胸部物理治疗和肺康复

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1、 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 一、胸部物理治疗一、胸部物理治疗基本概念基本概念又称支气管卫生疗法（Bronchial hygiene t

2、herapy，BHT）或胸部生理疗法（Chest physiotherapy）是用物理方法来预防或改善气道分泌物的淤滞，从而防止或逆转其所导致的病理过程的治疗方法。T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 胸部物理治疗在国外已开展30余年；20世纪70年代初期呼吸理疗还处在初级阶段，其概念也仅在于基本的翻身、拍背、吸痰等；80年代呼吸理疗在功能和服务领域不断扩大；90年代呼吸理疗更趋于完善，已

3、发展为医院中不可缺少的一个重要部门物理治疗部门。二、二、CPTCPT发展史发展史 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 三、三、CPTCPT目的目的-Why is it-Why is it important important T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,An

4、d nodding by the fire,take down this book 四、四、CPTCPT适应症适应症IndicationIndication T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book CPTCPT相对禁忌症相对禁忌症-Caution-Caution T I T L E H E R E T I T L E H E R EWhen you are old and grey and

5、full of sleep,And nodding by the fire,take down this book 五、CPTCPT方法方法-Way-Way T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 气道净化治疗原理松动痰液松动痰液促进咳痰促进咳痰体位引流体位引流改改良良技技术术胸部扣拍与振胸部扣拍与振动动高频胸壁振动高频胸壁振动呼气末正压呼气末正压肺内叩击通气肺内叩击通气气道内振动气道内振动

6、经经典典技技术术经经典典技技术术指指导导性性咳咳嗽嗽改改良良技技术术用力呼吸技术用力呼吸技术主动呼吸周期主动呼吸周期自然引流自然引流机械性呼气机械性呼气 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fi

7、re,take down this book 活动训练活动训练被动活动被动活动主动活动主动活动 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 缩唇呼吸缩唇呼吸（Pursed-Lip Breathing）患者闭嘴经鼻吸气，然后通过缩唇（吹口哨样口型）缓慢呼气45秒，缩唇大小以患者舒适为准，呼气时可伴有或不伴有腹肌收缩。T I T L E H E R E T I T L E H E R EWhen y

8、ou are old and grey and full of sleep,And nodding by the fire,take down this book 控制性深呼吸控制性深呼吸 （Controlled Deep Breathing）训练患者控制呼吸的频率、深度和部位，有意识地进行慢而深的呼吸，呼吸频率减慢，吸气容量增加，还有意识地控制吸气、呼气时间的长短和吸呼比，在吸气末停顿13秒再行呼吸 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the

9、 fire,take down this book 用以克服患者的浅快呼吸，使原来闭合的基底部气道开放，延长呼气时间消除肺内气体陷闭，尤其适用于焦虑、紧张的患者，有利于肺部分泌物的排出，改善V/Q比。T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 腹式呼吸锻炼（腹式呼吸锻炼（Diaphragmatic Breathing）吸气：吸气：腹部松弛、膈肌收缩、下胸部稍抬起呼气呼气:腹肌收缩、膈肌松弛、下胸

10、部回位，以呼出最大潮气量 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 气道净化治疗气道净化治疗体位引流体位引流 根据气管、支气管的解剖特点，借助重力的作用促使各肺叶、肺段的痰液排出，适用于各种支气管-肺疾病，伴有大量脓痰者。T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodd

11、ing by the fire,take down this book 右上叶尖段右上叶尖段 半坐卧位：在床或引流平台上，半坐卧位：在床或引流平台上，病人背靠枕头角度为病人背靠枕头角度为30-6030-60度度 右上叶后段右上叶后段左斜俯卧位：右前胸距床面左斜俯卧位：右前胸距床面4545度，左侧度，左侧垫高或将床脚抬高垫高或将床脚抬高 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 右上叶前段右上叶

12、前段仰卧位：右侧后背仰卧位：右侧后背垫高垫高3030度度 左上叶尖后段：左上叶尖后段：端坐位：上身略向前、向右倾斜端坐位：上身略向前、向右倾斜 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 左上叶前段左上叶前段仰卧位：左侧后背仰卧位：左侧后背垫高垫高3030度度 左上叶上舌段、下舌段左上叶上舌段、下舌段 仰卧位：左侧后背垫高仰卧位：左侧后背垫高4545度，右侧垫高或度，右侧垫高或将床脚抬高将床脚抬

13、高 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 右中叶外侧段、内侧段右中叶外侧段、内侧段 仰卧位：右后背垫高仰卧位：右后背垫高4545度度 后面观后面观两侧下叶背段两侧下叶背段 膝胸位或俯卧位：胸部垫高或膝胸位或俯卧位：胸部垫高或将床脚抬高将床脚抬高 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of

