Acessibilidade / Reportar erro

Functional respiratory re-education interventions in people with respiratory disease: a systematic literature review

Intervenciones de reeducación funcional respiratoria en la persona con enfermedad respiratoria: revisión sistemática de la literatura

ABSTRACT

Objectives:

to identify nursing interventions in rehabilitation, within the scope of functional respiratory reeducation, which allow a respiratory function improvement in people with respiratory disease.

Methods:

systematic literature review using the MEDLINE database search, adopting the PICO mnemonic and the Joanna Briggs Institute’s assessment of the level of evidence and methodological quality. The search for randomized controlled trials was carried out in June 2021 considering the period from 2015 to 2020, in English or Portuguese.

Results:

a sample of nine randomized controlled trials with methodological quality was obtained which highlighted the use of positive expiratory pressure devices as an important component and intervention for respiratory functional reeducation.

Conclusions:

nursing interventions in rehabilitation with an emphasis on functional respiratory reeducation are essential, showing improvements in people’s general health.

Descriptors:
Rehabilitation Nursing; Remedial Teachings; Respiratory Tract Disease; Health Gains; Systematic Review

RESUMEN

Objetivos:

identificar las intervenciones de enfermería en rehabilitación, en el ámbito de la reeducación funcional respiratoria, que permiten una mejoría de la función respiratoria en persona con enfermedad respiratoria.

Métodos:

revisión sistemática de la literatura con recurso a la investigación en la base de datos MEDLINE, adoptando la mnemónica PICO y evaluación del nivel de evidencia y calidad metodológica señalado por Joanna Briggs Institute. En el mes de junio de 2021, fue realizada la investigación de estudios randomizados controlados, en el intervalo de 2015 a 2020, en inglés o portugués.

Resultados:

se obtuvo muestra de nueve estudios randomizados controlados, con calidad metodológica, de los cuales se destaca el uso de dispositivos de presión espiratoria positiva como una importante componente e intervención de reeducación funcional respiratoria.

Conclusiones:

las intervenciones de enfermería en rehabilitación con énfasis en la reeducación funcional respiratoria son fundamentales, evidenciándose mejorías en la salud general de las personas.

Descriptores:
Enfermería en Rehabilitación; Enseñanza Correctiva; Enfermedad Respiratoria; Logros en Salud; Revisión Sistemática

RESUMO

Objetivos:

identificar as intervenções de enfermagem em reabilitação, no âmbito da reeducação funcional respiratória, que permitem uma melhoria da função respiratória na pessoa com doença respiratória.

Métodos:

revisão sistemática da literatura com recurso à pesquisa na base de dados MEDLINE, adotando a mnemónica PICO e a avaliação do nível de evidência e qualidade metodológica salientado por Joanna Briggs Institute. No mês de junho de 2021, foi realizada a pesquisa de estudos randomizados controlados, no intervalo de 2015 a 2020, em inglês ou português.

Resultados:

obteve-se amostra de nove estudos randomizados controlados, com qualidade metodológica, dos quais se destaca o uso de dispositivos de pressão expiratória positiva como uma importante componente e intervenção de reeducação funcional respiratória. Conclusões: as intervenções de enfermagem em reabilitação com ênfase na reeducação funcional respiratória são fundamentais, evidenciando-se melhorias na saúde geral das pessoas.

Descritores:
Enfermagem em Reabilitação; Reeducação; Doença Respiratória; Ganhos em Saúde; Revisão Sistemática

INTRODUCTION

According to the National Institute of Statistics(11 Instituto Nacional de Estatística (PT). Causas de morte: mortes por doenças do aparelho respiratório aumentaram 3,8%: 2018 [Internet]. Lisboa: INE; 2017[cited 2021 Jun 3]. Available from: https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_destaques&DESTAQUESdest_boui=399595771&DESTAQUESmodo=2&xlang=pt
https://www.ine.pt/xportal/xmain?xpid=IN...
), respiratory pathology was one of the main causes of mortality in Portugal in 2018, reaching 11.7% of the total number of deaths. Thus, since the respiratory system is one of the first to undergo changes, many of them due to gradual exposure to environmental pollutants, it is pertinent that nursing care corresponds to the real needs of people, and a readjustment of action plans may be necessary(22 Menoita EPC. Reabilitação respiratória na pessoa idosa. In: Cordeiro MCO, Menoita ECPC, coordinators. Manual de boas práticas na reabilitação respiratória: conceitos, princípios e técnicas. Loures: Lusociência; 2012. p. 317-20.).

In this sense, to be able to act early, it is important to know the respiratory physiological changes that may be associated with aging, such as the loss of muscle strength in the respiratory muscles, less airway distension and lung expansion capacity, and the reduced number of pulmonary alveoli, which consequently affects lung volumes and capacities. These changes condition the worsening of lung function, increasing the mortality rate, being that respiratory pathologies and infections represent an important cause of death and hospitalization. In the case of aging-related pneumonia, there is a reduction or absence of coughing and sputum and the consequent inefficiency in eliminating particles and secretions as an important symptomatology. In this context, the role of specialist nurses in rehabilitation nursing (SNRN) can make a difference in maintaining airway patency and improving lung function, through the implementation of functional respiratory reeducation (FRR) interventions. This non-invasive therapy with no harmful side effects integrates a set of techniques, based on the control of breathing, positioning, and movement, which allow improving not only alveolar ventilation and gas exchange, but also the symptoms resulting from inherent disease and pathophysiological changes(22 Menoita EPC. Reabilitação respiratória na pessoa idosa. In: Cordeiro MCO, Menoita ECPC, coordinators. Manual de boas práticas na reabilitação respiratória: conceitos, princípios e técnicas. Loures: Lusociência; 2012. p. 317-20.-33 Gomes BN, Ferreira D. Reeducação da função respiratória. In: Marques-Vieira C, Sousa L, coordinators. Cuidados de enfermagem de reabilitação à pessoa ao longo da vida. Loures: Lusodidacta; 2016. p. 253-62.).

The SNRN possess the competence to guarantee and enhance the person’s functional capacity, preventing respiratory function complications and disabilities(44 Ordem dos Enfermeiros (PT). Regulamento nº 350, de 22 de jun de 2015. Regulamento dos padrões de qualidade dos cuidados especializados em enfermagem em enfermagem de reabilitação [Internet]. [Lisboa]: DRE; 2015[cited 2021 Oct 19]. Available from: https://dre.pt/home/-/dre/67552234/details/maximized
https://dre.pt/home/-/dre/67552234/detai...
). Within the assessment of breathing, there may be signs and symptoms in people who have respiratory changes, such as dyspnea, coughing, secretions, chest pain, and hemoptysis. It is essential to also evaluate the respiratory rate, breathing pattern, amplitude, rhythm, and symmetry, as well as to observe the color of the skin and of the mucous membranes, perform pulmonary auscultation, and obtain data on pulse oximetry, arterial blood gases, chest radiography and functionality tests(55 Ferreira D, Santos A. Avaliação da pessoa com patologia respiratória. In: Marques-Vieira C, Sousa L, coordinators. Cuidados de enfermagem de reabilitação à pessoa ao longo da vida. Loures: Lusodidacta; 2016. p. 167-80.).

Cui et al.(66 Cui L, Liu H, Sun L. Multidisciplinary respiratory rehabilitation in combination with non-invasive positive pressure ventilation in the treatment of elderly patients with severe chronic obstructive pulmonary disease. Pak J Med Sci. 2019;2(35):500-5. https://doi.org/10.12669/pjms.35.2.459
https://doi.org/10.12669/pjms.35.2.459...
) verified in their study some benefits of FRR in combination with non-invasive ventilation in people with chronic obstructive pulmonary disease (COPD), noting in this population a relief of dyspnea and an increase in exercise tolerance and quality of life. Similarly, Liu et al.(77 Liu K, Zhang W, Yang Y, Zhang J, Li Y, Chen Y. Respiratory rehabilitation in elderly patients with COVID-19: a randomized controlled study. Complement Ther Clin Pract. 2020;39:101166. https://doi.org/10.1016/j.ctcp.2020.101166
https://doi.org/10.1016/j.ctcp.2020.1011...
) concluded in their study that a six-week FRR program can improve respiratory function, quality of life, and anxiety in patients with COVID-19. After these examples, it appears that, in fact, FRR brings benefits for people with respiratory pathology. However, it raises the question of which nursing interventions in rehabilitation, within the scope of FRR, allow this improvement and in which context they are implemented.

