INTRODUCTION

Extreme and intense climatic phenomena are currently an increasingly frequent reality, with serious consequences for the health of the population, reflected in the increase in morbidity and mortality experienced in these periods¹. The autumn and winter months are associated with an increase in the seasonal influenza epidemic, which despite being an acute respiratory disease and mostly benign, in some cases may have a more severe evolution (implying an increase in demand for health services) annually responsible for 3 to 5 million cases of severe disease and for 250,000 to 500,000 deaths worldwide^1,2. In Portugal, epidemiological surveillance is carried out by the Sentinel Medical Network in collaboration with the National Reference Laboratory for the Influenza Virus and Other Respiratory Viruses in the Department of Epidemiology of the Ricardo Jorge Institute, issuing weekly surveillance bulletins. According to them, for the 2018/2019 season there was an increase in the incidence rate beginning on December 3, 2018, assuming epidemic flu activity between January 21 and 27, 2019, with an incidence rate of 89.3 per 100,000 inhabitants due to the circulation of subtype A³.

Influenza virus infection, in addition to increasing the risk of exacerbating chronic diseases, presents as the most frequent complication secondary to bacterial overinfection, mainly caused by Streptococcus pneumoniae, Haemophilus Influenzae and Staphylococcus aureus^1,4.

Pneumonia is an infection of the lung parenchyma in which all or part of the alveoli are filled with fluid and erythrocytes, conferring the designation of pulmonary consolidation, replacing both the air available in the alveoli and the area available for gas exchange. This is a phenomenon that gives it a restrictive pattern due to the reduction in pulmonary compliance, reflected in an increase in respiratory rate, a reduction in tidal volume and in the ventilation-perfusion index⁵.

Pneumonia (n=40345) is assumed in Portugal as the main cause of hospitalization for respiratory disease in 2016, followed by chronic obstructive pulmonary disease (n=7864) and lung cancer (n=5541)⁶. Pneumonia is responsible for 7% of hospital admissions, with an increased prevalence in patients aged 80 years-old and over, with high percentages of morbidity and mortality, the latter being at 20%⁶.

Community-acquired pneumonia is one that has its origin in the community or that manifests within 48 hours after the person is hospitalized. Commonly, the person presents with chest pain, fever, dyspnea, cough, initially mucous and progressively purulent sputum, and chills. Pulmonary auscultation is marked by the presence of audible crackling ferns in both breaths, although more intense in the inspiratory phase and often in the posterior phase of the thorax at the level of the middle lung fields, simulating "hair squeezing between the fingers"^7,8. The presence of consolidations is identified by a hyporesonance to percussion⁹ and an increase in the thoraco-vocal shiver on palpation⁵.

In situations of hospitalization of a person with community-acquired pneumonia, the person should undergo control by chest teleradiography and arterial blood gas. Chest teleradiography is an essential means of diagnosis in this area, providing information on the lung parenchyma, mediastinum, bone structures and soft tissues⁵. In community-acquired pneumonia, the image of pulmonary consolidation is frequently present in the lower lobes, as well as the presence of a diffuse interstitial infiltrate resulting from the inflammatory process⁸. Arterial blood gas analysis allows the assessment of oxygen concentrations, the effectiveness of gas exchange between the alveoli-capillaries and acid-base balance, being a method for controlling the clinical evolution and determining the need for additional oxygen⁵.

Therapeutic treatment of community-acquired pneumonia is based on antibiotic therapy directed at the specific microorganism, and due to the need for an early start, it turns out to be empirical. In addition to antibiotic therapy, this treatment should be complemented with the administration of oxygen, nutritional support and prevention and treatment of possible associated metabolic disorders^7,8. Inhalation therapy, as the preferred route, is also assumed to be effective in the treatment and prevention of secretion stasis. Given the situation, there is a wide variety of therapies such as saline, bronchodilators, anti-inflammatory drugs, mucolytics and antibiotics, with equal therapeutic effects compared to other routes of drug administration, in addition to a reduction in adverse effects⁸.

The rehabilitation nurse (RN) is the health professional who is recognized for the ability to provide a set of therapeutic interventions (with emphasis on non-pharmacological ones) with the aim of improving residual functions, maintaining and recovering independence in life activities and minimize the impact of disabilities in terms of neurological, respiratory, cardiac, orthopedic, impairments and incapacities¹⁰.

In this sense, respiratory rehabilitation, as a holistic process that gives the person a full physical, mental, emotional, social and professional state, has become a standard of care recommended to people with respiratory pathology in its chronicity and/or exacerbation⁵, with the RN recognized as having specialized competences in the implementation of respiratory functional re-education programs, also called respiratory kinesitherapy¹¹.

