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呼吸康复的训练方法

2021-10-26 “康复医学书籍”公众号 “康复医学书籍”公众号

呼吸系统疾病康复治疗可促进呼吸道分泌物引流,改善呼吸模式,增加呼吸肌肌力和耐力,减轻紧张和焦虑等心理情绪,最后达到生理功能和心理状态不同程度的恢复。

呼吸系统疾病康复治疗可促进呼吸道分泌物引流,改善呼吸模式,增加呼吸肌肌力和耐力,减轻紧张和焦虑等心理情绪,最后达到生理功能和心理状态不同程度的恢复。

一、胸部体疗

1、体位引流

也称为支气管引流,使患病的肺部处于高位,引流支气管开口向下,利用重力原理,使肺和支气管内分泌物顺体位引流至支气管而被咳出。

2、训练有效咳嗽

应按以下步骤进行训练

①缓缓呼气,同时上身向前倾;

②咳嗽时将腹肌收缩,腹壁内收,一次吸气,连续咳三声;

③停止咳嗽,缩唇将余气尽量呼尽;

④再缓慢吸气,或平静呼吸片刻,准备再次咳嗽。如深吸气可能诱发咳嗽,可试分次吸气,勿使肺泡充分充气,增加咳嗽效率。

二、全身运动锻炼

全身运动锻炼包括以上肢为主的运动,以及下肢为主的运动。全身锻炼可增加机体活动量和心肺功能负荷,增加活动耐力。

三、呼吸锻炼

慢阻肺患者呼吸浅速,若有膈肌疲劳可出现胸腹矛盾呼吸, 这些呼吸模式异常可降低通气率。腹式呼吸、缩唇呼气和我国传统医学中的气功锻炼可以改善慢阻肺患者呼吸模式,提高呼吸效率。

观察发现慢阻肺缓解期患者进行松静内养功锻炼四个月,这些患者运动时呼吸形态改善,负荷呼吸时胸腹矛盾呼吸减轻。

1、腹式呼吸

(1)目的:协调膈肌和腹肌在呼吸运动中的活动,尽可能减少肋间肌和辅助呼吸肌的活动。慢阻肺患者膈肌下移、收缩效率减低以及气道阻力增加和胸肺有效顺应性减低往往动员辅助呼吸肌参与呼吸过程。

即使在安静情况下,呼吸常常以上胸廓活动为主,呼吸浅速。这种以胸式呼吸为主的表浅呼吸使泡通气比例降低,又易引起呼吸肌疲劳,并增加耗氧量。

通过腹式呼吸锻炼,使膈肌和腹肌协调运动,呼气时腹肌收缩,膈肌松弛,膈肌随腹腔内压升高而上抬,增加呼气潮气量;吸气时膈肌收缩下降,腹肌松弛,增加吸气量。尽量使肋间肌、辅助呼吸肌保持松弛休息状态,减少氧消耗。

(2)监测指标:满意的腹式呼吸可增加潮气量,减少功能残气量,提高肺泡通气量,降低呼吸功耗,使呼吸困难症状减轻,换气功能改善。

(3)锻炼方法:锻炼前应深入讲解与呼吸运动有关的解剖、生理和呼吸动力等基本常识,联系肺疾病的病理生理,说明腹式呼吸锻炼的意义、目的和要求。

根据病情,锻炼时可取卧位、半卧位或坐位。初学时以半卧位为容易。如取卧位或半卧位时,两膝下可垫小枕,使半曲,从而使腹肌松弛。

将左、右手分别按放上腹部和前胸部,以便于检测胸腹呼吸运动情况。全身肌肉放松,经鼻吸气,从口呼气,呼吸要缓、细、匀。吸气时可见上腹部鼓起,呼气时内收。

患者通过手感,了解胸腹活动是否符合要求,注意纠正。锻炼初期医护人员应在场,先作示范指导,日2次,每次10~15min。熟练后增加次数和时间,并在坐位或立位随时进行锻炼,力求最后养成自觉的呼吸习惯形式。

2、缩唇呼气

(1)目的:提高呼气时气道外口内压,使等压点向下游段较大气道转移,防止小气道过早闭合。在慢阻患者,由于气道阻力增加,呼气时胸内压上升,小气道内压力低于胸内压,使管腔受挤压而狭窄陷闭,引起泡气滞留和呼气量减少。

缩唇呼气增加呼气阻力,减少呼吸道内压力递减梯度,使等压点移向中央气道,使小气道保持较大的腔内压,防止呼气时小气道陷闭以利肺泡气排出,促进肺泡换气,改善缺氧及二氧化碳潴留。