14、sleep,And nodding by the fire,take down this book 右下叶内基底段右下叶内基底段 斜仰卧位：左背距床面斜仰卧位：左背距床面30-6030-60度，抬度，抬高床脚高床脚 右下叶前基底段右下叶前基底段 仰卧位：右臀部垫高或将床脚抬高仰卧位：右臀部垫高或将床脚抬高 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 两侧下叶侧基底段两侧下叶侧基底段 健侧卧位：健

15、侧腰部垫高，或将床脚健侧卧位：健侧腰部垫高，或将床脚抬高抬高 两侧下叶后基底段两侧下叶后基底段 膝胸位或俯卧位：下腹部垫高或将膝胸位或俯卧位：下腹部垫高或将床脚抬高床脚抬高 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 1.不宜在餐前、餐后1-2小时（胃潴留）防止呕吐、误吸；2.5-10min/次，2-3次/d3.夜间分泌物容易潴留，故在清晨醒后行体位引流效果最好注意事项注意事项 T I T L

16、E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 气道净化技术气道净化技术胸部扣拍胸部扣拍 扣拍是将手掌微曲(弓形手)，五指并拢，以腕部为支点，以惯性摇动手掌叩击病变部位或用机械扣拍器在吸气或呼气时叩击患者胸壁，频率约35次/分钟，一般认为叩拍力可通过胸壁传送到气道，将支气管壁上的分泌物松解。T I T L E H E R E T I T L E H E R EWhen you are old and grey an

17、d full of sleep,And nodding by the fire,take down this book 正确的叩击会产生一个空且深的声音;避开胸骨、脊椎、肝、肾、乳房等位置;拍背前应告知患者，使患者有心里准备.T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 气道净化技术气道净化技术振动振动 T I T L E H E R E T I T L E H E R EWhen you are

18、 old and grey and full of sleep,And nodding by the fire,take down this book 适用于成人体位性引流的叩击头适用于成人体位性引流的叩击头适用于老年人、儿童适用于老年人、儿童 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 特定型特定型 T I T L E H E R E T I T L E H E R EWhen you are

19、 old and grey and full of sleep,And nodding by the fire,take down this book 振动排痰仪使用注意事项振动排痰仪使用注意事项 避免交叉感染治疗前雾化吸入治疗每日23次 准备好吸痰设备 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 指导性咳嗽技术指导性咳嗽技术（directed cough，DC）一般采取的体位是低坐位，双肩放松

20、，头及上体稍前倾前屈，双臂可支撑在膝上，以放松腹部肌肉利于其收缩。然后指导患者以腹式呼吸深吸气，屏气一段时间后在身心放松下突然开放声门、运用腹肌的有力收缩将痰液咳出。T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 用力呼气技术（用力呼气技术（Forced Expiration Forced Expiration TechniqueTechnique，FETFET）在正常吸气后 -口与声门保持张开 -

21、收缩腹肌和肋间外肌用力呼气 -用力地发出无声的“哈”（这样可使患者在 呼气时尽可能维持较低的胸内压以避免较小气道的塌陷，因此适用于COPD患者）清除痰液 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 主动呼吸周期主动呼吸周期（Active Cycle Of Breathing）实际上综合了用力呼气、胸廓扩张运动和呼吸控制三种技术 T I T L E H E R E T I T L E H E R

22、EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 自然引流自然引流（autogenic drainage，AD）通过患者应用不同肺容通过患者应用不同肺容积的膈式呼吸和呼气气积的膈式呼吸和呼气气流来移动分泌物的一种流来移动分泌物的一种痰液引流方式，其目的痰液引流方式，其目的在于增大呼气流速。为在于增大呼气流速。为取得最佳疗效，患者需取得最佳疗效，患者需采取坐位采取坐位。T I T L E H E R E T I T L E H E R EWhen you are old

23、 and grey and full of sleep,And nodding by the fire,take down this book 机械吸机械吸-呼技术（呼技术（mechanical insufflation exsufflation，MI-E）自动/手动 正压时间负压时间暂停时间总压力控制正压控制气体流速一种能提供患者吸气正压，控制屏气时间并在呼气时快速转换成负压，从而产生一个高呼气流量以模拟咳嗽的仪器-MI-E（也称作“人工咳痰机”）T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of

24、sleep,And nodding by the fire,take down this book 有报道称，与传统胸部物理治疗相比，在囊性纤维化的患者中俩种方法同样有效，其中仅Kluft等发现应用高频胸壁震动能引出更多痰液。Kluft J,Beker L,Castagnino M,et al.A comparison of bronchial drainage treatments in cystic fibrosis.Pediatr Pulmonol,1996,22;271-274 T I T L E H E R E T I T L E H E R EWhen you are old an

25、d grey and full of sleep,And nodding by the fire,take down this book 患者在呼气时需对抗一个固定出口的阻力器，从而在气道内形成一定的呼气正压，可维持气道在整个呼气相开放，也有助于恢复肺不张。T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 在呼气过程中，随着钢球不断起落而形成震动气流，可到达松动痰液的效果 T I T L E H E

