Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial.

Importance: The effects of recruitment maneuvers and positive end-expiratory pressure (PEEP) titration on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remain uncertain. Objective: To determine if lung recruitment associated with PEEP titration according to the best respiratory-system compliance decreases 28-day mortality of patients with moderate to severe ARDS compared with a conventional low-PEEP strategy. Design, Setting, and Participants: Multicenter, randomized trial conducted at 120 intensive care units (ICUs) from 9 countries from November 17, 2011, through April 25, 2017, enrolling adults with moderate to severe ARDS. Interventions: An experimental strategy with a lung recruitment maneuver and PEEP titration according to the best respiratory-system compliance (n = 501; experimental group) or a control strategy of low PEEP (n = 509). All patients received volume-assist control mode until weaning. Main Outcomes and Measures: The primary outcome was all-cause mortality until 28 days. Secondary outcomes were length of ICU and hospital stay; ventilator-free days through day 28; pneumothorax requiring drainage within 7 days; barotrauma within 7 days; and ICU, in-hospital, and 6-month mortality. Results: A total of 1010 patients (37.5% female; mean [SD] age, 50.9 [17.4] years) were enrolled and followed up. At 28 days, 277 of 501 patients (55.3%) in the experimental group and 251 of 509 patients (49.3%) in the control group had died (hazard ratio [HR], 1.20; 95% CI, 1.01 to 1.42; P = .041). Compared with the control group, the experimental group strategy increased 6-month mortality (65.3% vs 59.9%; HR, 1.18; 95% CI, 1.01 to 1.38; P = .04), decreased the number of mean ventilator-free days (5.3 vs 6.4; difference, -1.1; 95% CI, -2.1 to -0.1; P = .03), increased the risk of pneumothorax requiring drainage (3.2% vs 1.2%; difference, 2.0%; 95% CI, 0.0% to 4.0%; P = .03), and the risk of barotrauma (5.6% vs 1.6%; difference, 4.0%; 95% CI, 1.5% to 6.5%; P = .001). There were no significant differences in the length of ICU stay, length of hospital stay, ICU mortality, and in-hospital mortality. Conclusions and Relevance: In patients with moderate to severe ARDS, a strategy with lung recruitment and titrated PEEP compared with low PEEP increased 28-day all-cause mortality. These findings do not support the routine use of lung recruitment maneuver and PEEP titration in these patients. Trial Registration: clinicaltrials.gov Identifier: NCT01374022.

Driving Pressure-limited Strategy for Patients with Acute Respiratory Distress Syndrome. A Pilot Randomized Clinical Trial.

Rationale: Evidence from observational studies suggests that driving pressure is strongly associated with pulmonary injury and mortality, regardless of positive end-expiratory pressure (PEEP) levels, tidal volume, or plateau pressure. Therefore, it is possible that targeting driving pressure may improve the safety of ventilation strategies for patients with acute respiratory distress syndrome (ARDS). However, the clinical effects of a driving pressure-limited strategy for ARDS has not been assessed in randomized controlled trials.Objectives: To evaluate the feasibility of testing a driving pressure-limited strategy in comparison with a conventional lung-protective ventilation strategy in patients with ARDS and a baseline driving pressure of ≥13 cm H2O.Methods: This was a randomized, controlled, nonblinded trial that included 31 patients with ARDS who were on invasive mechanical ventilation and had a driving pressure of ≥13 cm H2O. Patients allocated to the driving pressure-limited strategy were ventilated with volume-controlled or pressure-support ventilation modes, with tidal volume titrated to 4-8 ml/kg of predicted body weight (PBW), aiming at a driving pressure of 10 cm H2O, or the lowest possible. Patients in the control group were ventilated according to the ARDSNet (Acute Respiratory Distress Syndrome Network) protocol, using a tidal volume of 6 ml/kg PBW, which was allowed to be set down to 4 ml/kg PBW if the plateau pressure was >30 cm H2O. The primary endpoint was the driving pressure on Days 1-3.Results: Sixteen patients were randomized to the driving pressure-limited group and 15 were randomized to the conventional strategy group. All patients were considered in analyses. Most of the patients had mild ARDS with a mean arterial oxygen tension/fraction of inspired oxygen ratio of 215 (standard deviation [SD] = 95). The baseline driving pressure was 15.0 cm H2O (SD = 2.6) in both groups. In comparison with the conventional strategy, driving pressure from the first hour to the third day was 4.6 cm H2O lower in the driving pressure-limited group (95% confidence interval [CI], 6.5 to 2.8; P < 0.001). From the first hour up to the third day, tidal volume in the driving pressure-limited strategy group was kept lower than in the control group (mean difference [ml/kg of PBW], 1.3; 95% CI, 1.7 to 0.9; P < 0.001). We did not find statistically significant differences in the incidence of severe acidosis (pH < 7.10) within 7 days (absolute difference -12.1; 95% CI, -41.5 to -17.3) or any clinical secondary endpoint.Conclusions: In patients with ARDS, a trial assessing the effects of a driving pressure-limited strategy using very low tidal volumes versus a conventional ventilation strategy on clinical outcomes is feasible.Clinical trial registered with ClinicalTrials.gov (NCT02365038).

