Airway and parenchyma immune cells in influenza A(H1N1)pdm09 viral and non-viral diffuse alveolar damage.

BACKGROUND: Diffuse alveolar damage (DAD), which is the histological surrogate for acute respiratory distress syndrome (ARDS), has a multifactorial aetiology. Therefore it is possible that the immunopathology differs among the various presentations of DAD. The aim of this study is to compare lung immunopathology of viral (influenza A(H1N1)pdm09) to non-viral, extrapulmonary aetiologies in autopsy cases with DAD. METHODS: The lung tissue of 44 patients, was divided in the H1N1 group (n = 15) characterized by severe pulmonary injury due to influenza A(H1N1)pdm09 infection; the ARDS group (n = 13), characterized by patients with DAD due to non-pulmonary causes; and the Control group (n = 16), consisting of patients with non-pulmonary causes of death. Immunohistochemistry and image analysis were used to quantify, in the parenchyma and small airways, several immune cell markers. RESULTS: Both DAD groups had higher expression of neutrophils and macrophages in parenchyma and small airways. However, there was a higher expression of CD4+ and CD8+ T lymphocytes, CD83+ dendritic cells, granzyme A+ and natural killer + cell density in the lung parenchyma of the H1N1 group (p < 0.05). In the small airways, there was a lower cell density of tryptase + mast cells and dendritic + cells and an increase of IL-17 in both DAD groups (p < 0.05). CONCLUSION: DAD due to viral A(H1N1)pdm09 is associated with a cytotoxic inflammatory phenotype, with partially divergent responses in the parenchyma relative to the small airways. In non-viral DAD, main immune cell alterations were found at the small airway level, reinforcing the role of the small airways in the pathogenesis of the exudative phase of DAD.

Cholinergic hyperresponsiveness of peripheral lung parenchyma in chronic obstructive pulmonary disease.

BACKGROUND: Up to 60% of chronic obstructive pulmonary disease (COPD) patients can present airway hyperresponsiveness. However, it is not known whether the peripheral lung tissue also shows an exaggerated response to agonists in COPD. OBJECTIVES: To investigate the in vitro mechanical behavior and the structural and inflammatory changes of peripheral lung tissue in COPD patients and compare to nonsmoking controls. METHODS: We measured resistance and elastance at baseline and after acetylcholine (ACh) challenge of lung strips obtained from 10 COPD patients and 10 control subjects. We also assessed the alveolar tissue density of neutrophils, eosinophils, macrophages, mast cells and CD8+ and CD4+ cells, as well as the content of α-smooth muscle actin-positive cells and elastic and collagen fibers. We further investigated whether changes in in vitro parenchymal mechanics correlated to structural and inflammatory parameters and to in vivo pulmonary function. RESULTS: Values of resistance after ACh treatment and the percent increase in tissue resistance (%R) were higher in the COPD group (p ≤ 0.03). There was a higher density of macrophages and CD8+ cells (p < 0.05) and a lower elastic content (p = 0.003) in the COPD group. We observed a positive correlation between %R and eosinophil and CD8+ cell density (r = 0.608, p = 0.002, and r = 0.581, p = 0.001, respectively) and a negative correlation between %R and the ratio of forced expiratory volume in 1 s to forced vital capacity (r = -0.451, p < 0.05). CONCLUSIONS: The cholinergic responsiveness of parenchymal lung strips is increased in COPD patients and seems to be related to alveolar tissue eosinophilic and CD8 lymphocytic inflammation and to the degree of airway obstruction on the pulmonary function test.

Mobilization practices for patients with burn injury in critical care.