Currently, it is shown that respiratory rehabilitation reduces the symptoms presented, improving limb muscle function, exercise capacity, emotional function, quality of life, knowledge and self-efficacy, being considered an essential component in the integrated care of patients supported by better cost-effectiveness, reduced hospitalizations and reduced health costs¹².

Respiratory functional re-education is a non-invasive therapy with no harmful adverse effects, encompassing a set of techniques based on breath control, positioning and movement aimed at better efficiency in gas exchange and symptom reduction, complementing the established pharmacological treatments^5,12.

The intervention of respiratory rehabilitation in people with community-acquired pneumonia is dependent on the stage of the disease, and should be intervened after stabilization of severe hyperthermia and hemodynamic instability. In the initial phase, the intervention aims to reverse the volume reduction in the lung segments and prevent atelectasis and the consequent reduction in the ventilation-perfusion index, while as the disease progresses to its resolution, there is a reduction in the consolidation of lung fields and the occurrence of productive cough with secretions^5,8. The objective of the RN intervention focuses on optimizing ventilation with lung reexpansion, with special attention to the prevention and correction of postural changes; in the permeability of the airways with the drainage of secretions and promotion of an effective cough; the reduction of respiratory work and effort re-education^5,8.

The intervention of the RN should be based on the initial assessment of the person and the symptoms presented, complemented by imaging and clinical observation⁸. The ventilation focus is compromised by its restrictive nature, providing hypoventilation patterns, decreased inspiratory muscle action and increased respiratory effort⁵. To enhance lung re-expansion, it is necessary to modify ineffective breathing patterns based on techniques that make the person aware of ventilatory dynamics and mechanics. Techniques for correcting ventilatory asynergy and optimizing alveolar ventilation should be established, such as the control and dissociation of respiratory times; abdomino-diaphragmatic breathing; exhalation with the lips half-closed; thoracic and joint mobilization; abdomino-diaphragmatic re-education; selective and global costal re-education; respiratory muscle training with emphasis on inspiration and controlled inspiratory flow exercise¹¹. Within the focus expectorate, this shows a decrease in its effectiveness associated with pathophysiological changes in the airways, mucociliary system and the decrease in the strength of the inspiratory and expiratory muscles, also contributing to the impairment of ventilation and, consequently, of the respiratory function. A set of techniques such as effective coughing are included for this focus; drainage of secretions with accessory maneuvers; postural drainage; autogenic drainage; huffing and the forced expiration technique and active cycle of breathing techniques¹¹.

The bibliography refers to little scientific evidence about the real benefits of functional respiratory reeducation in people with pneumonia, although the intervention remains considerably applied⁵. In view of the above, this case study presents the guiding question: “What is the contribution of the Specialist Nurse in Rehabilitation Nursing in the respiratory function of a person with bacterial pneumonia secondary to viral infection by Influenza A?”.

This case study presents the general objective of evaluating the impact of the RN intervention, with the application of respiratory functional reeducation, in people with bacterial pneumonia secondary to viral infection by Influenza A.

For the purpose of the study, the following specific objectives are identified:

MATERIAL AND METHODS

The case study consists of a structured research method for knowledge of individual or group phenomena. For Yin, this is an empirical research when the limits between the phenomenon and context are not evident, with the objective of exploring, describing, and explaining the event¹³. In Nursing research, the case study allows that, through different sources of evidence, it is possible to study highly complex life phenomena¹³.

This case study is structured according to the theoretical frameworks of Yin and Stake in six stages: Problem definition; Case definition; Theoretical foundation; Preparation of the study protocol; Data collection; Analysis and discussion of results¹³.

In this case study, a person with Streptococcus pneumoniae Pneumonia secondary to viral infection by Influenza A is presented, addressing the rehabilitation program of the respiratory function during hospitalization in order to show the results obtained. Data collection was performed through anamnesis and consultation of the clinical file.

The respiratory rehabilitation program took place in February 2019 with the beginning of admission to hospital. The person was designated as an individual in order to safeguard data confidentiality and anonymity. In this way, due to the involvement of personal, non-transferable and confidentiality issues of the hospital clinic, it became essential to respect the ethical guidelines for nursing research, following the principles of Beneficiency; No Malefficiency; Loyalty; Justice; Veracity and Confidentiality, thus informing about the risks and benefits¹⁴. Informed consent was obtained prior to data collection.