(2)监测指标:慢阻肺患者采用缩唇程度由患者自行选择调整。缩唇口形太小,呼气阻力过大,呼气费力,呼气时间延长,呼出气量可能减少,患者也难以忍受;缩唇口形太大,则不能达到防止小气道陷闭的目的。

缩唇大小和呼气流量,以能使距离口唇15-20cm处蜡烛火焰随气流倾斜,不致熄灭为适度。缩唇呼气可与腹式呼吸结合起来锻炼。

3、全身性呼吸体操锻炼

在腹式呼吸练习的基础上,结合扩胸、弯腰、下蹲等体操运动,可起到进一步改善肺功能和增强体力的作用。

四、呼吸肌锻炼

1、呼吸肌肌力锻炼

(1)目的:通过锻炼增加吸气肌和呼气肌的力量。呼吸肌同身体其他部位肌肉一样,肌力锻炼可以引起肌丝和肌纤维数量增多,供应肌纤维的毛细血管数量增多,肌肉蛋白质合成增加而分解减少,结果肌纤维增粗,使肌肉收缩力量增强。

(2)锻炼方法:锻炼装置多属吸气或吸呼二相通气阻力器, 有以下几种类型:

①非线性阻力呼吸器:优点是体积小、携带方便、价格便宜;缺点是阻力负荷的调节较粗略,影响锻炼强度。

②阈值压力负荷装置;只有达到一定的压力后才能开始吸气,与非线性阻力呼吸器相比压力负荷易于调节,且较稳定。中山医院报告慢阻肺患者进行阈压力负荷吸气肌锻炼可增加呼吸肌肌力。

③耙流量阻力装置:通过调整吸气压力以达到一定吸气流量来确定压力负荷,使用也较方便。各种装置使用时,患者加鼻夹,用口呼吸。锻炼时间一般每次5-20min,每日2-3次,可在静息通气或通气条件下进行。

锻炼时要防止过度通气导致呼吸性碱中毒。随呼吸肌力量增加,应及时增加负荷。锻炼负荷与时间的搭配应根据患者主观感觉和适应情况而个体化。

(3)监测指标:其效果可以用最大吸气口腔压反映。最大吸气压反映了吸气肌最大收缩后引起的口腔负压变化,代表整个吸气肌群包括膈肌、肋间肌和辅助呼吸肌的功能。最大呼气压是评价呼气肌功能的指标,与评价患者的咳嗽及排痰能力有关。

另外,还可用跨膈压反映膈肌的收缩力,但需行食管插管测压,使临床应用受到限制。

2、呼吸肌耐力锻炼

(1)目的:增加呼吸肌耐力,提高呼吸肌抗疲劳能力。肌力锻炼主要影响快收缩糖酵解纤维,而耐力锻炼则影响慢收缩氧化纤维。耐力锻炼引起肌肉线粒体数量增加、体积增大,氧化酶增加,并增强肌肉的血液循环和氧化代谢,并使快收缩糖酵解纤 维转变为慢收缩氧化纤维。

(2)锻炼方法:耐力锻炼不同于肌力锻炼,应以增加通气量作为呼吸肌的负荷。如CO2过度通气锻炼采用主动深快呼吸法,呼吸频率达30-60/min。为防止通气增加时动脉和肺泡气CO2分压下降,需要较复杂的部分重复呼吸通路装置。

每天锻炼最少20min,锻炼次数可适当增加。当然,用于锻炼呼吸肌肌力的装置也在一定程度上增加呼吸肌耐力,也可用作呼吸肌耐力锻炼。

(3)监测指标:呼吸肌耐力指标有最大自主通气量、最大维持通气量(MSVC)、最大维持吸气压(SIPM)、膈肌张力-时间指数等。

应该指出的是,上述肌力或耐力锻炼的各种方法不能截然分开,它们往往对呼吸肌肌力和耐力均有作用,只是侧重点略有不同而已。

五、其他

1、气功

气功如松静内养功要求调身、调心和调息。调身要求全身放松。调心要求摒弃杂念,摆脱焦虑、抑郁的情绪。调息要求腹式呼吸,深长细匀。气功对肺功能康复和心理康复有一定的作用。

2、音乐疗法

舒缓的音乐可以通过对大脑边缘系统的影响, 起到调节心境,稳定情绪,放松全身的作用。音乐与其他松弛疗法联合使用,可起到协同作用。当代美国沉思乐是最常用的松弛音乐。它使用三到七种音调,旋律一步步地发展,节拍与呼吸频率一致,温和、圆润、轻柔、飘逸,没有急速的节奏变化。

3、松弛疗法

在医务人员指导下通过肌肉关节的运动或通过暗示,使患者消除紧张和恐惧。

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    2021-12-22 ms3000000770214786