PURPOSE: Patients with burn usually undergo prolonged hospitalization due partially to the treatment of wounds and scars. Although the benefits of early mobilization are well-known in critical care patients, there are a lack of studies reporting mobilization practices and functional status for patients with burn. MATERIALS: Clinical and physiotherapy data were daily collected, including ICU mobility scale (IMS) and reported barriers to mobilization therapy during a one-year period. At hospital discharge, the 6-min walking test (6MWT), Medical Research Council scale (MRCS) and handgrip strength test were applied to evaluate the patients' functionality. RESULTS: Of the 74 patients admitted, 66% were placed on mechanical ventilation (MV). Mobilization therapy was administered in 67.2% of physiotherapy sessions, with passive mobilization being the most prevalent (53.2%) followed by active in-bed exercises (13.6%). Reported barriers for mobilization included hemodynamic instability followed by limited time for assistance. At hospital discharge, the 6MWD was 270(136) meters. A positive correlation was found between handgrip evaluation and 6MWD and a negative correlation with hospital length of stay. CONCLUSIONS: Mobilization therapy of patients with burns in the ICU was characterized by a low mobility level during MV with a low functional status at hospital discharge.

Effects that passive cycling exercise have on muscle strength, duration of mechanical ventilation, and length of hospital stay in critically ill patients: a randomized clinical trial.

Objective: To evaluate the effects that passive cycling exercise, in combination with conventional physical therapy, have on peripheral muscle strength, duration of mechanical ventilation, and length of hospital stay in critically ill patients admitted to the ICU of a tertiary care university hospital. Methods: This was a randomized clinical trial involving 38 patients (≥ 18 years of age) on mechanical ventilation who were randomly divided into two groups: control (n = 16), receiving conventional physical therapy; and intervention (n = 22), receiving conventional physical therapy and engaging in passive cycling exercise five days per week. The mean age of the patients was 46.42 ± 16.25 years, and 23 were male. The outcomes studied were peripheral muscle strength, as measured by the Medical Research Council scale, duration of mechanical ventilation, and length of hospital stay. Results: There was a significant increase in peripheral muscle strength (baseline vs. final) in both groups (control: 40.81 ± 7.68 vs. 45.00 ± 6.89; and intervention: 38.73 ± 11.11 vs. 47.18 ± 8.75; p < 0.001 for both). However, the range of increase in strength was higher in the intervention group than in the control group (8.45 ± 5.20 vs. 4.18 ± 2.63; p = 0.005). There were no significant differences between the groups in terms of duration of mechanical ventilation or length of hospital stay. Conclusions: The results suggest that the performance of continuous passive mobilization on a cyclical basis helps to recover peripheral muscle strength in ICU patients. (ClinicalTrials.gov Identifier: NCT01769846 [http://www.clinicaltrials.gov/]).

Perme Intensive Care Unit Mobility Score and ICU Mobility Scale: translation into Portuguese and cross-cultural adaptation for use in Brazil.

OBJECTIVE:: To translate the Perme Intensive Care Unit Mobility Score and the ICU Mobility Scale (IMS) into Portuguese, creating versions that are cross-culturally adapted for use in Brazil, and to determine the interobserver agreement and reliability for both versions. METHODS:: The processes of translation and cross-cultural validation consisted in the following: preparation, translation, reconciliation, synthesis, back-translation, review, approval, and pre-test. The Portuguese-language versions of both instruments were then used by two researchers to evaluate critically ill ICU patients. Weighted kappa statistics and Bland-Altman plots were used in order to verify interobserver agreement for the two instruments. In each of the domains of the instruments, interobserver reliability was evaluated with Cronbach's alpha coefficient. The correlation between the instruments was assessed by Spearman's correlation test. RESULTS:: The study sample comprised 103 patients-56 (54%) of whom were male-with a mean age of 52 ± 18 years. The main reason for ICU admission (in 44%) was respiratory failure. Both instruments showed excellent interobserver agreement ( > 0.90) and reliability ( > 0.90) in all domains. Interobserver bias was low for the IMS and the Perme Score (-0.048 ± 0.350 and -0.06 ± 0.73, respectively). The 95% CIs for the same instruments ranged from -0.73 to 0.64 and -1.50 to 1.36, respectively. There was also a strong positive correlation between the two instruments (r = 0.941; p < 0.001). CONCLUSIONS:: In their versions adapted for use in Brazil, both instruments showed high interobserver agreement and reliability. OBJETIVO:: Realizar a tradução e a validação cultural para a língua portuguesa falada no Brasil e determinar a concordância e a confiabilidade dos instrumentos Perme Intensive Care Unit Mobility Score (designado Perme Escore) e ICU Mobility Scale (designada Escala de Mobilidade em UTI, EMU). MÉTODOS:: Os processos de tradução e adaptação cultural seguiram as seguintes etapas: preparação, tradução, reconciliação, síntese, tradução reversa, revisão, aprovação e pré-teste. Após esses processos, as versões em português dos dois instrumentos foram utilizadas por dois pesquisadores na avaliação de pacientes críticos em UTI. O índice kappa ponderado e a disposição gráfica de Bland-Altman foram utilizados para verificar a concordância entre os instrumentos. O coeficiente alfa de Cronbach foi utilizado para verificar a confiabilidade entre as respostas dos avaliadores dentro de cada domínio dos instrumentos. A correlação entre os instrumentos foi verificada pelo teste de correlação de Spearman. RESULTADOS:: A amostra foi composta por 103 pacientes, sendo a maioria homens (n = 56; 54%), com média de idade = 52 ± 18 anos. O principal motivo de internação nas UTIs foi insuficiência respiratória (em 44%). Os dois instrumentos apresentaram excelente concordância interobservador (> 0,90) e confiabilidade ( > 0,90) em todos os domínios. Constatou-se um baixo viés interobservador na EMU e no Perme Escore (-0,048 ± 0,350 e -0,06 ± 0,73, respectivamente). Os IC95% para os mesmos instrumentos variaram, respectivamente, de -0,73 a 0,64 e de -1,50 a 1,36, respectivamente. Além disso, verificou-se alta correlação positiva entre os dois instrumentos (r = 0,941; p < 0,001). CONCLUSÕES:: As versões dos dois instrumentos apresentaram alta concordância e confiabilidade interobservador.

