rehabilitasi medik ditujukan
pada deconditioning syndrome & kondisi
pernafasan
• Mobilisasi dini & chest Th. merupakan EBM dan
harus diberikan pada pasien penyakit kritis
menyesuaikan pada “kondisi umum, komorbiditas
& kerjasama pasien”
• Pasien tidak stabil dapat diberikan latihan secara
pasif dan chest therapy dengan monitor ketat
sebelum, selama, dan sesudah latihan
• Chest therapy merupakan latihan utama pada
pasien dengan ventilator mekanik
20
23. ‘Start to move’ – protocol Leuven:
step-up approach for progressive mobilization and physical activity program.
22
24. ‘start to move’ - protocol leuven: step-up approach of progressive mo- bilisation and physical activity program
1s5Q: response to 5 standardized questions for cooperation:
open and close your eyes
look at me
open your mouth and stick out your tongue
shake yes and no (nod your head)
I will count to 5, frown your eyebrows afterwards
2:FAIls= atleast1riskfactorpresent
3 : if basic assessment failed, decrease to level 0
4 : safety: each activity should be deferred if severe adverse events (cv., resp. and subject. intolerance) occur
during the intervention
mRC (medical Research Council) muscle strength sum scale(0-60) BBs: Berg Balance score
sIttIng to stAndIng
4 able to stand without using hands and stabilize independently 3 able to stand independently using hands
2 able to stand using hands after several tries 1 needs minimal aid to stand or stabilize
0 needs moderate or maximal assist to stand
stAndIng unsuPPoRted
4 able to stand safely for 2 minutes
3 able to stand 2 minutes with supervision
2 able to stand 30 seconds unsupported 1needsseveraltriestostand30secondsunsupported 0 unable to stand
30 seconds unsupported
sIttIng wItH BACK unsuPPoRted But Feet suPPoRted on FlooR oR on A stool
4 able to sit safely and securely for 2 minutes
3 able to sit 2 minutes under supervision
2 able to able to sit 30 seconds
1 able to sit 10 seconds
0 unable to sit without support 10 seconds 23
25. “prevent pulmonary atelectasis,
re-expand collapsed alveoli,
improve oxygenation,
improve lung compliance,
and facilitate movement of airway secretions
towards the central airways”
24
26. Tanpa alat:
-Positioning/alih baring
-Chest therapy pasif, kolaborasi
dengan inhalasi dan suction (bila perlu)
-Ankle pumping dan ankle stretch
-Latihan LGS
-Pertahankan posisi tegak di luar latihan
(≥30o)
Alat Sederhana:
Full Support / -Chest vibrator
Control Ventilator -NMES pocket
-Elastic bandage
Canggih:
-NMES
-CPM untuk gerakan sendi
- Rotational bed
-Pneumatic compression /
compression stocking
-Tilting table (pendampingan)
27. Tanpa Alat:
-Positioning / alih baring / rotasi trunk 45o
-Chest therapy pasif / aktif asistif
kolaborasi dengan inhalasi dan suction
-Assistive breathing
-Ankle pumping dan ankle stretch
Assist Support -Latihan LGS
Setting: -Pertahankan posisi tegak di luar latihan
-Volume Control (≥30o)
-Pressure Control
-Dual mode
Alat Sederhana:
-Chest vibrator
Canggih: -NMES pocket
- NMES -Elastic bandage
-CPM untuk gerakan sendi
-Rotational bed
-Pneumatic compression /
compression stocking
-Tilting table (pendampingan)
28. Tanpa alat:
-Fokus pada breathing exercise
(penguatan inspirasi) dan kontrol
breathing
-Positioning/alih baring/rotasi trunk 45o
-Chest therapy aktif asistif / aktif
kolaborasi dengan inhalasi dan suction,
fasilitasi batuk / batuk efektif
CPAP atau Spontan -Ankle pumping dan ankle stretch
dengan PEEP -Latihan LGS
-Mobilisasi aktif duduk berdiri
-Pertahankan posisi tegak di luar latihan
(≥30o)
Alat Sederhana:
-Chest vibrator
Canggih -NMES pocket
-NMES -Elastic bandage
-Pneumatic compression / -Theraband exercise dan dumble untuk
compression stocking Upper Extremity training
-Tilting table (pendampingan) -Walker untuk alat bantu berdiri dan
jalan
29. Tanpa alat:
-Fokus pada peningkatan kemampuan
bernapas dalam dan kontrol breathing
-Chest therapy dan fasilitasi batuk
efektif / mandiri
-Mobilisasi di tingkatkan, ambulasi
sekitar bed dengan / tanpa bantuan
Alat Sederhana:
-Chest vibrator
-NMES pocket
-Elastic bandage
T Piece
-Theraband exercise dan dumble