The specific instruments for the assessment of respiratory function were based on the Guiding Guide for the Good Practice for Respiratory Rehabilitation of the Ordem dos Enfermeiros (Nursing Council). Thus, the assessment was incident on the Pathological Process, based on signs and symptoms of respiratory pathology: chest pain, measured by the Numerical Pain Scale; Dyspnea, measured by the Modified Borg Scale; coughing and sputum due to the macroscopic aspect and the Body Process, carrying out the assessment of respiratory function through physical examination (inspection, palpation, percussion and auscultation), arterial blood gas and chest teleradiography.

The results shown in this study approach a person who presented as selection criteria: elderly people, aged 65 years-old or over; absence of known personal respiratory history and Influenza A infection in the current hospitalization.

RESULTS

The individual's respiratory function rehabilitation program included a total of four sessions, all of which were alert and very participatory in the implemented interventions.

The evaluation of the results obtained from the interventions of the rehabilitation program took place as defined by the Guiding Guide for Good Respiratory Rehabilitation Practice, starting with the assessment of the pathological process, giving a subjective assessment of the respiratory function, through the signs and symptoms presented⁵. Pain assessment was performed using the Numerical Pain Scale (Table 2). The individual rated pain level 0, before and after the intervention.

Dyspnea is experienced as respiratory distress. This discomfort was continuously monitored by the individual, using the Modified Borg Scale. Its result was recorded throughout the sessions, before the intervention and after a period of rest. Its monitoring during the established plan did not limit the performance of the outlined exercises, verifying that there was a gradual improvement in effort tolerance (Graphic 1). In the first sessions, there is an explicit greater respiratory discomfort and tiredness expressed by the individual, which progressively diminished, stating “I don't feel tired at all” after a period of rest at the end of the session (Graphic 1).

Initially, the cough was productive and ineffective, failing to expel secretions. This data showed the need for an adjustment in the validation process of knowledge and ability to use the cough technique. Coughing became more effective in the 2nd session, with better mobilization of secretions, which despite being in small quantities, allowed their elimination (Table 4). The characteristics of the secretions were possible to be evaluated during the planned exercises, presenting themselves as thick and mucopurulent. With the acquisition of the ability to use the technique of assisted and progressively directed coughing, associated with nebulization with previous saline solution, there was better fluidity of the same, ending up in the last session as there were only dry cough accesses (Table 3).

As part of the assessment of the body process, a systematic assessment was carried out in order to identify pathophysiological changes during the evolution of the pathology, as well as the implemented interventions. This assessment consisted of a physical examination which included inspection, palpation, percussion and auscultation.

The inspection essentially focused on the evolution of the breathing pattern, the presence of respiratory distress and postural deformities.

It was found that, at first, the individual had the need to resort to the use of accessory muscles of breathing, which provide with greater muscle tension. Although there were no thoracic asymmetries and absence of spinal deformities, a constant elevation of the shoulders and shoulder blades was notable, which simultaneously conferred a stressful posture, reflected in the subjective perception of dyspnea. Progressively, with the measures adopted for postural correction and relaxation techniques, it stopped resorting to accessory muscles associated with a more regular breathing pattern and a type of breathing with emphasis on diaphragmatic excursion and, consequently, on the inspiratory phase. This fact was possible with the synchrony and collaboration obtained in the dissociation of respiratory times, in the 2^nd session (Table 4).

Constant weaning from oxygen supply, through follow-up and medical prescription, was tolerated, not limiting both the number of sets and repetitions in the following sessions, as well as in the assessment using instruments such as the Modified Borg Scale. Through palpation, a bilateral evaluation of the chest and diaphragm was performed, essential for the follow-up of the evaluation of chest elasticity, which was found to be slight. During the sessions, the thoraco-vocal tremor showed an increase felt in the later phase, more incident in the bases, not registering a significant reduction with the accompanying expulsion of secretions (Table 5).

Percussion showed results aimed at different densities of lung fields. In the four sessions carried out, it was verified that the sound was never compromised at the apical level. On the other hand, and in a characteristic way in this pathology, dullness was found bilaterally installed in the bases and only in the last two sessions was there a slight clear pulmonary sound (Table 6).

Specialized care in respiratory rehabilitation was guided by auscultation performed at the beginning of the intervention and when necessary during the session, providing important data for the dynamics of the nursing intervention statement. Based on the analysis of the data obtained, the almost general decrease in vesicular murmur was evident in the previous auscultation up to the 3^rd session. On the posterior face, the best recordings were obtained with a clearly audible vesicular murmur. The crackling rattles, in the inspiratory phase, were the only adventitious sounds present in this study, having been audible bilaterally in the middle and lower thirds. With the performance of promotional exercises for airway cleaning in conjunction with the ability to use expectoratoin techniques, in the fourth session, crackling ferns were found only present in both bases at a lower intensity (Table 7 and 8).