This review was based on the Transitions Theory, proposed by Afaf Meleis, since the theory defends transition as a change in environments, states, or conditions, which requires the person to adapt to this new reality. In this sense, the SNRN appears as a professional endowed with skills that allow them to help people in this transition process, from the lowest functionality at the respiratory level to the state of maximum possible functionality(88 Silva CFT, Pedreira LC, Amaral JB, Mussi FC, Martorell-Povesa MA, Souza ML. The care offered by nurses to elders with coronary artery disease from the perspective of transitions theory. Rev Bras Enferm. 2021;74(suppl 2):e202000992. https://doi.org/10.1590/0034-7167-2020-0992
https://doi.org/10.1590/0034-7167-2020-0...
).

The role of the SNRN towards the person with changes in the respiratory system is transversal to any of the phases of the life cycle. Thus, any implemented program must meet the person’s individuality, adapting the selected techniques and interventions according to the pathologies and intended objectives(22 Menoita EPC. Reabilitação respiratória na pessoa idosa. In: Cordeiro MCO, Menoita ECPC, coordinators. Manual de boas práticas na reabilitação respiratória: conceitos, princípios e técnicas. Loures: Lusociência; 2012. p. 317-20.). As the SNRN specific interventions are not clearly identified and defined in other countries, there was a need to use trials that used rehabilitation interventions or programs of action of other health professionals, whose interventions were within the domain of/according to competences of the SNRN, as well as permitted by the Nurses’ Order.

OBJECTIVES

To identify nursing interventions in rehabilitation, within the scope of functional respiratory reeducation, which allow a respiratory function improvement in people with respiratory disease.

METHODS

This is a systematic literature review (SLR), which consists of an explicit and systematic methodology, capable of being reproduced, and which makes it possible to identify, evaluate, and compile trials from the most diverse areas of knowledge. For its elaboration, a study question is initially defined; an investigation protocol is created, and its registration is carried out; the inclusion and exclusion criteria are identified; to answer the formulated question, a search for trials in scientific databases is carried out, in accordance with the outlined research strategy; subsequently, a selection and review of the obtained articles is performed by at least two people to avoid the risk of bias, and the quality of each one is critically evaluated; finally, it is possible to collect data, summarize, and assess the quality of the evidence found, presenting its results in a publication(99 Sousa LMM, Firmino CF, Marques-Vieira CMA, Severino SSP, Pestana HCFC. Scientific literature reviews: types, methods and applications in nursing. Rev Port Enferm Reab. 2018;1(1):45-54. https://doi.org/10.33194/rper.2018.v1.n1.07.4391
https://doi.org/10.33194/rper.2018.v1.n1...
). According to the Joanna Briggs Institute (JBI), the PICO mnemonic can be used to define a clear title of a systematic review, translating its evidence and effectiveness by specifying the Population, Intervention, Comparator (if any), and Outcome(1010 Apóstolo JLA. Síntese da evidência no contexto da translação da ciência. Coimbra: Escola Superior de Enfermagem de Coimbra; 2017.). In view of the mnemonics addressed, an adaptation was elaborated, in which “C” is excluded, as it does not relate to the formulated question. Thus, Chart 1 was constructed.

Chart 1
Adaptation of the PICO mnemonic for the elaboration of the question

Therefore, the following question was elaborated: “What are the rehabilitation nursing interventions, within the scope of functional respiratory reeducation, that promote the improvement of respiratory function in people with respiratory disease?”.

As a research strategy, in addition to the PICO question to formulate the research question, English or Portuguese literature published between 2015 and 2020 and the Boolean/phrase search mode with the Boolean operators AND and OR in the PubMed search engine were considered (MEDLINE database).

The selected inclusion criteria were: complete articles, randomized controlled trials (RCT), publications from 2015 to 2020, MEDLINE database, and age of participants equal to or greater than 18 years.

The present SLR exclusively contains trials whose population is constituted by people with respiratory pathology; the interventions of the trials must include specific nursing interventions in rehabilitation and/or rehabilitation programs in hospitals, care institutions and/or outpatient clinics, which may be associated and integrated in an interdisciplinary team; trials assess the results of the interventions mentioned above. We included in this SLR trials with people with respiratory disease and aged 18 years and over, trials that analyze the results of FRR interventions which are accepted as competence of the SNRN in Portugal (slow expiration with glottis opened in lateral posture [ELTGOL], postural drainage, accessory maneuvers [percussions], positive expiratory pressure [PEP]/Flutter®, intrapulmonary and extrapulmonary oscillation, controlled inspiratory flow exercise [CIFE], active cycle of breathing techniques [ACBT], teaching coughing and huffing, expiration with semi-closed lips, diaphragmatic breathing, costal re-education, rest and relaxation techniques, breath awareness and control, exercise training, respiratory muscle training, and selective costal opening), published from January 2015 to December 2020, in the English or Portuguese language.

The exclusion criteria were: language other than Portuguese or English; samples made up of people under 18 years of age; did not clearly state the type of study treated or the date of publication; ambiguous methodology; unrelated to the purpose of the study; did not present methodological quality as per JBI criteria (score < 9).

In order to select controlled quality descriptors, the MeSH criterion was used. However, as too many trials were obtained, the results of which were not very specific, there was a need to use uncontrolled descriptors, whose terms were associated with the area of health in research and defined in the scientific community. Therefore, the following descriptors were used: (pulmonary rehabilitation OR respiratory rehabilitation OR breathing exercises) AND (airway clearance OR bronchorrhea OR bronchiectasis OR expectoration). The searches were carried out in June 2021.

The choice of a single search engine, PubMed, which allows access to the MEDLINE database, made it possible to obtain a satisfactory number of results, with the required level of evidence and methodological quality, for the descriptors and specific criteria defined.

Next, there is Figure 1, which exemplifies the steps of the research methodology adopted in this work.

Figure 1
Flowchart used for study selection - PRISMA 2020(1111 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. http://doi.org/10.1136/bmj.n71
http://doi.org/10.1136/bmj.n71...
)

The articles obtained were analyzed and evaluated according to the Joanna Briggs Institute Manual in order to verify their level of strength and evidence. Likewise, the JBI Critical Appraisal Checklist questionnaires were filled out for randomized controlled trials, in order to verify their methodological quality(1212 Joanne Briggs Institute. JBI levels of evidence [Internet]. Adelaide: JBI; 2013[cited 2021 Jun 8]. Available from: https://jbi.global/sites/default/files/2019-05/JBI-Levels-of-evidence_2014_0.pdf
https://jbi.global/sites/default/files/2...
,1313 Joanna Briggs Institute. Checklist for randomized controlled trials: critical appraisal tools for use in JBI systematic reviews [Internet]. Adelaide: JBI; 2020[cited 2021 Jun 08]. Available from: https://jbi.global/sites/default/files/2021-03/Checklist_for_RCTs.docx
https://jbi.global/sites/default/files/2...
). This procedure was performed by six independent authors.

Chart 2 shows the titles of the nine articles obtained, as well as the respective level of evidence and methodological quality.

Chart 2
Level of evidence and results of the JBI Critical Appraisal Checklist for randomized controlled trials

RESULTS

After reading and analyzing the articles chosen for this SLR, a summary for each was performed, presented in Chart 3, which includes: each trials’ identification and design, objective and participants, the interventions highlighted as relevant for the present SLR, and the results obtained.

Chart 3
Summary from article analysis

The selected articles are from several countries, namely Spain (S1), Turkey (S2), China/Taiwan (S3), Australia (S4, S8), Italy (S5, S7), Portugal (S6), and Brazil (S9); and have population samples ranging from 15 to 120 participants. The average age of participants for trials S1, S3, S5, and S7 was close to 70 years. In trials S2, S4, S6, S8, and S9, the mean ages ranged between 27 and 59.6 years. The rehabilitation programs implemented were mostly in an outpatient setting, except for study S3, which included inpatients.