26、R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book Vargas F,Bui HN,Boyer A,et al.Intrapulmonary percussive ventilation on mucus clearance in ducbenne muscular dyatrophy patients：a randomized controlled trial.crit Care，2005,9:382-389有研究报道，IPV对

27、于伴轻度呼吸性酸中毒的AECOPD患者是一项安全有效的技术，可避免病情进一步加重 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 静止不动是分泌物积聚的主要原因 早期下床活动和及时翻身，为目前预防肺不张及术后肺炎的常用方法 训练时注意监测患者HR、BP、SpO2及其主观感受 活动强度：不超过最高心率的70%（最高心率=220-年龄）T I T L E H E R E T I T L E H E R

28、EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book CPTCPT的疗效标准的疗效标准:分泌物减少25mld。病变部位呼吸音改善，无啰音，听诊清晰。胸x片改善。呼吸模式与呼吸机的设定条件降低。患者对治疗的反应良好。SpO2与血气分析好转。病人无发热。T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down

29、this book 肺康复肺康复 1974年，美国胸科医师学会（ACCP）首次提出肺康复定义,直至1997年美国ACCP/ACCVP发表首部肺康复循证医学指南，并于2007年进行了更新，指出肺康复是对有症状、日常生活能力下降的慢性呼吸系肺康复是对有症状、日常生活能力下降的慢性呼吸系统疾病患者采取的多学科综合干预措施。在患者个体化治疗中加入统疾病患者采取的多学科综合干预措施。在患者个体化治疗中加入综合性肺康复方案，通过稳定或逆转疾病的全身表现而减轻症状、综合性肺康复方案，通过稳定或逆转疾病的全身表现而减轻症状、优化功能状态，增加患者依从性，减少医疗费用优化功能状态，增加患者依从性，减少医疗费用。

30、T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 肺康复的目的肺康复的目的 T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 新指南强调，肺康复适用于所有稳定期慢性呼吸系统疾病患者。新指南强调，肺康复适用于所

31、有稳定期慢性呼吸系统疾病患者。T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 肺康复方法肺康复方法1.治愈/稳定疾病；主要手段是药物治疗、氧疗、呼吸支持等手段；2.保留生活和活动能力：主要是运动疗法、肺的物理治疗、营养治疗等；3.达到主动康复和行为改变的目的：教育课程。前者主要解决了生命，后者主要解决生存的质量，二者完美结前者主要解决了生命，后者主要解决生存的质量，二者完美结合，才能使患者达到最大获

32、益。合，才能使患者达到最大获益。T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 肺康复评价运动能力的试验肺康复评价运动能力的试验常用的运动试验包括心肺运动试验(CPET)、6分钟步行试验(6MWT)、往返疾步走试验(SWT)。T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And noddi

33、ng by the fire,take down this book 6 6分钟步行试验（分钟步行试验（6 min walk test6 min walk test，6MWT6MWT）美国胸科学会2008年发布了6MWT指南，指出6MWT简便、易行、价廉、安全，且能客观反应患者日常实际活动量等特点，有利于给患者制定治疗和康复方案。6MWT6MWT是一项用以反映人体机能的综合性测试方法，本身不有具体的是一项用以反映人体机能的综合性测试方法，本身不有具体的诊断意义。诊断意义。T I T L E H E R E T I T L E H E R EWhen you are old and grey a

34、nd full of sleep,And nodding by the fire,take down this book 6MWT主要适用于测量中重度心脏或肺疾病患者对于医疗干预的反应，也可用于评价患者功能状态以及预测发病率和死亡率（表1）。T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 绝对禁忌证绝对禁忌证 1月内有不稳定性心绞痛或心肌梗死者。相对禁忌证相对禁忌证 静息心率120次/分 收缩压 1

35、80 mmHg，舒张压 100 mmHg。T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 试验方法试验方法理想的试验要有温度控制、安静及空气流通的环境平坦的地面没有障碍或其他行人干扰最好有扶手或墙壁，以防病人摔倒划出一段长达30米的直线距离距离分段标记、掉头方向标记 T I T L E H E R E T I T L E H E R EWhen you are old and grey and fu

36、ll of sleep,And nodding by the fire,take down this book T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 将病人带至起始线 喊“开始”口号，同时启动计时器，病人立即开始步行 病人每次回到起点就记录一次圈数 定时告知剩余时间，并给予一些鼓励性言语 时间到6分钟时，喊“停”口号，让病人立即停止行走 T I T L E H E R E T I T L

37、E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book 6MWT6MWT试验结果评价试验结果评价 如6MWT150m，提示负性相关事件（死亡、在住院率、疾病加重）发生率增大。个体患者治疗后提高50m以上才有临床意义。T I T L E H E R E T I T L E H E R EWhen you are old and grey and full of sleep,And nodding by the fire,take down this book