Vital parameters never conferred limitations or even contraindications to the intervention. From this analysis, regular recording of heart rate (Table 9) should be highlighted, not suggesting exercise intensity conditioning. SpO2 always remained above 95% with the beginning of the rehabilitation sessions, taking into account that weaning from oxygen therapy was performed from session to session. With no worsening of dyspnea after rest, the last session was the only one in which SpO2 was recorded with a supplemental intake lower than at the beginning, reflecting only 1% less (Table 9).

Complementary diagnostic tests are essential for the assessment of the individual's respiratory pathology, as well as its evolution.

Figure 1 shows the imaging evolution by means of teleradiography of the individual's chest. The three cephalograms present a central image that expresses a global parenchymal infiltrate. The greatest consolidation remained at the level of the pulmonary bases bilaterally. In the last image (2/21/2019), there is a maintained alignment of the diaphragmatic hemicupulas and a slight increase in hypertransparency of both lung fields.

Arterial blood gas reflect the exchange of gases between alveoli and the pulmonary blood stream, being an integral part of the study of respiratory function⁵.

By analyzing the values obtained in arterial blood gas, it can be seen that the first 3 sessions are marked by considerable hypoxemia, which had no observable repercussions in the recording of SpO2 or heart rate. These records were obtained in sessions performed with a longer time interval. In the last session there is a general stabilization of parameters within the limits established by the literature and a slight improvement in hypoxemia.

DISCUSSION

The results obtained during the evaluation of the rehabilitation sessions demonstrate that the specialized care of rehabilitation nursing plays an important role in the re-education of the respiratory function of the person with restrictive respiratory pathology, namely bacterial pneumonia.

The approach to the hospitalized person with respiratory pathology is multidisciplinary, involving the medical team, health technicians, operational assistants, and it is only possible for nurses, who maintain direct contact with the person on a daily basis, to carry out systematic monitoring of the health condition and thus establish diagnoses of rehabilitation nursing that allow the most appropriate intervention and in an individualized way, accelerating recovery in situations of acute illness, already demonstrated with level of evidence A by the last update of the ATS/ERS document in 2013⁵.

Respiratory rehabilitation programs include a holistic view of the person receiving care, providing individualized aspects of care that must meet the person's preferences and expectations¹⁶. Based on the results obtained, the symptoms associated with the acute episode were minimized, being considered one of the objectives to be achieved with a program of this type⁵.

The initial assessment with the target person was essential to collect information both subjectively and through physical examination and allowed for the adaptation of interventions following the stage of the disease. This assessment is enriched if complemented by the analysis of complementary means of diagnosis.

The selection of assessment instruments such as the Modified Borg Scale and its ability to directly measure dyspnea by the person at different times allowed for the adaptation of the intensity and frequency of the exercises to the person's condition and expectations; the importance of training with moments of pause and recovery is also highlighted, as well as the evaluation of symptoms after sessions. The implementation of techniques to relieve muscle tension and awareness of respiratory times at an early stage, complemented with exercises to re-educate the respiratory function, showed reductions in the perception of dyspnea felt, ending up with no report of perceived tiredness after rest in the last sessions, with a rating of 0 out of 10 possible on the Modified Borg Scale.

Acting on the dimension of knowledge and on the ability to learn the cough technique enabled the person to perform it independently and more directed to their needs, provided gains in the mobilization and elimination of secretions in the various sessions carried out, ending in the last session only in the presence of dry cough. In addition to this intervention, in a characteristic way.

The program established and defended by the guiding bibliographic evidence based on the opinion of experts^5,8-9 showed efficacy in the results obtained in the pathological process, however, it was not equally evident in the monitoring of the body process.

In the physical examination, consisting of four stages, percussion and palpation were not by themselves a record of significant and/or defining changes in the staging of the disease evolution process. The benefits recorded focused on inspection for improved breathing pattern, being more regular with respiratory rates between 12 and 20 cycles/min, relaxation of accessory muscles of breathing and auscultation of the posterior phase of the thorax, with a overall increase in vesicular murmur and an absence of the sizzling ferns felt in the bilateral middle third. At the last assessment, these adventitious sounds were still present in the lung bases, although at a lower intensity, which coincided with the best ability to cough.

Together with the exercise program for diaphragmatic and costal re-education, the techniques performed at the level of rest, postural correction and associated thoracic mobilizations allowed for better tolerance to exertion and reduced oxygen supply. The SpO2 evaluation method, non-invasive and easy to apply using a portable oximeter, allowed this evaluation to be carried out continuously with the necessary safety for the person. It was possible to verify that the possibility of allowing visual contact of the SpO2 result obtained during the exercises worked as a positive stimulus for their motivation.