DISCUSSION

This SLR aims to identify the nursing interventions in rehabilitation, within the scope of the FRR, that enable an improvement in respiratory function in people with respiratory disease, within a population sample ranging from 15 to 120 participants and with an average age ranging from 27 to close to 75 years old.

While analyzing the articles, it was found that the ELTGOL technique was common to the studies by Muñoz et al.(1414 Muñoz G, Gracia J, Buxó M, Alvarez A, Vendrell M. Long-term benefits of airway clearance in bronchiectasis: a randomised placebo-controlled trial. Eur Respir J. 2018;51(1):1701926. https://doi.org/10.1183/13993003.01926-2017
https://doi.org/10.1183/13993003.01926-2...
) and Marques et al.(1919 Marques A, Pinho C, Francesco S, Martins P, Neves J, Oliveira A. A randomized controlled trial of respiratory physiotherapy in lower respiratory tract infections. Respir Med. 2020;162:105861. https://doi.org/10.1016/j.rmed.2019.105861
https://doi.org/10.1016/j.rmed.2019.1058...
). In the study by Muñoz et al.(1414 Muñoz G, Gracia J, Buxó M, Alvarez A, Vendrell M. Long-term benefits of airway clearance in bronchiectasis: a randomised placebo-controlled trial. Eur Respir J. 2018;51(1):1701926. https://doi.org/10.1183/13993003.01926-2017
https://doi.org/10.1183/13993003.01926-2...
), it was shown that performing this technique twice a day helped to eliminate secretions, with a lower number of exacerbations in patients with bronchiectasis. At the same time, it is concluded that this technique, integrated in a FRR program with associated pharmacological treatment, provided greater recovery in terms of symptoms and functional parameters in bronchorrhea patients, particularly, with LRTI(1919 Marques A, Pinho C, Francesco S, Martins P, Neves J, Oliveira A. A randomized controlled trial of respiratory physiotherapy in lower respiratory tract infections. Respir Med. 2020;162:105861. https://doi.org/10.1016/j.rmed.2019.105861
https://doi.org/10.1016/j.rmed.2019.1058...
).

The results found in researches that address the ELTGOL technique are corroborated by Herrero-Cortina et al.(2323 Herrero-Cortina B, Vilaró J, Martí D, Torres A, San Miguel-Pagola M, Alcaraz V, et al. Short-term effects of three slow expiratory airway clearance techniques in patients with bronchiectasis: a randomised crossover trial. Physiotherapy. 2015;102(4):357-64. http://doi.org/10.1016/j.physio.2015.07.005
http://doi.org/10.1016/j.physio.2015.07....
), who analyzed slow expiration techniques, including ELTGOL, and concluded that it induced a greater elimination of secretions, reducing the amount of sputum produced until the end of the day on which the FRR session was held; in turn, this has had a positive, short-term effect on the quality of life of people with bronchiectasis. Therefore, ELTGOL improves ventilation and oxygenation in a certain area of the lung, ensuring airway permeability and constituting objectives of the CIFE technique, also referred to in the study by Marques et al.(1919 Marques A, Pinho C, Francesco S, Martins P, Neves J, Oliveira A. A randomized controlled trial of respiratory physiotherapy in lower respiratory tract infections. Respir Med. 2020;162:105861. https://doi.org/10.1016/j.rmed.2019.105861
https://doi.org/10.1016/j.rmed.2019.1058...
) and related to the gains obtained with the implementation of the FRR(2424 Cordeiro MCO, Menoita ECPC. Reeducação funcional respiratória. In: Cordeiro MCO, Menoita ECPC, coordinators. Manual de boas práticas na reabilitação respiratória: conceitos, princípios e técnicas. Loures: Lusociência; 2012. p. 61-115.). The application of this allows for a recovery of functional capacity, a mobilization of secretions from the peripheral airway, and an improvement in pulmonary ventilation(2525 Ordem dos Enfermeiros (PT). Guia orientador de boa prática: reabilitação respiratória [Internet]. [Lisboa]: Ordem dos Enfermeiros; 2018[cited 2021 Jun 10]. Available from: https://www.ordemenfermeiros.pt/media/5441/gobp_reabilita%C3%A7%C3%A3o-respirat%C3%B3ria_mceer_final-para-divulga%C3%A7%C3%A3o-site.pdf
https://www.ordemenfermeiros.pt/media/54...
). This last expected result is also common to the technique of global back opening with a mobilization of the upper limbs, highlighted in the study by Liao et al.(1616 Liao L-Y, Chen K-M, Chung W-S, Chien J-Y. Efficacy of a respiratory rehabilitation exercise training package in hospitalized elderly patients with acute exacerbation of COPD: a randomized control trial. Int J Chron Obstruct Pulmon Dis. 2015;10(1):1703-9. http://doi.org/10.2147/COPD.S90673
http://doi.org/10.2147/COPD.S90673...
) in patients with COPD, by promoting chest expansion, muscle strengthening, and joint mobility, complements which are essential to FRR programs(2424 Cordeiro MCO, Menoita ECPC. Reeducação funcional respiratória. In: Cordeiro MCO, Menoita ECPC, coordinators. Manual de boas práticas na reabilitação respiratória: conceitos, princípios e técnicas. Loures: Lusociência; 2012. p. 61-115.). This mobilization of the upper limbs, reported in the study by Liao et al.(1616 Liao L-Y, Chen K-M, Chung W-S, Chien J-Y. Efficacy of a respiratory rehabilitation exercise training package in hospitalized elderly patients with acute exacerbation of COPD: a randomized control trial. Int J Chron Obstruct Pulmon Dis. 2015;10(1):1703-9. http://doi.org/10.2147/COPD.S90673
http://doi.org/10.2147/COPD.S90673...
), is still associated with the training of walking/mobilization of the lower limbs with breathing control, which allows the improvement of dyspnea, as well as the QoL of people with COPD(2626 Cordeiro MCO, Mateus DM, Menoita EC, Rocha B, Marques P, Rocha S, et al. Treino de exercício na pessoa com patologia respiratória crónica. In: Cordeiro MCO, Menoita ECPC, coordinators. Manual de boas práticas na reabilitação respiratória: conceitos, princípios e técnicas. Loures: Lusociência; 2012. p. 117-43.).

Such mobilization can be combined with the back re-education technique referred to in the trial by Simoni et al.(2222 Simoni LHS, Santos DO, Souza HCD, Baddini-Martinez JA, Santos MK, Gastaldi AC. Acute effects of oscillatory PEP and thoracic compression on secretion removal and impedance of the respiratory system in non-cystic fibrosis bronchiectasis. Respir Care. 2019;64(7):818-27. https://doi.org/10.4187/respcare.06025
https://doi.org/10.4187/respcare.06025...
). In this one, the lower back re-education produced an increase in the elimination of secretions through an increase in the expiratory flow. This technique thus favors alveolar ventilation and chest expansion because of chest mobilization, which contributes to airway clearance and inspiratory muscle strengthening(2525 Ordem dos Enfermeiros (PT). Guia orientador de boa prática: reabilitação respiratória [Internet]. [Lisboa]: Ordem dos Enfermeiros; 2018[cited 2021 Jun 10]. Available from: https://www.ordemenfermeiros.pt/media/5441/gobp_reabilita%C3%A7%C3%A3o-respirat%C3%B3ria_mceer_final-para-divulga%C3%A7%C3%A3o-site.pdf
https://www.ordemenfermeiros.pt/media/54...
).