Impact of an early physiotherapy program after kidney transplant during hospital stay: a randomized controlled trial.

INTRODUCTION: Cardiorespiratory and musculoskeletal dysfunctions are common in the postoperative period of kidney transplant patients and are often accompanied by low exercise tolerance. OBJECTIVE: The purpose of this study was to evaluate the impact of an early physiotherapy program during hospital stay on functional capacity and peripheral and respiratory muscle strength after kidney transplant. METHODS: An open, randomized clinical trial was conducted in patients undergoing living donor kidney transplant. Sixty-three patients were included (intervention group-IG: n = 30; control group-CG: n = 33). IG received an early physiotherapy program from first postoperative day until hospital discharge and CG received standard care. The variables of interest were measured preoperatively and at discharge except for respiratory muscle strength and vital capacity (VC), which were also measured on the first postoperative day. Functional capacity was evaluated through six-minute walk test (6MWT); peripheral and respiratory muscle strength using a dynamometer and manovacuometer, respectively; and VC through spirometer. RESULTS: After surgery, there was a reduction in functional walking capacity and peripheral muscle strength without different between groups (p > 0.05); however, respiratory muscle strength was significantly higher in IG (p < 0.001) at hospital discharge, when comparing with CG. CONCLUSIONS: An early physiotherapy program during hospitalization for patients undergoing living donor kidney transplant caused a lower reduction in respiratory muscle strength and without additional benefits in the functional capacity, when compared to a control group, although the clinical relevance of this finding is uncertain.

Morbidity, mortality, and categorization of the risk of perioperative complications in lung cancer patients.

OBJECTIVE: To determine morbidity and mortality rates by risk category in accordance with the American College of Chest Physicians guidelines, to determine what role pulmonary function tests play in this categorization process, and to identify risk factors for perioperative complications (PCs). METHODS: This was a historical cohort study based on preoperative and postoperative data collected for cases of lung cancer diagnosed or suspected between 2001 and 2010. RESULTS: Of the 239 patients evaluated, only 13 (5.4%) were classified as being at high risk of PCs. Predicted postoperative FEV1 (FEV1ppo) was sufficient to define the risk level in 156 patients (65.3%); however, cardiopulmonary exercise testing (CPET) was necessary for identifying those at high risk. Lung resection was performed in 145 patients. Overall morbidity and mortality rates were similar to those reported in other studies. However, morbidity and mortality rates for patients at an acceptable risk of PCs were 31.6% and 4.3%, respectively, whereas those for patients at high risk were 83.3% and 33.3%. Advanced age, COPD, lobe resection, and lower FEV1ppo were correlated with PCs. CONCLUSIONS: Although spirometry was sufficient for risk assessment in the majority of the population studied, CPET played a key role in the identification of high-risk patients, among whom the mortality rate was seven times higher than was that observed for those at an acceptable risk of PCs. The risk factors related to PCs coincided with those reported in previous studies.

Impact of laparoscopic surgery on thoracoabdominal mechanics and inspiratory muscular activity.