The Expression of Water and Ion Channels in Diffuse Alveolar Damage Is Not Dependent on DAD Etiology.

INTRODUCTION: Aquaporins and ion channels are membrane proteins that facilitate the rapid movement of water and solutes across biological membranes. Experimental and in vitro studies reported that the function of these channels and pulmonary edema resolution are impaired in acute lung injury (ALI). Although current evidence indicates that alveolar fluid clearance is impaired in patients with ALI/diffuse alveolar damage (DAD), few human studies have addressed the alterations in pulmonary channels in this clinical condition. Additionally, it is not known whether the primary cause of DAD is a relevant variable for the channel dysfunction. METHODS: Autopsied lungs of 43 patients with acute respiratory failure (ARF) due to DAD of three different etiologies, non-pulmonary sepsis, H1N1 viral infection and leptospirosis, were compared to 18 normal lungs. We quantified the expression of aquaporin (AQP) 1, AQP3, AQP5, epithelial Na+ channel (ENaC) and sodium potassium ATPase (Na-K-ATPase) in the alveolar septum using immunohistochemistry and image analysis. RESULTS: The DAD group presented with increased expression of AQP3, AQP5 and Na-K-ATPase and decreased expression of ENaC compared to controls. However, there was no difference in protein expression within the DAD groups of different etiologies. CONCLUSION: Water and ion channels are altered in patients with ARF due to DAD. The cause of DAD does not seem to influence the level of impairment of these channels.

Mobility therapy and central or peripheral catheter-related adverse events in an ICU in Brazil.

OBJECTIVE: To determine whether mobility therapy is associated with central or peripheral catheter-related adverse events in critically ill patients in an ICU in Brazil. METHODS: A retrospective analysis of the daily medical records of patients admitted to the Clinical Emergency ICU of the University of São Paulo School of Medicine Hospital das Clínicas Central Institute between December of 2009 and April of 2011. In addition to the demographic and clinical characteristics of the patients, we collected data related to central venous catheters (CVCs), hemodialysis (HD) catheters and indwelling arterial catheters (IACs): insertion site; number of catheter days; and types of adverse events. We also characterized the mobility therapy provided. RESULTS: Among the 275 patients evaluated, CVCs were used in 49%, HD catheters were used in 26%, and IACs were used in 29%. A total of 1,268 mobility therapy sessions were provided to patients while they had a catheter in place. Catheter-related adverse events occurred in 20 patients (a total of 22 adverse events): 32%, infection; 32%, obstruction; and 32%, accidental dislodgement. We found that mobility therapy was not significantly associated with any catheter-related adverse event, regardless of the type of catheter employed: CVC-OR = 0.8; 95% CI: 0.7-1.0; p = 0.14; HD catheter-OR = 1.04; 95% CI: 0.89-1.21; p = 0.56; or IAC-OR = 1.74; 95% CI: 0.94-3.23; p = 0.07. CONCLUSIONS: In critically ill patients, mobility therapy is not associated with the incidence of adverse events involving CVCs, HD catheters, or IACs.