The work by Ozalp et al.(1515 Ozalp O, Inal-Ince D, Cakmak A, Calik-Kutukcu E, Saglam M, Savci S, et al. High-intensity inspiratory muscle training in bronchiectasis: a randomized controlled trial. Respirology. 2018;24(3):246-53. https://doi.org/10.1111/resp.13397
https://doi.org/10.1111/resp.13397...
) seeks to find the benefits of high intensity training of inspiratory muscles, and the results found may be related to the trial by Marques et al.(1919 Marques A, Pinho C, Francesco S, Martins P, Neves J, Oliveira A. A randomized controlled trial of respiratory physiotherapy in lower respiratory tract infections. Respir Med. 2020;162:105861. https://doi.org/10.1016/j.rmed.2019.105861
https://doi.org/10.1016/j.rmed.2019.1058...
), which highlights exercise training, and with the trials by Dwyer et al.(1414 Muñoz G, Gracia J, Buxó M, Alvarez A, Vendrell M. Long-term benefits of airway clearance in bronchiectasis: a randomised placebo-controlled trial. Eur Respir J. 2018;51(1):1701926. https://doi.org/10.1183/13993003.01926-2017
https://doi.org/10.1183/13993003.01926-2...
,1818 Nicolini A, Grecchi B, Ferrari-Bravo M, Barlascini C. Safety and effectiveness of the high-frequency chest wall oscillation vs intrapulmonary percussive ventilation in patients with severe COPD. Int J Chron Obstruct Pulmon Dis. 2018;13:617-25. http://doi.org/10.2147/COPD.S145440
http://doi.org/10.2147/COPD.S145440...
), which investigate the benefits of exercising on a treadmill in eliminating secretions and clearing the airways.

In the research by Marques et al.(1919 Marques A, Pinho C, Francesco S, Martins P, Neves J, Oliveira A. A randomized controlled trial of respiratory physiotherapy in lower respiratory tract infections. Respir Med. 2020;162:105861. https://doi.org/10.1016/j.rmed.2019.105861
https://doi.org/10.1016/j.rmed.2019.1058...
), with the implementation of a FRR program in which exercise training was integrated, there were improvements in oxygen saturation values, in the dyspnea scale mMRC, in terms of pulmonary crackles and in the six-minute walk test. Therefore, exercise training is an effective strategy for the desensitization of dyspnea in people with COPD(2626 Cordeiro MCO, Mateus DM, Menoita EC, Rocha B, Marques P, Rocha S, et al. Treino de exercício na pessoa com patologia respiratória crónica. In: Cordeiro MCO, Menoita ECPC, coordinators. Manual de boas práticas na reabilitação respiratória: conceitos, princípios e técnicas. Loures: Lusociência; 2012. p. 117-43.). These results are identical to those of the study by Ozalp et al.(1515 Ozalp O, Inal-Ince D, Cakmak A, Calik-Kutukcu E, Saglam M, Savci S, et al. High-intensity inspiratory muscle training in bronchiectasis: a randomized controlled trial. Respirology. 2018;24(3):246-53. https://doi.org/10.1111/resp.13397
https://doi.org/10.1111/resp.13397...
), in which it was concluded that a high intensity training of the inspiratory muscles shows higher values in the social aspects of QoL, lower values of dyspnea in people with bronchiectasis, as well as less fatigue, just with the implementation of regular exercise training. This statement is corroborated by other authors, who report that the application of inspiratory muscle training reflects an increase in these muscles’ strength, as well as an improvement in the level of pulmonary ventilation, also positively intervening in people’s QoL, when relating with the decrease in the sensation of dyspnea(2727 Palmela FMC. O efeito do treino dos músculos inspiratórios em pacientes com doença pulmonar obstrutiva crónica: revisão bibliográfica [Internship Project]. Porto (Portugal): Universidade Fernando Pessoa; 2020[cited 2021 Jun 21]. 15 p. Available from: http://hdl.handle.net/10284/9177
http://hdl.handle.net/10284/9177...
).

Dwyer et al.(1414 Muñoz G, Gracia J, Buxó M, Alvarez A, Vendrell M. Long-term benefits of airway clearance in bronchiectasis: a randomised placebo-controlled trial. Eur Respir J. 2018;51(1):1701926. https://doi.org/10.1183/13993003.01926-2017
https://doi.org/10.1183/13993003.01926-2...
,1818 Nicolini A, Grecchi B, Ferrari-Bravo M, Barlascini C. Safety and effectiveness of the high-frequency chest wall oscillation vs intrapulmonary percussive ventilation in patients with severe COPD. Int J Chron Obstruct Pulmon Dis. 2018;13:617-25. http://doi.org/10.2147/COPD.S145440
http://doi.org/10.2147/COPD.S145440...
) based themselves on the fact that physical exercise can replace airway clearance related interventions. They concluded that exercise alone on a treadmill was effective in eliminating secretions by facilitating the act of expectorating. Such statements can be related to the study by Marques et al.(1919 Marques A, Pinho C, Francesco S, Martins P, Neves J, Oliveira A. A randomized controlled trial of respiratory physiotherapy in lower respiratory tract infections. Respir Med. 2020;162:105861. https://doi.org/10.1016/j.rmed.2019.105861
https://doi.org/10.1016/j.rmed.2019.1058...
), in which there is an improvement in pulmonary crackle auscultation. In this sense, the auscultation of adventitious noises is a viable method to assess the effects of airway clearing techniques(2828 Herrero-Cortina B, Oliveira A, Polverino E, Gómez-Trullén EM, Torres A, Marques A. Feasibility of computerized adventitious respiratory sounds to assess the effects of airway clearance techniques in patients with bronchiectasis. Physiother Theory Pract. 2019;36(11):1245-55. https://doi.org/10.1080/09593985.2019.1566945
https://doi.org/10.1080/09593985.2019.15...
).

A cardiopulmonary rehabilitation program produces beneficial effects on the functioning of the respiratory system, stabilization of respiratory pressures, muscle strengthening and exercise tolerance, functional independence in carrying out activities of daily living, less fatigue, and changes in QoL(2929 Nagamine BP, Maciel DMVL. Novos desafios da reabilitação em pacientes DPOC. Res Soc Dev. 2021;10(4):1-6. http://doi.org/10.33448/rsd-v10i4.13901
http://doi.org/10.33448/rsd-v10i4.13901...
). It is noteworthy that QoL is considered an essential parameter, as it is a common result obtained in some studies, which reveal that the positive effects in this domain arise with the application of the ELTGOL(1414 Muñoz G, Gracia J, Buxó M, Alvarez A, Vendrell M. Long-term benefits of airway clearance in bronchiectasis: a randomised placebo-controlled trial. Eur Respir J. 2018;51(1):1701926. https://doi.org/10.1183/13993003.01926-2017
https://doi.org/10.1183/13993003.01926-2...
) and H-IMT(1515 Ozalp O, Inal-Ince D, Cakmak A, Calik-Kutukcu E, Saglam M, Savci S, et al. High-intensity inspiratory muscle training in bronchiectasis: a randomized controlled trial. Respirology. 2018;24(3):246-53. https://doi.org/10.1111/resp.13397
https://doi.org/10.1111/resp.13397...
) techniques.

