Bronquiectasia e fisioterapia desobstrutiva: ênfase em drenagem postural e postural e a percussão são efetivas na mobilização da secreção pulmonar, uma . NAC. rtousp () Limpeza brônquica na portadores de bronquiectasia, atendidosno Laboratóriode Fisioterapia Respiratória do. Primera página del artículo de sobre bronquiectasias. y no están tan habituados al empleo de la fisioterapia respiratoria como tratamiento. na. De todos ellos, el análisis multivariado determinó que la presencia de obstrucción.
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ABSTRACT Bronchiectasis consists bronquiectwsia abnormal, permanent and irreversible dilation of bronchi and bronchia, bronqiiectasia recurrent infections, inflammation, hypersecretion and reduction of mucus clearance.
It predominantly affects women of between 28 and 48 years old and more frequently affects the inferior lobes. Clinical manifestations are chronic cough, fever and voluminous expectoration, with a fetid odor. The etiology fisiotterapia unspecific and is considered the final stage of diverse pathological processes.
It can be classified in cylindrical, varicose and cystic, and also in respect to located and whether it affects multiple segments.
Postural drainage and chest clapping are commonly used clearence however, fisioterxpia are few published comparative population studies or reviews of techniques.
In this context, this study aimed at evaluating the efficaciouness of postural drainage and chest clapping on bronchus clearence in bronchiectasis patients and to compare the effects and associations of these techniques with others reported in the literature. Recent research reported that postural drainage and chest clapping are effective therapies fisloterapia mobilize pulmonary secretions as they increase the velocity of mucus transportion, improving pulmonary function and gas exchange.
This requires the assistance of a professional, which can make the necessary daily treatment difficult. For this reason physiotherapists have been choosing techniques that bronquiectwsia more independence to patients. Keywords Respiratory tract diseases. Online Submission Register here Advanced Search. The affected airways become flaccid and tortuous with obstructions and fibrosis .
However, due to the emergence of preventative programs in developed countries, the number of hospitalizations for bronchiectasis has dropped over the last few decades, with high prevalence and incidence only in under-developed countries [4,5]. Gomes Neto et al. The physiopathology consists of colonization of microorganisms and in the interaction of several enzymes and chemical mediators that cause inflammatory reactions and destruction of the bronchial tree; there is infiltration of neutrophils in the tissue that reduce the frequency of ciliary beats, resulting in impairment of the mucociliary transport and consequent bronchial obstruction [1,4].
Bronchiectasis most frequently involves both the lower lobes; when the involvement is unilateral it affects the terminal bronchi and bronchia and is more frequently seen on the fisioterxpia and in the lingula and medial lobe.
Clinical manifestations of the disease include chronic cough, fever and purulent voluminous expectoration with a fetid odor . Hypersecretion of the airways predominates in the morning or with changes in position, the patients can present with hemoptysis, weight loss, lack of appetite, halitosis, lethargy and prostration.
Hypertrophic accessory musculature, dyspnea, thoracic pain, fatigue, pulmonary auscultation with fisiotearpia stertor crackles and wheezes are observed during the physical examination, [5,7]. Bronquiechasia the evolution of the disease, there is a reduction in the expiration volume and vital capacity, the pulmonary tissue becomes retracted with pleural adherences; the bronchiectasic segments present with purulent secretions; the mucous membrane become swollen and ulcerated and the tissue of the mucociliary lining becomes cubic [1,5].
The etiology bronquiecyasia bronchiectasis is non-specific, represented as the final stage of several pathologic processes .
The majority of cases have idiopathic causes and, to a lesser degree, a congenital cause, with deficiencies in the elements of the bronchial wall and the cilia . Other causes include infections, obstructions, inhalation and aspiration of ammonia, gastric aspiration, alcoholism, heroin use, allergies, rheumatologic and neurological diseases, non-specific low respiratory function after infections, cystic fibrosis and primary immunodeficiency [5,8].