Early mobilization practice in a single Brazilian intensive care unit.

OBJECTIVES: To characterize the provision of early mobilization therapy in critically ill patients in a Brazilian medical intensive care unit (ICU) and to investigate the relationship between physical activity level and clinical outcomes. METHODS: Intensive care unit and physiotherapy data were collected retrospectively from 275 consecutive patients. Here we report on the subset of patients (n = 120) who were mechanically ventilated during their ICU stay (age, 49 ± 18 years; Simplified Acute Physiology Score 3, 45 [25]). RESULTS: Median (interquartile range) time of mechanical ventilation and ICU length of stay were 3 (4) and 8 (10) days, respectively. Intensive care unit and 1-year mortality were 31% and 50%, respectively. During the ICU stay, these patients all received respiratory physiotherapy and 90% (n = 108) received mobilization therapy. When intubated and ventilated, mobilization therapy was performed in 76% (n = 92) of the patients with no adverse events. The most common activity was in-bed exercises (55%), and the number of out-of-bed activities (sitting out of bed, standing, or walking) was small (29%) and more prevalent in patients with tracheostomy than with an endotracheal tube (27% × 2%, respectively). CONCLUSION: In our Brazilian ICU, mobilization therapy in critically ill patients was safe and feasible; however, similar to other countries, in-bed exercises were the most prevalent activity. During mechanical ventilation, only a small percentage of activities involved standing or mobilizing away from the bed.

Chemical composition modulates the adverse effects of particles on the mucociliary epithelium.

OBJECTIVE: We compared the adverse effects of two types of real ambient particles; i.e., total suspended particles from an electrostatic precipitator of a steel mill and fine air particles from an urban ambient particulate matter of 2.5 µm, on mucociliary clearance. METHOD: Mucociliary function was quantified by mucociliary transport, ciliary beating frequency and the amount of acid and neutral mucous in epithelial cells through morphometry of frog palate preparations. The palates were immersed in one of the following solutions: total suspended particles (0.1 mg/mL), particulate matter 2.5 µm 0.1 mg/mL (PM0.1) or 3.0 mg/mL (PM3.0) and amphibian Ringer's solution (control). Particle chemical compositions were determined by X-ray fluorescence and gas chromatography/mass spectrometry. RESULTS: Exposure to total suspended particles and PM3.0 decreased mucociliary transport. Ciliary beating frequency was diminished by total suspended particles at all times during exposure, while particulate matter of 2.5 µm did not elicit changes. Particulate matter of 2.5 µm reduced epithelial mucous and epithelium thickness, while total suspended particles behaved similarly to the control group. Total suspended particles exhibited a predominance of Fe and no organic compounds, while the particulate matter 2.5 µm contained predominant amounts of S, Fe, Si and, to a lesser extent, Cu, Ni, V, Zn and organic compounds. CONCLUSION: Our results showed that different compositions of particles induced different airway epithelial responses, emphasizing that knowledge of their individual characteristics may help to establish policies aimed at controlling air pollution.

Ineffectiveness of using the pressure relief valve technique during cuff inflation.