OBJECTIVE: To evaluate the effect of laparoscopic surgery on pulmonary volume distributions and inspiratory muscles activity. Respiratory consequences associated with postoperative pain were also evaluated. METHODS: This study enrolled 20 patients without lung disease performed spirometry and chest wall kinematic analyses (i.e., chest wall, upper and lower ribcage and abdominal volumes), and measured the activity of inspiratory muscular before and 2 days after laparoscopic surgery. Pain was also assessed. RESULTS: After laparoscopy, the patients demonstrated decreased volumes in all three thoracoabdominal compartments: abdomen (ABD), upper and lower rib cage (URC and LRC, respectively) compared with the pre-operative measurements: ABD=0.38±0.20L vs. 0.55±0.25L; URC=0.45±0.18L vs. 0.55±0.21L; and LRC=0.31±0.18L vs. 0.41±0.23L; p<0.05. A reduction in the inspiratory muscular activity after surgery was also observed (sternocleidomastoid: 10.6±5.1×10(-3)mV vs. 12.8±6.3×10(-3)mV; intercostals: 16.8±12.4×10(-3)mV vs. 25.1±21.3×10(-3)mV; p<0.05). In addition, lower volumes during deep breathing were observed in patients who reported significant pain than those who did not (0.51±0.17L vs. 0.79±0.29L; p<0.05, respectively). CONCLUSION: Laparoscopic surgery reduces chest wall ventilation and inspiratory muscular activity during deep breathing. The effects appear to depend on the patient's reported pain level.

Volume rather than flow incentive spirometry is effective in improving chest wall expansion and abdominal displacement using optoelectronic plethysmography.

BACKGROUND: Incentive spirometers are widely used in clinical practice and classified as flow-oriented (FIS) and volume-oriented (VIS). Until recently the respiratory inductive plethysmography used to evaluate the effects of incentive spirometry on chest wall mechanics presented limitations, which may explain why the impact of VIS and FIS remains poorly known. OBJECTIVE: To compare the effects of VIS and FIS on thoracoabdominal mechanics and respiratory muscle activity in healthy volunteers. METHODS: This cross-sectional trial assessed 20 subjects (12 female, ages 20-40 years, body mass index 20-30 kg/m(2)). All subjects performed 8 quiet breaths and 8 deep breaths with FIS and VIS, in a randomized order. We measured thoracoabdominal chest wall, upper and lower rib-cage, and abdominal volumes with optoelectronic plethysmography, and the muscle activity of the sternocleidomastoid and superior and inferior intercostal muscles with electromyography. RESULTS: VIS increased chest wall volume more than did FIS (P = .007) and induced a larger increase in the upper and lower rib-cages and abdomen (156%, 91%, and 151%, respectively, P < .001). By contrast, FIS induced more activity in the accessory muscles of respiration than did VIS (P < .001). CONCLUSIONS: VIS promotes a greater increase in chest wall volume, with a larger abdominal contribution and lower respiratory muscle activity, than does FIS in healthy adults.

Impact of an early physiotherapy program after kidney transplant during hospital stay: a randomized controlled trial / Impacto de um programa precoce de fisioterapia após transplante renal durante a internação: um estudo clínico randomizado controlado

Abstract Introduction: Cardiorespiratory and musculoskeletal dysfunctions are common in the postoperative period of kidney transplant patients and are often accompanied by low exercise tolerance. Objective: The purpose of this study was to evaluate the impact of an early physiotherapy program during hospital stay on functional capacity and peripheral and respiratory muscle strength after kidney transplant. Methods: An open, randomized clinical trial was conducted in patients undergoing living donor kidney transplant. Sixty-three patients were included (intervention group-IG: n = 30; control group-CG: n = 33). IG received an early physiotherapy program from first postoperative day until hospital discharge and CG received standard care. The variables of interest were measured preoperatively and at discharge except for respiratory muscle strength and vital capacity (VC), which were also measured on the first postoperative day. Functional capacity was evaluated through six-minute walk test (6MWT); peripheral and respiratory muscle strength using a dynamometer and manovacuometer, respectively; and VC through spirometer. Results: After surgery, there was a reduction in functional walking capacity and peripheral muscle strength without different between groups (p > 0.05); however, respiratory muscle strength was significantly higher in IG (p < 0.001) at hospital discharge, when comparing with CG. Conclusions: An early physiotherapy program during hospitalization for patients undergoing living donor kidney transplant caused a lower reduction in respiratory muscle strength and without additional benefits in the functional capacity, when compared to a control group, although the clinical relevance of this finding is uncertain.