Moreover, bronchiectasis is frequently seen in patients with acquired immunodeficiency virus . In Brazil, the main causes are viral or bacterial respiratory infections during childhood as well as tuberculosis . Bronchiectasis is classified in cylindrical, varicose and saccate and in focal or multiple segmental. The cylindrical form is characterized by homogenous dilation but maintains its form and communication with the distal parenchyma .
The varicose form, on the other hand, presents with greater dilation, local constrictions and an irregular format; the most severe form is represented by the saccate form, with rounded dilations and the absence of communication with the pulmonary parenchyma . The clinical history and radiological and computed tomography findings enable diagnosis [2,8]. Bronchography in isolation assesses the extent of the disease and verifies if there is a necessity for surgery.
After establishing the existence of the disease and discarding the hypothesis of surgery, conservative treatment is initiated  which includes bronchodilator drugs, mucolytic agents, corticoids and antibiotics, as well as hyper-dehydration and bronchoaspiration .
Among the resources utilized for bronchial clearance, postural drainage with percussion have been the subject of few studies, except when they are associated to other techniques, with the exception of the study by Van der Schans et al. Pryor  stressed the efficiency of the maneuvers of forced expiration and Caromano et al. Finally, McIlwaine et al. Fink  added that in the clinical practice, percussion with postural drainage is effective in the transportation of pulmonary secretions improving the well-being of the patient.
Bronchiectasis: diagnostic and therapeutic features A study of patients
Van der Schans et al. OBJECTIVE To verify the efficacy of postural drainage with percussion on the bronchial hygiene of bronchiectasic patients in recent studies as well as the effect on associations with other techniques. POSTURAL DRAINAGE Postural drainage consists in bronquiecttasia gravitational forces from the positioning of the patient so as to increase the transportation of mucous from lobes and specific sections of the lungs brpnquiectasia the direction of the central airways, where the secretions should be removed more rapidly through coughing and aspiration [12,15].
Fink  reported that nine of twelve possible positions are required to drain all the areas of the lungs. The patient should remain for three to fifteen minutes in each position, giving a minimum amount of time of one hour at a frequency of three to four times per day. Effects of postural drainage have been investigated using pulmonary function tests and analysis of the arterial gases.
This technique has been scientifically proven to be relevant in the bronchial hygiene of patients suffering from cystic fibrosis and bronchiectasis . Langenderfer  added, following the data of the American Association for Respiratory Carethat the contraindications of the ‘Trendelenburg’ position are: This procedure promotes the mobilization of the secretions by means of vibrations  and is performed with the patient in varying drainage positions .
Thoracic percussion also increases the intrathoracic bronquiectaaia and hypoxemia, with the latter being unimportant when the technique is used for periods of less than 30 seconds and combined with three or four lung expansion exercises .
The contraindications, according to the American Association of Respiratory Careas reported by Fink  include pulmonary tuberculosis, tumoral resection from the thorax or neck, pulmonary contusion and coagulopathies.
Langenderfer  added to these quoting Murphy et al fisiotreapia However, today they are associated with other techniques [11,14]. The efficacy of percussion and postural drainage requires the assistance of a professional, which can make the daily use of therapy difficult . For this reason, in some countries, physiotherapists have utilized techniques that facilitate application and thus independence of the patient .
New physiotherapeutic techniques appeared including the Flutter device, autogenic drainage, forced expiration technique, active cycle, expiratory positive pressure therapy and intrapulmonary percussive ventilation [3,11,12,14]. Reviews of publications and field studies emerged due to the apparent necessity of research on the cost-benefits of physiotherapeutic procedures of bronchial hygiene for bronchiectasis .
For Pryor , the forced expiration maneuvers suggest more efficacious techniques of bronchial clearance for patients with chronic obstructive pulmonary disease. Nevertheless, there are no application protocols that prove their efficiency in the maintenance or the improvement of pulmonary function in patients with cystic fibrosis or bronchiectasis. The physiotherapeutic sessions lasted one hour, with inhalation of saline solution associated with postural drainage in the lateral decubitus fisiiterapia, vibrocompression and active-assisted mobilization of fixioterapia thorax.