untuk Upper Extremity training
-Walker untuk alat bantu berdiri dan
jalan
Canggih:
-NMES
-Pneumatic compression /compression
stocking
-Tilting table (pendampingan)
30. Tanpa alat:
-Latihan inspirasi dalam dan PLB,
kontrol breathing
-Chest therapy dan fasilitasi batuk
efektif / mandiri
-Tingkatkan mobilisasi aktif dan
ambulasi
Extubasi
Alat Sederhana:
-Chest vibrator dan nebuliser
-Insentive spirometri (latihan
inspirasi)
-Elastic bandage
Canggih: -Theraband exercise dan dumble
-Acapella (bila perlu, untuk untuk Upper Extremity training
membantu pengeluaran -Walker untuk alat bantu berdiri
sputum) dan jalan
-Postural drainage bed
-Static bike
-Pneumatic compression /
compression stocking
-Tilting table (pendampingan)
Editor's Notes
ROM cegah edema
Resistive muscle training can include the use of pulleys, elastic bands and weight belts. The chair cycle and the earlier mentioned bed cycle allow patients to perform an individualized exercise training program
Figure 5 increasing airway clearance. Interventions aimed at increasing inspiratory volume (deep breathing exercises, mobilization and body positioning) lung expansion, increase regional ventilation, reduce airway resistance and optimize pulmonary compliance. Interventions aimed at increasing expiratory flow include forced expirations, such as huffing and coughing. Manually- assisted cough, using thoracic or abdominal compression may be indicated for patients with expiratory muscle weakness or fatigue
MHI involves a manual slow deep inspiration with a resuscitator bag, an inspiratory hold of 2-3 seconds [52], followed by a quick release of the bag to enhance expiratory flow and mimic a forced expiration. MHI might have important negative side-effects. First, MHI can precipitate marked hemodynamic changes associated with a decreased cardiac output, which result from large fluctuations in intra-thoracic pressure [53]. Second, MHI can also increase intracranial pressure which might have implications for patients with brain injury. This increase is, however, usually limited, so that cerebral perfusion pressure remains stable [54]. A pressure of 40 cm H2O has been recommended as an upper limit. Airway suctioning may have detrimental side effects (bronchial lesions, hypoxaemia), but reassurance, sedation, and pre- oxygenation of the patient may minimize these effects [57]. Suctioning can be performed via an in-line closed suctioning system or an open system. The in-line system increased the costs, but did not decrease the incidence of ventilator-associated pneumonia (VAP) nor the duration of mechanical ventilation, length of ICU stay or mortality [58]. Closed suctioning may be less effective than open suctioning for secretion clearance during pressure support ventilation [59]. The routine instillation of normal saline during airway suctioning has potential adverse effects on oxygen saturation and cardiovascular stability, and variable results in terms of increasing sputum yield [60]. Chest wall compression prior to endotracheal suctioning did not improve airway secretion removal, oxygenation, or ventilation after endotracheal suctioning in an unselected population of mechanically ventilated patients [61]. VAP is a common complication in mechanically ventilated patients and is associated with higher mortality rates, prolonged hospitalization, and high medical costs [62]. Studies have shown that avoidance of intubation by NIV reduces the incidence of nosocomial pneumonia in a subgroup of patients [63,64]. Physiotherapy including manual hyperinflation, positioning plus suctioning showed no differences in VAP versus suctioning alone [65]. Yet, in contrast, another study reported a lower incidence of VAP (8% vs 39%) in the group receiving physiotherapy [66]. However, the duration of mechanical ventilation, length of ICU stay and mortality did not differ between the groups. The addition of physiotherapy in a population of ventilated patients for various reasons of respiratory insufficiency was associated with prolongation of mechanical ventilation [67].