Resumo Introdução: Distúrbios cardiorrespiratórios e musculoesqueléticos são comuns no período pós-operatório de pacientes de transplante renal, e são frequentemente acompanhados por baixa tolerância a exercícios. Objetivo: O presente estudo pretendeu avaliar o impacto de um programa precoce de fisioterapia durante a internação sobre a capacidade funcional e força muscular periférica e respiratória após transplante renal. Métodos: Foi realizado um estudo clínico randomizado aberto com pacientes submetidos a transplantes renais com doadores vivos. Sessenta e três pacientes foram incluídos (grupo de intervenção GI: n = 30; grupo de controle - GC: n = 33). O GI recebeu o programa precoce de fisioterapia a partir do primeiro dia de pós-operatório até a alta hospitalar e o GC recebeu tratamento padrão. As variáveis de interesse foram medidas no pré-operatório e na alta, exceto por força muscular respiratória e capacidade vital (CV), que foram medidas no primeiro dia de pós-operatório. A capacidade funcional foi avaliada através do teste da caminhada dos seis minutos (TC6); força muscular periférica e respiratória com o uso de um dinamômetro e um manovacuômetro, respectivamente; e a CV por meio de um espirômetro. Resultados: Após a cirurgia houve reduções na capacidade funcional de caminhar e na força muscular respiratória sem diferenças entre os grupos (p > 0,05); contudo, a força muscular respiratória foi significativamente mais elevada no GI (p < 0,001) no momento da alta hospitalar em comparação ao GC. Conclusões: O programa precoce de fisioterapia oferecido durante a internação dos pacientes submetidos a transplantes renais com doadores vivos produziu uma menor redução da força muscular respiratória e não resultou em benefícios adicionais na capacidade funcional, apesar da relevância clínica desse achado ser incerta.

Morbidity, mortality, and categorization of the risk of perioperative complications in lung cancer patients / Mortalidade, morbidade e categorização de risco para complicações perioperatórias em pacientes com câncer de pulmão

OBJECTIVE: To determine morbidity and mortality rates by risk category in accordance with the American College of Chest Physicians guidelines, to determine what role pulmonary function tests play in this categorization process, and to identify risk factors for perioperative complications (PCs). METHODS: This was a historical cohort study based on preoperative and postoperative data collected for cases of lung cancer diagnosed or suspected between 2001 and 2010. RESULTS: Of the 239 patients evaluated, only 13 (5.4%) were classified as being at high risk of PCs. Predicted postoperative FEV1 (FEV1ppo) was sufficient to define the risk level in 156 patients (65.3%); however, cardiopulmonary exercise testing (CPET) was necessary for identifying those at high risk. Lung resection was performed in 145 patients. Overall morbidity and mortality rates were similar to those reported in other studies. However, morbidity and mortality rates for patients at an acceptable risk of PCs were 31.6% and 4.3%, respectively, whereas those for patients at high risk were 83.3% and 33.3%. Advanced age, COPD, lobe resection, and lower FEV1ppo were correlated with PCs. CONCLUSIONS: Although spirometry was sufficient for risk assessment in the majority of the population studied, CPET played a key role in the identification of high-risk patients, among whom the mortality rate was seven times higher than was that observed for those at an acceptable risk of PCs. The risk factors related to PCs coincided with those reported in previous studies. .

OBJETIVO: Determinar as taxas de morbidade e mortalidade por categoria de risco conforme as diretrizes do American College of Chest Physicians, verificar como exames funcionais participaram dessa categorização e identificar fatores de risco para complicações perioperatórias (CPOs). MÉTODOS: Estudo de coorte histórica a partir de avaliações pré e pós-operatórias de casos diagnosticados ou suspeitos de câncer de pulmão avaliados entre 2001 e 2010. RESULTADOS: Dos 239 pacientes avaliados, apenas 13 (5,4%) foram considerados como de alto risco para CPOs. O cálculo do VEF1 previsto para o pós-operatório (VEF1ppo) foi suficiente para a estratificação do risco em 156 pacientes (65,3%); entretanto, o teste de exercício cardiopulmonar (TECP) foi necessário para a identificação de alto risco. Foram operados 145 pacientes, e as taxas globais de morbidade e mortalidade encontradas foram semelhantes às de outros estudos. Entretanto, as taxas de morbidade e mortalidade para aqueles com risco aceitável foram de 31,6% e 4,3%, respectivamente, enquanto as taxas para aqueles com alto risco foram de 83,3% e 33,3%. Idade mais avançada, presença da DPOC, ressecção de um ou mais lobos e VEF1ppo mais baixo estiveram relacionados à ocorrência de CPOs. CONCLUSÕES: Embora a espirometria tenha sido suficiente para a determinação de risco na maioria da população estudada, o TECP teve papel fundamental na identificação de pacientes com risco alto, que apresentaram uma taxa de mortalidade sete vezes maior que os de risco aceitável. Os fatores de risco relacionados a CPOs coincidiram aos relatados em outros estudos. .