Regarding breathing with semi-closed lips, this allows for greater control of the breathing pattern, reducing the associated breathing work(2525 Ordem dos Enfermeiros (PT). Guia orientador de boa prática: reabilitação respiratória [Internet]. [Lisboa]: Ordem dos Enfermeiros; 2018[cited 2021 Jun 10]. Available from: https://www.ordemenfermeiros.pt/media/5441/gobp_reabilita%C3%A7%C3%A3o-respirat%C3%B3ria_mceer_final-para-divulga%C3%A7%C3%A3o-site.pdf
https://www.ordemenfermeiros.pt/media/54...
). Breathing with semi-closed lips is highlighted in the study by Liao et al.(1616 Liao L-Y, Chen K-M, Chung W-S, Chien J-Y. Efficacy of a respiratory rehabilitation exercise training package in hospitalized elderly patients with acute exacerbation of COPD: a randomized control trial. Int J Chron Obstruct Pulmon Dis. 2015;10(1):1703-9. http://doi.org/10.2147/COPD.S90673
http://doi.org/10.2147/COPD.S90673...
) and in the study by Marques et al.(1919 Marques A, Pinho C, Francesco S, Martins P, Neves J, Oliveira A. A randomized controlled trial of respiratory physiotherapy in lower respiratory tract infections. Respir Med. 2020;162:105861. https://doi.org/10.1016/j.rmed.2019.105861
https://doi.org/10.1016/j.rmed.2019.1058...
), being that the latter study also emphasizes the resting and relaxation position and diaphragmatic breathing. Diaphragmatic breathing, with or without semi-closed lips, promotes an increase in lung volumes and oxygenation without increasing the sensation of dyspnea(3030 Mendes LPS, Moraes KS, Hoffman M, Vieira DSR, Ribeiro-Samora GA, Lage SM, et al. Effects of diaphragmatic breathing with and without pursed-lips breathing in subjects with COPD. Respir Care. 2019;64(2):136-44. https://doi.org/10.4187/respcare.06319
https://doi.org/10.4187/respcare.06319...
). Similarly, breathing with semi-closed lips, together with diaphragmatic breathing, has proven to be effective in improving respiratory function and physical capacity in patients with COPD(3131 Yang Y, Wei L, Wang S, Ke L, Zhao H, Mao J, et al. The effects of pursed lip breathing combined with diaphragmatic breathing on pulmonary function and exercise capacity in patients with COPD: a systematic review and meta-analysis. Physiother Theory Pract. 2020;1-11. https://doi.org/10.1080/09593985.2020.1805834
https://doi.org/10.1080/09593985.2020.18...
). All these techniques promote breathing control, resulting in a lesser sensation of dyspnea, as reported in the studies by Liao et al.(1616 Liao L-Y, Chen K-M, Chung W-S, Chien J-Y. Efficacy of a respiratory rehabilitation exercise training package in hospitalized elderly patients with acute exacerbation of COPD: a randomized control trial. Int J Chron Obstruct Pulmon Dis. 2015;10(1):1703-9. http://doi.org/10.2147/COPD.S90673
http://doi.org/10.2147/COPD.S90673...
) and Marques et al.(1919 Marques A, Pinho C, Francesco S, Martins P, Neves J, Oliveira A. A randomized controlled trial of respiratory physiotherapy in lower respiratory tract infections. Respir Med. 2020;162:105861. https://doi.org/10.1016/j.rmed.2019.105861
https://doi.org/10.1016/j.rmed.2019.1058...
). Therefore, the relevance of such techniques is highlighted, which should integrate all FRR sessions, namely at the beginning of any session, which should start with the resting and relaxation position in association with the control and dissociation of respiratory times(2424 Cordeiro MCO, Menoita ECPC. Reeducação funcional respiratória. In: Cordeiro MCO, Menoita ECPC, coordinators. Manual de boas práticas na reabilitação respiratória: conceitos, princípios e técnicas. Loures: Lusociência; 2012. p. 61-115.).

In terms of aid devices that use O-PEP to promote the elimination of secretions and the consequent clearing of the airways, Flutter® stands out in the trials done by Dwyer et al.(1717 Dwyer TJ, Zainuldin R, Daviskas E, Bye PTP, Alison JA. Effects of treadmill exercise versus Flutter® on respiratory flow and sputum properties in adults with cystic fibrosis: a randomised, controlled, cross-over trial. BMC Pulm Med. 2017;17(14):14. https://doi.org/10.1186/s12890-016-0360-8
https://doi.org/10.1186/s12890-016-0360-...
) and by Simoni et al.(2222 Simoni LHS, Santos DO, Souza HCD, Baddini-Martinez JA, Santos MK, Gastaldi AC. Acute effects of oscillatory PEP and thoracic compression on secretion removal and impedance of the respiratory system in non-cystic fibrosis bronchiectasis. Respir Care. 2019;64(7):818-27. https://doi.org/10.4187/respcare.06025
https://doi.org/10.4187/respcare.06025...
). In the work by Dwyer et al.(1717 Dwyer TJ, Zainuldin R, Daviskas E, Bye PTP, Alison JA. Effects of treadmill exercise versus Flutter® on respiratory flow and sputum properties in adults with cystic fibrosis: a randomised, controlled, cross-over trial. BMC Pulm Med. 2017;17(14):14. https://doi.org/10.1186/s12890-016-0360-8
https://doi.org/10.1186/s12890-016-0360-...
), it was found that the Flutter® increases the peak expiratory flow and helps to eliminate secretions, highlighting the tendency of this device for expiratory airflow in adults with cystic fibrosis, as well as increased subjective sensation of expectoration. In addition to the PEP-generating device, the teaching of coughing and huffing was mentioned in the Dwyer et al.(1717 Dwyer TJ, Zainuldin R, Daviskas E, Bye PTP, Alison JA. Effects of treadmill exercise versus Flutter® on respiratory flow and sputum properties in adults with cystic fibrosis: a randomised, controlled, cross-over trial. BMC Pulm Med. 2017;17(14):14. https://doi.org/10.1186/s12890-016-0360-8
https://doi.org/10.1186/s12890-016-0360-...
,2121 Dwyer TJ, Daviskas E, Zainuldin R, Verschuer J, Eberl S, Bye PTP, et al. Effects of exercise and airway clearance (positive expiratory pressure) on mucus clearance in cystic fibrosis: a randomised cross-over trial. Eur Respir J. 2019;53(4):1801793. https://doi.org/10.1183/13993003.01793-2018
https://doi.org/10.1183/13993003.01793-2...
) trials, which demonstrated an improvement in airway clearing. However, huffing has an advantage over coughing, as it has a greater potential in mobilizing secretions(2525 Ordem dos Enfermeiros (PT). Guia orientador de boa prática: reabilitação respiratória [Internet]. [Lisboa]: Ordem dos Enfermeiros; 2018[cited 2021 Jun 10]. Available from: https://www.ordemenfermeiros.pt/media/5441/gobp_reabilita%C3%A7%C3%A3o-respirat%C3%B3ria_mceer_final-para-divulga%C3%A7%C3%A3o-site.pdf
https://www.ordemenfermeiros.pt/media/54...
).

Also, with regard to the positive expiratory pressures provided by Flutter®, the research by Nicolini et al.(2020 Nicolini A, Mascardi V, Grecchi B, Ferrari-Bravo M, Banfi P, Barlascini C. Comparison of effectiveness of temporary positive expirayory pressure versus oscillatory positive expiratory pressure in severe COPD patients. Clin Respir J. 2017;12(3):1274-82. https://doi.org/10.1111/crj.12661
https://doi.org/10.1111/crj.12661...
) and Dwyer et al.(2121 Dwyer TJ, Daviskas E, Zainuldin R, Verschuer J, Eberl S, Bye PTP, et al. Effects of exercise and airway clearance (positive expiratory pressure) on mucus clearance in cystic fibrosis: a randomised cross-over trial. Eur Respir J. 2019;53(4):1801793. https://doi.org/10.1183/13993003.01793-2018
https://doi.org/10.1183/13993003.01793-2...
) are highlighted. In these trials, the O-PEP and T-PEP airway clearing devices, in addition to being well tolerated, enabled the improvement of pulmonary function and dyspnea(2020 Nicolini A, Mascardi V, Grecchi B, Ferrari-Bravo M, Banfi P, Barlascini C. Comparison of effectiveness of temporary positive expirayory pressure versus oscillatory positive expiratory pressure in severe COPD patients. Clin Respir J. 2017;12(3):1274-82. https://doi.org/10.1111/crj.12661
https://doi.org/10.1111/crj.12661...
), favoring coughing spells and the consequent elimination of secretions(2121 Dwyer TJ, Daviskas E, Zainuldin R, Verschuer J, Eberl S, Bye PTP, et al. Effects of exercise and airway clearance (positive expiratory pressure) on mucus clearance in cystic fibrosis: a randomised cross-over trial. Eur Respir J. 2019;53(4):1801793. https://doi.org/10.1183/13993003.01793-2018
https://doi.org/10.1183/13993003.01793-2...
). T-PEP also demonstrated an efficacy like other techniques in reducing exacerbations(2020 Nicolini A, Mascardi V, Grecchi B, Ferrari-Bravo M, Banfi P, Barlascini C. Comparison of effectiveness of temporary positive expirayory pressure versus oscillatory positive expiratory pressure in severe COPD patients. Clin Respir J. 2017;12(3):1274-82. https://doi.org/10.1111/crj.12661
https://doi.org/10.1111/crj.12661...
). Other authors corroborate this by stating that patients’ access to the T-PEP device evidenced a lower number of exacerbations in patients with COPD, improving the parameters of respiratory function and the values of the dyspnea scale(3232 Mascardi V, Grecchi B, Barlascini C, Banfi P, Nicolini A. Effectiveness of temporary positive expiratory pressure (T-PEP) at home and at hospital in patients with severe chronic obstructive pulmonary disease. J Thorac Dis. 2016;8(10):2895-902. http://doi.org/10.21037/jtd.2016.10.69
http://doi.org/10.21037/jtd.2016.10.69...
).