From these results, the authors concluded that respiratory physiotherapy by means of bronchial hygiene was efficacious without imposing an excessive physical load. Postural drainage, percussion, vibration, shaking, cough and forced expiration techniques were utilized. The presented beneficial effects fisioterapai an increase in the expectoration and pulmonary clearance; however, statistically significant effects in the pulmonary function variables or differences between the use of manual and mechanical techniques were not observed.
Ten patients were submitted to alternate sessions of the Flutter VRP1 device and postural drainage, percussion and vibration with two sessions weekly for four weeks. The mean quantity expectorated in the two programs did not give a statistically significant difference. The authors concluded that such techniques are equally efficacious in the removal of secretions from patients with bronchiectasis. Analyzing the results, they observed a greater impact on the health of the patients that utilized Flutter, reflected in the number of hospitalizations and in fisioteralia pulmonary function.
Moreover, the final positive expiratory pressure stabilized or improved the pulmonary function, a result that had already been demonstrated in another study in by the same authors, who compared the positive expiratory pressure with postural drainage and percussion with the former being more efficacious. Physiotherapeutic interventions and clinical manifestations of the disease reflect in the psychological and social aspects of the patient, as despite of guaranteeing an improvement in the bronchial brknquiectasia transportation, the disease can have negative effects such as dependence on interventions by a professional and the necessity of making therapy every day.
On the other hand, further studies are necessary the identify physiotherapeutic protocols, their duration, repetitions, frequency, number of professionals involved, description of the selected techniques and the cost-benefit ratio for the patient [12,17]. The respiratory physiotherapeutic treatment makes conventional clearance techniques, such as postural drainage and percussion, available.
These techniques are efficacious in preventing bronchial mucous retention. Several studies indicate that postural drainage with percussion is efficacious in bronchial hygiene. However, there are few studies that show the association of these techniques, even though they are commonly used in clinical practice. There is evidence of their efficacy due to the increased velocity of mucous transportation, the gas exchange and improvement in the pulmonary function.
Nevertheless, the final positive expiratory pressure technique provides a significantly greater improvement in the pulmonary function when fieioterapia to postural drainage with percussion. Other procedures are also utilized such as the Flutter device, autogenic drainage, the positive expiratory pressure technique, forced expiration techniques and intrapulmonary percussive ventilation. The techniques require care in their application and some are performed independently such as Flutter, autogenic drainage and the positive expiratory pressure technique and others not, such as postural drainage, percussion, intrapulmonary percussive ventilation and vibrocompression.
The majority of the published studies do not show significant differences in the results when comparing the efficacy of the clearance techniques, suggesting that the most comfortable technique and the one that has less social compromise should be utilized for the patient. In the literature, only one study, published by Van der Schans et al. In the works by Caromano et al. The lack of comparative studies on postural drainage with percussion, that detail the populational sample and methodological resources, make a discussion of the results and the utilization of the physiotherapeutic resources difficult.
Thus, there is an apparent need for further studies comparing conventional clearance techniques in particular in respect to bronchiectasis. Long-term comparative trial of positive expiratory pressure versus oscillating positive expiratory pressure flutter physiotherapy in the treatment of cystic flsioterapia. Curr Opin Infect Dis. Jamnik S, Santoro IL.
Bronquiectasia localizada e multissegmentar: Bronquiectasias en la infancia. Bronquiectasias en pacientes HIV positivos.
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Buenos Aires ;59 1: Cinesioterapia em piscina na bronquiectasia: Alternatives to percussion and postural drainage: Physiotherapy and bronchial mucus transport. Physiotherapy for airway clearance in adults. Jones A, Rowe BH. Bronchopulmonary hygiene physical therapy in bronquiectasis and chronic obstructive disease: Positioning versus postural drainage. A bronquiectxsia of the therapeutic effectiveness of and preference for postural drainage and percussion, intrapulmonary percussive ventilation, and bronquiectaxia chest wall compression in hospitalized cystic fibrosis patients.
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