Influence of pleural drainage on postoperative pain, vital capacity and six-minute walk test after pulmonary resection.

OBJECTIVE: To evaluate the influence of pleural drainage on the distance covered on the six-minute walk test, pain intensity and vital capacity in patients submitted to pulmonary resection. METHODS: Thirteen consecutive patients from the Thoracic Surgery Infirmary of Hospital São Paulo, Brazil, submitted to closed pleural drainage (0.5-in multiperforated chest tube) in the postoperative period following pulmonary resection (lobectomy, segmentectomy and pulmonary nodule resection) were evaluated. The decision for chest tube removal followed clinical criteria defined by the surgical team, who did not participate in the study. Vital capacity, pain intensity (using a visual analog pain scale) and the distance covered on the six-minute walk test were determined 30 min prior to and 30 min after the removal of the chest tube. The statistical analysis was performed using paired t-tests, and the level of significance was set at 0.05. RESULTS: After the removal of the chest tube, the visual analog scale pain scores were significantly lower (3.46 cm vs. 1.77 cm; p = 0.001) and the distance covered on the six-minute walk test was significantly higher (374.34 m vs. 444.62 m; p = 0.03). Vital capacity prior to and after chest tube removal was not significantly affected (2.15 L and 2.25 L, respectively; p = 0.540). CONCLUSIONS: The results of the present study suggest that the presence of a chest tube is a factor significantly associated with postoperative pain and functional limitation in patients submitted to pulmonary resection.

Influência do dreno pleural sobre a dor, capacidade vital e teste de caminhada de seis minutos em pacientes submetidos à ressecção pulmonar / Influence of pleural drainage on postoperative pain, vital capacity and six-minute walk test after pulmonary resection

OBJETIVO: Avaliar a influência do dreno pleural sobre a distância percorrida no teste de caminhada de seis minutos, da intensidade da dor e da capacidade vital de pacientes submetidos à ressecção pulmonar. MÉTODOS: Foram avaliados treze pacientes consecutivos, internados na Enfermaria da Cirurgia de Tórax do Hospital São Paulo, submetidos à drenagem pleural fechada (dreno tubular multiperfurado de 0,5 polegada), no período pós-operatório de ressecção pulmonar (lobectomia, segmentectomia e nodulectomia). A opção pela retirada do dreno seguiu critérios clínicos definidos por médicos da equipe cirúrgica alheios ao estudo. A determinação da capacidade vital, da intensidade da dor através da escala visual analógica de dor e da distância percorrida no teste de caminhada de seis minutos foram realizadas 30 min antes da retirada do dreno e 30 min após. A análise estatística dos dados foi realizada através do teste t pareado, com nível de significância estabelecido em 0,05. RESULTADOS: Após a retirada do dreno, os valores obtidos na avaliação da escala visual analógica de dor foram significativamente menores (3,46 cm vs. 1,77 cm; p = 0,001), e a distância percorrida no teste de caminhada de seis minutos foi significativamente maior (374,34 m vs. 444,62 m; p = 0,03). A capacidade vital antes e após a retirada do dreno não foi alterada de forma significativa (2,15 L vs. 2,25 L, respectivamente; p = 0,540). CONCLUSÕES: Os resultados deste estudo sugerem que a presença do dreno pleural é um importante fator associado à dor pós-operatória e à limitação funcional em pacientes submetidos à ressecção pulmonar.