The use of Flutter® was associated with a lower number of complaints of coughing and fatigue, and with an increase in the production and elimination of secretions, with identification of similar results for the ACBT(3333 Üzmezoğlu B, Altıay G, Özdemir L, Tuna H, Süt N. The efficacy of Flutter® and active cycle of breathing techniques in patients with bronchiectasis: a prospective, randomized, comparative study. Turk Thorac J. 2018;19(3):103-9. https://doi.org/10.5152/TurkThoracJ.2018.17050
https://doi.org/10.5152/TurkThoracJ.2018...
), this technique being highlighted in the study by Marques et al.(1919 Marques A, Pinho C, Francesco S, Martins P, Neves J, Oliveira A. A randomized controlled trial of respiratory physiotherapy in lower respiratory tract infections. Respir Med. 2020;162:105861. https://doi.org/10.1016/j.rmed.2019.105861
https://doi.org/10.1016/j.rmed.2019.1058...
), by integrating a FRR program that obtained as results an improvement in the symptoms of respiratory infection, which includes the presence of sputum. Both postural drainage associated with ACBT and postural drainage with percussion are linked with an improvement in the elimination of secretions and a reduction in dyspnea, although the greatest results are seen in the association of ACBT with postural drainage(3434 Phillips J, Lee A, Pope R, Hing W. Effect of airway clearance techniques in patients experiencing an acute exacerbation of bronchiectasis: a systematic review. Physiother Theory Pract. 2019;36(12):1300-15. https://doi.org/10.1080/09593985.2019.1579286
https://doi.org/10.1080/09593985.2019.15...
). Even so, these results are in line with the study by Liao et al.(1616 Liao L-Y, Chen K-M, Chung W-S, Chien J-Y. Efficacy of a respiratory rehabilitation exercise training package in hospitalized elderly patients with acute exacerbation of COPD: a randomized control trial. Int J Chron Obstruct Pulmon Dis. 2015;10(1):1703-9. http://doi.org/10.2147/COPD.S90673
http://doi.org/10.2147/COPD.S90673...
), in which the application of postural drainage is studied along with percussion (associated with breathing control and mobilization of the upper limbs) in elderly hospitalized with COPD and who obtained as results a sensation of less dyspnea, a greater tolerance to the exercise, and a greater capacity to expectorate.

Highlighted in the trial by Nicolini et al.(1818 Nicolini A, Grecchi B, Ferrari-Bravo M, Barlascini C. Safety and effectiveness of the high-frequency chest wall oscillation vs intrapulmonary percussive ventilation in patients with severe COPD. Int J Chron Obstruct Pulmon Dis. 2018;13:617-25. http://doi.org/10.2147/COPD.S145440
http://doi.org/10.2147/COPD.S145440...
), the IPV and HFCWO devices are also relevant to ensure airway permeability. In the present trial, when comparing the two devices, it was found that the IPV showed an improvement in terms of maximum inspiratory and expiratory pressure, as well as greater effectiveness in clearing the airways and strengthening the pulmonary muscles. Still, the two devices have been shown to improve lung function and the performance of ADL in people with COPD, through intrapulmonary and extrapulmonary oscillation. A device such as the IPV generates positive airway pressure oscillations upon exhalation and has the expected result of mobilizing bronchial secretions, as expected from HFCWO. This differs from the first device in terms of oscillations, which are applied externally to the chest wall, and adds other expected results, such as reduced air trapping, improved ventilation, and increased residual capacity(2525 Ordem dos Enfermeiros (PT). Guia orientador de boa prática: reabilitação respiratória [Internet]. [Lisboa]: Ordem dos Enfermeiros; 2018[cited 2021 Jun 10]. Available from: https://www.ordemenfermeiros.pt/media/5441/gobp_reabilita%C3%A7%C3%A3o-respirat%C3%B3ria_mceer_final-para-divulga%C3%A7%C3%A3o-site.pdf
https://www.ordemenfermeiros.pt/media/54...
).

Health education sessions are also highlighted in the investigations by Liao et al.(1616 Liao L-Y, Chen K-M, Chung W-S, Chien J-Y. Efficacy of a respiratory rehabilitation exercise training package in hospitalized elderly patients with acute exacerbation of COPD: a randomized control trial. Int J Chron Obstruct Pulmon Dis. 2015;10(1):1703-9. http://doi.org/10.2147/COPD.S90673
http://doi.org/10.2147/COPD.S90673...
) and Marques et al.(1919 Marques A, Pinho C, Francesco S, Martins P, Neves J, Oliveira A. A randomized controlled trial of respiratory physiotherapy in lower respiratory tract infections. Respir Med. 2020;162:105861. https://doi.org/10.1016/j.rmed.2019.105861
https://doi.org/10.1016/j.rmed.2019.1058...
) as an essential component of FRR. The implementation of FRR programs that include an educational aspect in addition to exercise makes it possible to verify, in the short term, improvements in physical capacity and QoL in people with bronchiectasis(3535 Lee AL, Hill CJ, McDonald CF, Holland AE. Pulmonary rehabilitation in individuals with non-cystic fibrosis bronchiectasis: a systematic review. Arch Phys Med Rehabil. 201616;98(4):774-82. https://doi.org/10.1016/j.apmr.2016.05.017
https://doi.org/10.1016/j.apmr.2016.05.0...
).

In general, within the selected studies, it was found that the implementation of a set of isolated interventions or those included in a rehabilitation program resulted in an improvement in lung function and, therefore, in an increase in the production and more effective elimination of secretions, airway clearance, lower values on the dyspnea scale, and a relief of dyspnea-related symptoms (reduced impact of coughing), fewer exacerbations, less fatigue, greater exercise tolerance, strengthening of the pulmonary muscles, better maximal inspiratory and expiratory pressures, alterations in pulmonary auscultation, and improvements verified in arterial blood gases and oxygen saturation, these techniques being well tolerated by people. Other gains were also verified, namely in terms of QoL, recovery of functional parameters, and performance of ADL.

Thus, for the transition process to be successful, specifically in the transition from the state of least functionality to that of maximum functionality, transitional care must be based on the steps of the nursing process and in accordance with a holistic view of the person(88 Silva CFT, Pedreira LC, Amaral JB, Mussi FC, Martorell-Povesa MA, Souza ML. The care offered by nurses to elders with coronary artery disease from the perspective of transitions theory. Rev Bras Enferm. 2021;74(suppl 2):e202000992. https://doi.org/10.1590/0034-7167-2020-0992
https://doi.org/10.1590/0034-7167-2020-0...
).

Study limitations

As limitations to the SLR, it can be stated that most trials included FRR programs that encompassed several interventions and techniques of the SNRN, being difficult in some cases to identify which intervention produced the beneficial effect. Regarding the techniques and interventions, these acquire a different nomenclature depending on the country of origin of the study, which constituted another limitation to this SLR. In addition to studies addressing respiratory pathologies with pulmonary hypersecretion, they constitute different pathologies that present their particularities in terms of gains in rehabilitation. In the same way, they comprised, in the inclusion criteria, a very wide age group, making it difficult to study a specific population group. The use of only one database and the inclusion of works written only in Portuguese and English were also limitations to the realization of this SLR, as well as the exclusion of publications carried out in 2021 and some uncontrolled methodological aspects, such as the access to the database taking place in June and submission for publication happening only in August.