    学习

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=1083266, encodeId=60cf1083266a1, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=93, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f69c6419467, createdName=ms3000000770214786, createdTime=Wed Dec 22 23:04:13 CST 2021, time=2021-12-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1079318, encodeId=175710e931857, content=写得不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3d945605913, createdName=ms7000001100972409, createdTime=Sun Dec 12 20:46:40 CST 2021, time=2021-12-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1078922, encodeId=c36910e892279, content=相当不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=126, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3d945605913, createdName=ms7000001100972409, createdTime=Sat Dec 11 00:11:52 CST 2021, time=2021-12-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1074021, encodeId=5d6410e4021a7, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=176, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=08415729146, createdName=ms6000001694589922, createdTime=Thu Nov 25 23:36:38 CST 2021, time=2021-11-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1072942, encodeId=46fd10e29429d, content=正需要,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=180, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=dddc5479681, createdName=ms1000000207599010, createdTime=Mon Nov 22 19:52:26 CST 2021, time=2021-11-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1625739, encodeId=77b21625e3966, content=<a href='/topic/show?id=1cc139638ec' target=_blank style='color:#2F92EE;'>#呼吸康复#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=83, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39638, encryptionId=1cc139638ec, topicName=呼吸康复)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=031f20842174, createdName=nymo, createdTime=Wed Oct 27 14:21:41 CST 2021, time=2021-10-27, status=1, ipAttribution=)]
    2021-12-12 ms7000001100972409

    写得不错

    0

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    2021-12-11 ms7000001100972409

    相当不错

    0

  4. [GetPortalCommentsPageByObjectIdResponse(id=1083266, encodeId=60cf1083266a1, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=93, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f69c6419467, createdName=ms3000000770214786, createdTime=Wed Dec 22 23:04:13 CST 2021, time=2021-12-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1079318, encodeId=175710e931857, content=写得不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3d945605913, createdName=ms7000001100972409, createdTime=Sun Dec 12 20:46:40 CST 2021, time=2021-12-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1078922, encodeId=c36910e892279, content=相当不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=126, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3d945605913, createdName=ms7000001100972409, createdTime=Sat Dec 11 00:11:52 CST 2021, time=2021-12-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1074021, encodeId=5d6410e4021a7, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=176, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=08415729146, createdName=ms6000001694589922, createdTime=Thu Nov 25 23:36:38 CST 2021, time=2021-11-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1072942, encodeId=46fd10e29429d, content=正需要,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=180, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=dddc5479681, createdName=ms1000000207599010, createdTime=Mon Nov 22 19:52:26 CST 2021, time=2021-11-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1625739, encodeId=77b21625e3966, content=<a href='/topic/show?id=1cc139638ec' target=_blank style='color:#2F92EE;'>#呼吸康复#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=83, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39638, encryptionId=1cc139638ec, topicName=呼吸康复)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=031f20842174, createdName=nymo, createdTime=Wed Oct 27 14:21:41 CST 2021, time=2021-10-27, status=1, ipAttribution=)]
    2021-11-25 ms6000001694589922

    学习了

    0

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    2021-11-22 ms1000000207599010

    正需要,学习了

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1083266, encodeId=60cf1083266a1, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=93, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f69c6419467, createdName=ms3000000770214786, createdTime=Wed Dec 22 23:04:13 CST 2021, time=2021-12-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1079318, encodeId=175710e931857, content=写得不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3d945605913, createdName=ms7000001100972409, createdTime=Sun Dec 12 20:46:40 CST 2021, time=2021-12-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1078922, encodeId=c36910e892279, content=相当不错, beContent=null, objectType=article, channel=null, level=null, likeNumber=126, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3d945605913, createdName=ms7000001100972409, createdTime=Sat Dec 11 00:11:52 CST 2021, time=2021-12-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1074021, encodeId=5d6410e4021a7, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=176, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=08415729146, createdName=ms6000001694589922, createdTime=Thu Nov 25 23:36:38 CST 2021, time=2021-11-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1072942, encodeId=46fd10e29429d, content=正需要,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=180, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=dddc5479681, createdName=ms1000000207599010, createdTime=Mon Nov 22 19:52:26 CST 2021, time=2021-11-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1625739, encodeId=77b21625e3966, content=<a href='/topic/show?id=1cc139638ec' target=_blank style='color:#2F92EE;'>#呼吸康复#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=83, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=39638, encryptionId=1cc139638ec, topicName=呼吸康复)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=031f20842174, createdName=nymo, createdTime=Wed Oct 27 14:21:41 CST 2021, time=2021-10-27, status=1, ipAttribution=)]
    2021-10-27 nymo

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