OBJECTIVE: To evaluate the influence of pleural drainage on the distance covered on the six-minute walk test, pain intensity and vital capacity in patients submitted to pulmonary resection. METHODS: Thirteen consecutive patients from the Thoracic Surgery Infirmary of Hospital São Paulo, Brazil, submitted to closed pleural drainage (0.5-in multiperforated chest tube) in the postoperative period following pulmonary resection (lobectomy, segmentectomy and pulmonary nodule resection) were evaluated. The decision for chest tube removal followed clinical criteria defined by the surgical team, who did not participate in the study. Vital capacity, pain intensity (using a visual analog pain scale) and the distance covered on the six-minute walk test were determined 30 min prior to and 30 min after the removal of the chest tube. The statistical analysis was performed using paired t-tests, and the level of significance was set at 0.05. RESULTS: After the removal of the chest tube, the visual analog scale pain scores were significantly lower (3.46 cm vs. 1.77 cm; p = 0.001) and the distance covered on the six-minute walk test was significantly higher (374.34 m vs. 444.62 m; p = 0.03). Vital capacity prior to and after chest tube removal was not significantly affected (2.15 L and 2.25 L, respectively; p = 0.540). CONCLUSIONS: The results of the present study suggest that the presence of a chest tube is a factor significantly associated with postoperative pain and functional limitation in patients submitted to pulmonary resection.

Volumes, capacidades pulmonares e força muscular respiratória no pós-operatório de gastroplastia / Lung volumes, lung capacities and respiratory muscle strength following gastroplasty

INTRODUÇAO: A gastroplastia tem sido cada vez mais indicada no tratamento de obesos mórbidos, pacientes nos quais podemos identificar alteração pronunciada de volumes e capacidades pulmonares. OBJETIVO: Avaliar o comportamento dos volumes e capacidades pulmonares, força muscular respiratória, padrão respiratório e as possíveis complicações pulmonares pós-operatórias. MÉTODO: Vinte e um pacientes (três homens) com média de idade de 39 ± 9,7 anos, média de índice de massa corpórea de 50,4 Kg/m², candidatos à gastroplastia, foram avaliados no pré-operatório, primeiro, terceiro e quinto dias de pós-operatório e submetidos a mensuração de volume corrente, capacidade vital, volume minuto, pressões máximas expiratória e inspiratória, e circunferências abdominal e torácica. Observou-se a ocorrência de complicações pulmonares pós-operatórias e mortalidade. RESULTADOS: No primeiro e terceiro dias de pós-operatório houve queda de 47 por cento e 30,5 por cento na capacidade vital, 18 por cento e 12,5 por cento no volume minuto, 28 por cento e 21 por cento no volume corrente, 47 por cento e 32 por cento no índice diafragmático, 51 por cento e 26 por cento na pressão inspiratória máxima, e 39,5 por cento e 26 por cento na pressão expiratória máxima, respectivamente (p < 0,05). No quinto dia de pós-operatório, todos os valores das variáveis analisadas apresentaram-se maiores que os do primeiro pós-operatório, evidenciando um crescimento linear, com retorno total aos seus valores pré-operatórios apenas de volume corrente, volume minuto e índice diafragmático. Houve uma incidência de complicações pulmonares pós-operatórias de 4,7 por cento e não houve óbitos. CONCLUSAO: Pacientes submetidos a gastroplastia apresentam redução da função pulmonar, evidenciando um comportamento bastante semelhante ao já observado no pós-operatório de outras cirurgias do andar superior do abdome.

Avaliação pulmonar pré-operatória em cirurgias não-cardíacas e sem ressecção pulmonar / Preoperative pulmonary evaluation of non-cardiac surgery without pulmonary resection

Os clínicos reconhecem bem a importância e os fatores de risco para a ocorrência de complicações cardíacas no período pós-operatório, mas subestiman as complicações pulmonares pós-operatórias. Elas são muito importantes na análise do risco cirúrgico de doentes que serão submetidos a cirurgias não-cardiotorácicas, porque, além de não prevalentes quanto as complicações cardíacas, aumentam a morbidade e a mortalidade, o tempo de permanência hospitalar e, consequentemente, os custos. Fatores de risco relacionados ao procedimento operatório são mais importantes que os relacionados ao doente em predizer eventos pulmonares pós-operatórios, mas os clínicos devem avaliar ambos. O reconhecimento desses fatores é essencial para a prescrição de estratégias com reconhecida capacidade de reduzir a ocorrência dessas complicações pulmonares. As estrategias incluem otimização das doenças pulmonares crônicas...