Contributions to the field of nursing, health, or public policy

Based on scientific evidence, it is possible to identify several rehabilitation nursing interventions, with an emphasis on FRR, which produce health gains in people with respiratory disease. Likewise, based on the identified and highlighted interventions, its importance in the level of respiratory function can be highlighted, namely in improving the effectiveness of the mechanism for clearing the airways and promoting sputum and coughing, reducing the sensation of dyspnea, as well as better results in arterial blood gases, oxygen saturation, pulmonary auscultation, and functionality tests.

Still, there is a need to invest not only in carrying out more trials, but also in the implementation of programs in the area of rehabilitation nursing that study, prove, and identify the particularities of the SNRN techniques or interventions in a unique way, noting which are the resulting health gains, in addition to those seen in this SLR and without other associated variables such as the existence of concomitant pharmacological treatment.

It is suggested that, in the future, more trials are carried out, specifically of long duration, and that particularize a certain age group, as in the case of the elderly population. This study also allows for the promotion of the application of good practices in the context of rehabilitation nursing care.

CONCLUSIONS

The realization of this SLR made it possible to take balance of the existing knowledge about interventions for functional respiratory reeducation and the benefits they produce in people with respiratory disease. In its production, it was essential to reflect rigor and quality for this work to be credible and to reduce the risk of biased results, which could jeopardize and undermine the provision of nursing care, as well as the knowledge produced. Thus, in order to highlight rehabilitation nursing and demonstrate its central role in health care, it is necessary to constantly increase the degree of recommendation and the strength and quality of the evidence produced, based on the performance of this type of work.

Therefore, in order to answer the initially formulated question, nursing interventions in rehabilitation, within the scope of functional respiratory reeducation, which allow a respiratory function improvement in people with respiratory disease are: ELTGOL, CIFE, back opening with mobilization of the upper limbs, lower limb walking/mobilization training with breathing control, lower back re-education, high-intensity training of inspiratory muscles, exercise training, treadmill exercises, postural drainage and percussion, breathing with semi-closed lips, resting position and relaxation, diaphragmatic breathing, ACBT, Flutter®/O-PEP, T-PEP, intrapulmonary and extrapulmonary oscillation, cough teaching associated with huffing, and health education sessions.

Despite the aforementioned limitations, this SLR answered the initially formulated question, allowing evidence, within the scope of the FRR and the rehabilitation nursing programs, of health gains in people’s respiratory function, such as the improvement of airway clearing mechanisms, through the promotion of coughing and elimination of secretions, reduction of dyspnea, and improvements obtained in arterial blood gases, oxygen saturation, pulmonary auscultation and functionality tests. Thus, this SLR led to the production of knowledge based on scientific evidence in the field of rehabilitation nursing.