OBJECTIVE: To test the effectiveness of using a cuff pressure relief valve technique to maintain cuff pressure levels within the normal in vitro range (Phase 1) in patients admitted to the intensive care unit (Phase 2) and to test the reproducibility of the technique using different syringes. METHODS: In Phase 1, a tracheal tube was inserted into a trachea model. Ten- and 20mL syringes were used to inflate the cuff through the tracheal tube. The cuff was slowly and steadily inflated until the syringe plunger would move in the opposite direction of the application. After the plunger stopped, the cuff pressures were recorded. In Phase 2, the same maneuvers for inflating the cuff were performed on 20 patients using 5, 10, and 20mL syringes and were compared with manometer measurements. The intraclass correlation coefficient and Bland-Altman analysis were employed to determine the reproducibility and agreement between syringes. Data were expressed as medians (interquartile range). RESULTS: There was no reproducibility between syringes with an intraclass correlation coefficient ranging between -0.33 and 0.8 (p>0.05). The pressures generated with the syringes were higher than the pressures generated using a standard manometer: the 5mL syringe pressure was 105cmH2O (82.5-120cmH2O), the 10mL syringe pressure was 69cmH2O (47.5-111.3cmH2O), and the 20mL syringe pressure was 45cmH2O (35-59.5cmH2O). The Bland-Altman analysis confirmed the large bias and variability between the syringes used, compared with the manometer. CONCLUSION: The use of syringes is not an effective technique for determining the cuff pressure in patients admitted to the intensive care unit.

Immunopathological aspects of schistosomiasis-associated pulmonary arterial hypertension.

OBJECTIVES: Pulmonary hypertension is a lethal complication of chronic hepatosplenic schistosomiasis. Little is known of the underlying (immuno-)histopathological characteristics of lung vasculopathy. METHODS: We characterized vasculopathy and inflammation in lung tissue of 10 patients with Schistosomiasis-associated PH (SCH-PH) in comparison to 22 idiopathic pulmonary arterial hypertension (IPAH) patients and 10 normal controls. SCH-PH cases were younger than controls. RESULTS: Plexiform lesions and/or angiomatoid lesions were found in 10/10 SCH-PH, and 19/22 IPAH patients (χ² p = 0.22). Lung granulomas with Schistosoma eggs were found in 2/10 of SCH-PH cases. PAH cases had increased peri-arterial density of CD3+ T cells, chymase+ and tryptase+ mast cells when compared to controls (p ≤ 0.047). SCH-PH showed increased density of CD4+ cells when compared to controls (p = 0.025), paralleled by an increased density of dendritic CD83+ cells when compared to both controls and IPAH patients (p ≤ 0.022). CONCLUSION: Both SCH-PH and IPAH feature plexogenic arteriopathy and increased periarterial T cell and mast cell density. SCH-PH and IPAH differ only with respect to the density of dendritic CD83+ cells. These findings imply ongoing antigenic stimulation in SCH-PH, yet a pattern of pulmonary vasculopathy similar to IPAH, suggestive of a final common pathway in their pathogenesis of PAH.

Characterization of the use of a cycle ergometer to assist in the physical therapy treatment of critically ill patients.

OBJECTIVE: The objective of this study was to use a cycle ergometer to assess cardiorespiratory changes during active exercise and to verify patients' satisfaction with this type of activity. METHODS: A single intervention involving active lower limb exercise was performed with a cycle ergometer (without load) for 5 minutes. The following variables were measured before, during and immediately after exercise: heart rate, blood pressure, respiratory rate, peripheral oxygen saturation and the Borg dyspnea scale score. Following the exercise, the patients answered a questionnaire to evaluate their satisfaction with this type of activity. RESULTS: A total of 38 patients (65% male) with a mean age of 48 ± 16 years old participated in the study. Enrolled patients presented a sequential organ failure assessment (SOFA) score of 2 (0 - 5 scale). During the exercise, 16% of the patients used ventilation support and 55% of them were breathing at room air. A comparison of the initial and final values of the variables indicated increases in the heart rate (92 ± 17 beats/min vs. 95 ± 18 beats/min; p<0.05), the respiratory rate (19 ± 8 breaths/min vs. 23 ± 8 breaths/min; p<0.05) and the Borg dyspnea scale score (1.3 ± 1.8 vs. 2.8 ± 2.2; p<0.05). In addition, 85% of the patients reported enjoying the activity. Only 25% of the patients reported some discomfort, and 100% of the patients wanted to repeat this type of activity in future treatments. CONCLUSION: During the cycle ergometer exercises, minor cardiorespiratory changes were observed in the patients. The evaluated patients reported high satisfaction with this type of activity.