Incentive spirometry was important not only in the training of respiratory muscles⁸ but also in the motivation and commitment to complying with the sessions due to its ability to establish visual goals to be achieved. Its use may occur before the session and after the rest, with improved results in this second evaluation compared to the first.

Chest radiography confirmed pulmonary involvement, as well as the location and extent of lobar consolidation⁸. The appearance of hypertransparency was slightly evident on the last day, not following the evolution presented by data such as SpO2, Modified Borg Scale monitoring, pulmonary auscultation and the reduction in sputum upon coughing. However, the imaging changes may not immediately translate current changes⁸.

This case study reflects the importance of the RN in developing and improving its respiratory function assessment techniques in order to carry out a systematic assessment, if necessary, readjust its intervention based on the data obtained.

In this research, it would have been beneficial to carry out sessions with a shorter time interval, because a greater evolution between the 20th and 21st of February. According to gasometric values obtained, the reversion of the marked hypoxemia occurred only in this period and was not limited by the reduction of oxygen supply, which was initially at a rate of 5L/min and which at the end of the program was administered at 1L/min. This situation is not in line with what Cordeiro & Menoita defend in their bibliography, when state that the people as the target of this study, that is, without previous respiratory pathology, in a situation of bacterial pneumonia, regular arterial blood gas analysis is not justified, except in low SpO2⁸.

It is relatively frequent that people with Influenza A who are overinfected with bacterial pneumonia develop severe hypoxemia conditions difficult to reverse. In this case study, both focuses were addressed with the appropriate interventions directed towards their resolution, supported by the most updated bibliography. The lack of other similar studies did not make it possible to establish a comparison of the increase in pO2 associated with a respiratory rehabilitation intervention plan.

FINAL THOUGHTS

This case study highlighted the benefits of the respiratory function, in the ventilation and expectoration focuses, resulting from the specialized intervention of the specialist nurse in rehabilitation nursing.

In respiratory functional reeducation, it is essential to perform a subjective assessment of respiratory function, complemented by physical examination and complementary diagnostic data, such as chest teleradiography and gasimetric data. It results in a set of data that allow the rehabilitation nurse to analyze the information obtained, identify problems and plan the respective interventions, supported by reliable and valid instruments.

Thus, the gains obtained by the functional respiratory reeducation centered on the perception of dyspnea by the Modified Borg Scale, with a reduction from 2 to 0; on breathing pattern with absence of recruitment to accessory muscles, decrease in respiratory cycles per minute accompanied by a more regular pattern with diaphragmatic excursion; on auscultation, essentially of the posterior thorax, with an overall increase in vesicular murmur and reduction in crackling sounds; on chest X-ray with the appearance, although slight but progressive, of hypertransparency in both lung fields; in cough, with training to use directed cough, ending the sessions with an essentially dry cough; in gasimetric results showing the beginning of reversal of hypoxemia in the last session; in the weaning from the supplemental oxygen supply, starting with 5L/min and ending with 1L/min.

To obtain the abovementioned gains, it was essential to use specialized techniques directed to the different focuses, including the ventilation focus: interventions such as the resting position, massage of accessory muscles, control and dissociation of respiratory times, expiration with semi-closed lips, rotation of the humeral scapula, global opening with a stick, bilateral lower costal and abdominodiaphragmatic re-education, thoracic mobilization exercises and incentive spirometry. In the spectorate focus, techniques such as accessory maneuvers (vibration, percussion and compression), assisted/directed coughing, huffing and the forced expiration technique are evidenced, supported by the previous use of nebulizers with saline solution.

Based on the epidemiological data obtained, bacterial pneumonia as a possibility of secondary infection resulting from Influenza A is an increasingly growing fact. It is hoped that this case will contribute to giving visibility to the importance that rehabilitation nursing can have in reducing the comorbidities resulting from these episodes. It would be beneficial to develop more studies on this pathology, which despite being characteristically restrictive, suffers from seasonal influence.

It is suggested in future studies the possibility of performing earlier and more regular sessions (or even preferably daily) in order to contribute to a better clarification of the importance that the intervention of respiratory functional reeducation by RN can obtain in sustained severe hypoxemia and thus reduce the length of hospital stay, culminating in an increased level of evidence. Intervention plans with greater emphasis on aerobic exercises using cycle ergometers and thoracic mobilizations are also suggested, allowing the ventilation-perfusion index. In some cases, intervention plans of shorter duration and/or divided into two daily moments will be considered.