REFERENCES

  • 1
    Instituto Nacional de Estatística (PT). Causas de morte: mortes por doenças do aparelho respiratório aumentaram 3,8%: 2018 [Internet]. Lisboa: INE; 2017[cited 2021 Jun 3]. Available from: https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_destaques&DESTAQUESdest_boui=399595771&DESTAQUESmodo=2&xlang=pt
    » https://www.ine.pt/xportal/xmain?xpid=INE&xpgid=ine_destaques&DESTAQUESdest_boui=399595771&DESTAQUESmodo=2&xlang=pt
  • 2
    Menoita EPC. Reabilitação respiratória na pessoa idosa. In: Cordeiro MCO, Menoita ECPC, coordinators. Manual de boas práticas na reabilitação respiratória: conceitos, princípios e técnicas. Loures: Lusociência; 2012. p. 317-20.
  • 3
    Gomes BN, Ferreira D. Reeducação da função respiratória. In: Marques-Vieira C, Sousa L, coordinators. Cuidados de enfermagem de reabilitação à pessoa ao longo da vida. Loures: Lusodidacta; 2016. p. 253-62.
  • 4
    Ordem dos Enfermeiros (PT). Regulamento nº 350, de 22 de jun de 2015. Regulamento dos padrões de qualidade dos cuidados especializados em enfermagem em enfermagem de reabilitação [Internet]. [Lisboa]: DRE; 2015[cited 2021 Oct 19]. Available from: https://dre.pt/home/-/dre/67552234/details/maximized
    » https://dre.pt/home/-/dre/67552234/details/maximized
  • 5
    Ferreira D, Santos A. Avaliação da pessoa com patologia respiratória. In: Marques-Vieira C, Sousa L, coordinators. Cuidados de enfermagem de reabilitação à pessoa ao longo da vida. Loures: Lusodidacta; 2016. p. 167-80.
  • 6
    Cui L, Liu H, Sun L. Multidisciplinary respiratory rehabilitation in combination with non-invasive positive pressure ventilation in the treatment of elderly patients with severe chronic obstructive pulmonary disease. Pak J Med Sci. 2019;2(35):500-5. https://doi.org/10.12669/pjms.35.2.459
    » https://doi.org/10.12669/pjms.35.2.459
  • 7
    Liu K, Zhang W, Yang Y, Zhang J, Li Y, Chen Y. Respiratory rehabilitation in elderly patients with COVID-19: a randomized controlled study. Complement Ther Clin Pract. 2020;39:101166. https://doi.org/10.1016/j.ctcp.2020.101166
    » https://doi.org/10.1016/j.ctcp.2020.101166
  • 8
    Silva CFT, Pedreira LC, Amaral JB, Mussi FC, Martorell-Povesa MA, Souza ML. The care offered by nurses to elders with coronary artery disease from the perspective of transitions theory. Rev Bras Enferm. 2021;74(suppl 2):e202000992. https://doi.org/10.1590/0034-7167-2020-0992
    » https://doi.org/10.1590/0034-7167-2020-0992
  • 9
    Sousa LMM, Firmino CF, Marques-Vieira CMA, Severino SSP, Pestana HCFC. Scientific literature reviews: types, methods and applications in nursing. Rev Port Enferm Reab. 2018;1(1):45-54. https://doi.org/10.33194/rper.2018.v1.n1.07.4391
    » https://doi.org/10.33194/rper.2018.v1.n1.07.4391
  • 10
    Apóstolo JLA. Síntese da evidência no contexto da translação da ciência. Coimbra: Escola Superior de Enfermagem de Coimbra; 2017.
  • 11
    Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. http://doi.org/10.1136/bmj.n71
    » http://doi.org/10.1136/bmj.n71
  • 12
    Joanne Briggs Institute. JBI levels of evidence [Internet]. Adelaide: JBI; 2013[cited 2021 Jun 8]. Available from: https://jbi.global/sites/default/files/2019-05/JBI-Levels-of-evidence_2014_0.pdf
    » https://jbi.global/sites/default/files/2019-05/JBI-Levels-of-evidence_2014_0.pdf
  • 13
    Joanna Briggs Institute. Checklist for randomized controlled trials: critical appraisal tools for use in JBI systematic reviews [Internet]. Adelaide: JBI; 2020[cited 2021 Jun 08]. Available from: https://jbi.global/sites/default/files/2021-03/Checklist_for_RCTs.docx
    » https://jbi.global/sites/default/files/2021-03/Checklist_for_RCTs.docx
  • 14
    Muñoz G, Gracia J, Buxó M, Alvarez A, Vendrell M. Long-term benefits of airway clearance in bronchiectasis: a randomised placebo-controlled trial. Eur Respir J. 2018;51(1):1701926. https://doi.org/10.1183/13993003.01926-2017
    » https://doi.org/10.1183/13993003.01926-2017
  • 15
    Ozalp O, Inal-Ince D, Cakmak A, Calik-Kutukcu E, Saglam M, Savci S, et al. High-intensity inspiratory muscle training in bronchiectasis: a randomized controlled trial. Respirology. 2018;24(3):246-53. https://doi.org/10.1111/resp.13397
    » https://doi.org/10.1111/resp.13397
  • 16
    Liao L-Y, Chen K-M, Chung W-S, Chien J-Y. Efficacy of a respiratory rehabilitation exercise training package in hospitalized elderly patients with acute exacerbation of COPD: a randomized control trial. Int J Chron Obstruct Pulmon Dis. 2015;10(1):1703-9. http://doi.org/10.2147/COPD.S90673
    » http://doi.org/10.2147/COPD.S90673
  • 17
    Dwyer TJ, Zainuldin R, Daviskas E, Bye PTP, Alison JA. Effects of treadmill exercise versus Flutter® on respiratory flow and sputum properties in adults with cystic fibrosis: a randomised, controlled, cross-over trial. BMC Pulm Med. 2017;17(14):14. https://doi.org/10.1186/s12890-016-0360-8
    » https://doi.org/10.1186/s12890-016-0360-8
  • 18
    Nicolini A, Grecchi B, Ferrari-Bravo M, Barlascini C. Safety and effectiveness of the high-frequency chest wall oscillation vs intrapulmonary percussive ventilation in patients with severe COPD. Int J Chron Obstruct Pulmon Dis. 2018;13:617-25. http://doi.org/10.2147/COPD.S145440
    » http://doi.org/10.2147/COPD.S145440
  • 19
    Marques A, Pinho C, Francesco S, Martins P, Neves J, Oliveira A. A randomized controlled trial of respiratory physiotherapy in lower respiratory tract infections. Respir Med. 2020;162:105861. https://doi.org/10.1016/j.rmed.2019.105861
    » https://doi.org/10.1016/j.rmed.2019.105861
  • 20
    Nicolini A, Mascardi V, Grecchi B, Ferrari-Bravo M, Banfi P, Barlascini C. Comparison of effectiveness of temporary positive expirayory pressure versus oscillatory positive expiratory pressure in severe COPD patients. Clin Respir J. 2017;12(3):1274-82. https://doi.org/10.1111/crj.12661
    » https://doi.org/10.1111/crj.12661
  • 21
    Dwyer TJ, Daviskas E, Zainuldin R, Verschuer J, Eberl S, Bye PTP, et al. Effects of exercise and airway clearance (positive expiratory pressure) on mucus clearance in cystic fibrosis: a randomised cross-over trial. Eur Respir J. 2019;53(4):1801793. https://doi.org/10.1183/13993003.01793-2018
    » https://doi.org/10.1183/13993003.01793-2018
  • 22
    Simoni LHS, Santos DO, Souza HCD, Baddini-Martinez JA, Santos MK, Gastaldi AC. Acute effects of oscillatory PEP and thoracic compression on secretion removal and impedance of the respiratory system in non-cystic fibrosis bronchiectasis. Respir Care. 2019;64(7):818-27. https://doi.org/10.4187/respcare.06025
    » https://doi.org/10.4187/respcare.06025
  • 23
    Herrero-Cortina B, Vilaró J, Martí D, Torres A, San Miguel-Pagola M, Alcaraz V, et al. Short-term effects of three slow expiratory airway clearance techniques in patients with bronchiectasis: a randomised crossover trial. Physiotherapy. 2015;102(4):357-64. http://doi.org/10.1016/j.physio.2015.07.005
    » http://doi.org/10.1016/j.physio.2015.07.005
  • 24
    Cordeiro MCO, Menoita ECPC. Reeducação funcional respiratória. In: Cordeiro MCO, Menoita ECPC, coordinators. Manual de boas práticas na reabilitação respiratória: conceitos, princípios e técnicas. Loures: Lusociência; 2012. p. 61-115.
  • 25
    Ordem dos Enfermeiros (PT). Guia orientador de boa prática: reabilitação respiratória [Internet]. [Lisboa]: Ordem dos Enfermeiros; 2018[cited 2021 Jun 10]. Available from: https://www.ordemenfermeiros.pt/media/5441/gobp_reabilita%C3%A7%C3%A3o-respirat%C3%B3ria_mceer_final-para-divulga%C3%A7%C3%A3o-site.pdf
    » https://www.ordemenfermeiros.pt/media/5441/gobp_reabilita%C3%A7%C3%A3o-respirat%C3%B3ria_mceer_final-para-divulga%C3%A7%C3%A3o-site.pdf
  • 26
    Cordeiro MCO, Mateus DM, Menoita EC, Rocha B, Marques P, Rocha S, et al. Treino de exercício na pessoa com patologia respiratória crónica. In: Cordeiro MCO, Menoita ECPC, coordinators. Manual de boas práticas na reabilitação respiratória: conceitos, princípios e técnicas. Loures: Lusociência; 2012. p. 117-43.
  • 27
    Palmela FMC. O efeito do treino dos músculos inspiratórios em pacientes com doença pulmonar obstrutiva crónica: revisão bibliográfica [Internship Project]. Porto (Portugal): Universidade Fernando Pessoa; 2020[cited 2021 Jun 21]. 15 p. Available from: http://hdl.handle.net/10284/9177
    » http://hdl.handle.net/10284/9177
  • 28
    Herrero-Cortina B, Oliveira A, Polverino E, Gómez-Trullén EM, Torres A, Marques A. Feasibility of computerized adventitious respiratory sounds to assess the effects of airway clearance techniques in patients with bronchiectasis. Physiother Theory Pract. 2019;36(11):1245-55. https://doi.org/10.1080/09593985.2019.1566945
    » https://doi.org/10.1080/09593985.2019.1566945
  • 29
    Nagamine BP, Maciel DMVL. Novos desafios da reabilitação em pacientes DPOC. Res Soc Dev. 2021;10(4):1-6. http://doi.org/10.33448/rsd-v10i4.13901
    » http://doi.org/10.33448/rsd-v10i4.13901
  • 30
    Mendes LPS, Moraes KS, Hoffman M, Vieira DSR, Ribeiro-Samora GA, Lage SM, et al. Effects of diaphragmatic breathing with and without pursed-lips breathing in subjects with COPD. Respir Care. 2019;64(2):136-44. https://doi.org/10.4187/respcare.06319
    » https://doi.org/10.4187/respcare.06319
  • 31
    Yang Y, Wei L, Wang S, Ke L, Zhao H, Mao J, et al. The effects of pursed lip breathing combined with diaphragmatic breathing on pulmonary function and exercise capacity in patients with COPD: a systematic review and meta-analysis. Physiother Theory Pract. 2020;1-11. https://doi.org/10.1080/09593985.2020.1805834
    » https://doi.org/10.1080/09593985.2020.1805834
  • 32
    Mascardi V, Grecchi B, Barlascini C, Banfi P, Nicolini A. Effectiveness of temporary positive expiratory pressure (T-PEP) at home and at hospital in patients with severe chronic obstructive pulmonary disease. J Thorac Dis. 2016;8(10):2895-902. http://doi.org/10.21037/jtd.2016.10.69
    » http://doi.org/10.21037/jtd.2016.10.69
  • 33
    Üzmezoğlu B, Altıay G, Özdemir L, Tuna H, Süt N. The efficacy of Flutter® and active cycle of breathing techniques in patients with bronchiectasis: a prospective, randomized, comparative study. Turk Thorac J. 2018;19(3):103-9. https://doi.org/10.5152/TurkThoracJ.2018.17050
    » https://doi.org/10.5152/TurkThoracJ.2018.17050
  • 34
    Phillips J, Lee A, Pope R, Hing W. Effect of airway clearance techniques in patients experiencing an acute exacerbation of bronchiectasis: a systematic review. Physiother Theory Pract. 2019;36(12):1300-15. https://doi.org/10.1080/09593985.2019.1579286
    » https://doi.org/10.1080/09593985.2019.1579286
  • 35
    Lee AL, Hill CJ, McDonald CF, Holland AE. Pulmonary rehabilitation in individuals with non-cystic fibrosis bronchiectasis: a systematic review. Arch Phys Med Rehabil. 201616;98(4):774-82. https://doi.org/10.1016/j.apmr.2016.05.017
    » https://doi.org/10.1016/j.apmr.2016.05.017

Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho
ASSOCIATE EDITOR: Maria Itayra Padilha

Publication Dates

  • Publication in this collection
    30 Mar 2022
  • Date of issue
    2022

History

  • Received
    26 Aug 2021
  • Accepted
    28 Nov 2021
Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br