Expression of acute-phase cytokines, surfactant proteins, and epithelial apoptosis in small airways of human acute respiratory distress syndrome.

PURPOSE: Recent studies suggest a role for distal airway injury in acute respiratory distress syndrome (ARDS). The epithelium lining the small airways secretes a large number of molecules such as surfactant components and inflammatory mediators. There is little information on how these small airway secretory functions are altered in ARDS. MATERIALS AND METHODS: We studied the lungs of 31 patients with ARDS (Pao(2)/fraction of inspired oxygen ≤200, 45 ± 14 years, 16 men) and 11 controls (52 ± 16 years, 7 men) submitted to autopsy and quantified the expression of interleukin (IL) 6, IL-8, surfactant proteins (SP) A and SP-B in the epithelium of small airways using immunohistochemistry and image analysis. In addition, an index of airway epithelial apoptosis was determined by the terminal deoxynucleotidyl transferase-mediated deoxyuridine-triphosphatase nick-end labeling assay, caspase 3, and Fas/Fas ligand expression. The density of inflammatory cells expressing IL-6 and IL-8 within the small airway walls was also quantified. RESULTS: Acute respiratory distress syndrome airways showed an increase in the epithelial expression of IL-8 (P = .006) and an increased density of inflammatory cells expressing IL-6 (P = .004) and IL-8 (P < .001) compared with controls. There were no differences in SP-A and SP-B epithelium expression or in epithelial apoptosis index between ARDS and controls. CONCLUSION: Distal airways are involved in ARDS lung inflammation and show a high expression of proinflammatory interleukins in both airway epithelial and inflammatory cells. Apoptosis may not be a major mechanism of airway epithelial cell death in ARDS.

Effects that passive cycling exercise have on muscle strength, duration of mechanical ventilation, and length of hospital stay in critically ill patients: a randomized clinical trial / Efeito do exercício passivo em cicloergômetro na força muscular, tempo de ventilação mecânica e internação hospitalar em pacientes críticos: ensaio clínico randomizado

ABSTRACT Objective: To evaluate the effects that passive cycling exercise, in combination with conventional physical therapy, have on peripheral muscle strength, duration of mechanical ventilation, and length of hospital stay in critically ill patients admitted to the ICU of a tertiary care university hospital. Methods: This was a randomized clinical trial involving 38 patients (≥ 18 years of age) on mechanical ventilation who were randomly divided into two groups: control (n = 16), receiving conventional physical therapy; and intervention (n = 22), receiving conventional physical therapy and engaging in passive cycling exercise five days per week. The mean age of the patients was 46.42 ± 16.25 years, and 23 were male. The outcomes studied were peripheral muscle strength, as measured by the Medical Research Council scale, duration of mechanical ventilation, and length of hospital stay. Results: There was a significant increase in peripheral muscle strength (baseline vs. final) in both groups (control: 40.81 ± 7.68 vs. 45.00 ± 6.89; and intervention: 38.73 ± 11.11 vs. 47.18 ± 8.75; p < 0.001 for both). However, the range of increase in strength was higher in the intervention group than in the control group (8.45 ± 5.20 vs. 4.18 ± 2.63; p = 0.005). There were no significant differences between the groups in terms of duration of mechanical ventilation or length of hospital stay. Conclusions: The results suggest that the performance of continuous passive mobilization on a cyclical basis helps to recover peripheral muscle strength in ICU patients. (ClinicalTrials.gov Identifier: NCT01769846 [http://www.clinicaltrials.gov/])

RESUMO Objetivo: Avaliar os efeitos da realização de exercícios passivos com um cicloergômetro, associada à fisioterapia convencional, na força muscular periférica, no tempo de ventilação mecânica e no tempo de internação hospitalar em pacientes críticos internados em UTI de um hospital universitário terciário. Métodos: Ensaio clínico randomizado envolvendo 38 pacientes (idade > 18 anos) em ventilação mecânica e divididos aleatoriamente em grupo controle (n = 16), que realizou fisioterapia convencional, e grupo intervenção (n = 22) submetidos a fisioterapia convencional e exercícios passivos em cicloergômetro cinco vezes por semana. A média de idade dos pacientes foi de 46,42 ± 16,25 anos, e 23 eram homens. Os desfechos analisados foram força muscular periférica, mensurada pela escala Medical Research Council, tempo de ventilação mecânica e tempo de internação hospitalar. Resultados: Houve um aumento significativo da força muscular periférica (basal vs. final) tanto no grupo controle (40,81 ± 7,68 vs. 45,00 ± 6,89; p < 0,001) quanto no grupo intervenção (38,73 ± 11,11 vs. 47,18 ± 8,75; p < 0,001). Entretanto, a variação do aumento da força foi maior no grupo intervenção que no controle (8,45 ± 5,20 vs. 4,18 ± 2,63; p = 0,005). Não foram observadas diferenças significativas entre os grupos quanto ao tempo de ventilação mecânica e tempo de internação hospitalar. Conclusões: Os resultados sugerem que a realização de mobilização passiva contínua de forma cíclica auxilia na recuperação da força muscular periférica de pacientes internados em UTI. (ClinicalTrials.gov Identifier: NCT01769846 [http://www.clinicaltrials.gov/])

Perme Intensive Care Unit Mobility Score and ICU Mobility Scale: translation into Portuguese and cross-cultural adaptation for use in Brazil / Perme Intensive Care Unit Mobility Score e ICU Mobility Scale: tradução e adaptação cultural para a língua portuguesa falada no Brasil

ABSTRACT Objective: To translate the Perme Intensive Care Unit Mobility Score and the ICU Mobility Scale (IMS) into Portuguese, creating versions that are cross-culturally adapted for use in Brazil, and to determine the interobserver agreement and reliability for both versions. Methods: The processes of translation and cross-cultural validation consisted in the following: preparation, translation, reconciliation, synthesis, back-translation, review, approval, and pre-test. The Portuguese-language versions of both instruments were then used by two researchers to evaluate critically ill ICU patients. Weighted kappa statistics and Bland-Altman plots were used in order to verify interobserver agreement for the two instruments. In each of the domains of the instruments, interobserver reliability was evaluated with Cronbach's alpha coefficient. The correlation between the instruments was assessed by Spearman's correlation test. Results: The study sample comprised 103 patients-56 (54%) of whom were male-with a mean age of 52 ± 18 years. The main reason for ICU admission (in 44%) was respiratory failure. Both instruments showed excellent interobserver agreement ( > 0.90) and reliability ( > 0.90) in all domains. Interobserver bias was low for the IMS and the Perme Score (−0.048 ± 0.350 and −0.06 ± 0.73, respectively). The 95% CIs for the same instruments ranged from −0.73 to 0.64 and −1.50 to 1.36, respectively. There was also a strong positive correlation between the two instruments (r = 0.941; p < 0.001). Conclusions: In their versions adapted for use in Brazil, both instruments showed high interobserver agreement and reliability.

RESUMO Objetivo: Realizar a tradução e a validação cultural para a língua portuguesa falada no Brasil e determinar a concordância e a confiabilidade dos instrumentos Perme Intensive Care Unit Mobility Score (designado Perme Escore) e ICU Mobility Scale (designada Escala de Mobilidade em UTI, EMU). Métodos: Os processos de tradução e adaptação cultural seguiram as seguintes etapas: preparação, tradução, reconciliação, síntese, tradução reversa, revisão, aprovação e pré-teste. Após esses processos, as versões em português dos dois instrumentos foram utilizadas por dois pesquisadores na avaliação de pacientes críticos em UTI. O índice kappa ponderado e a disposição gráfica de Bland-Altman foram utilizados para verificar a concordância entre os instrumentos. O coeficiente alfa de Cronbach foi utilizado para verificar a confiabilidade entre as respostas dos avaliadores dentro de cada domínio dos instrumentos. A correlação entre os instrumentos foi verificada pelo teste de correlação de Spearman. Resultados: A amostra foi composta por 103 pacientes, sendo a maioria homens (n = 56; 54%), com média de idade = 52 ± 18 anos. O principal motivo de internação nas UTIs foi insuficiência respiratória (em 44%). Os dois instrumentos apresentaram excelente concordância interobservador (> 0,90) e confiabilidade ( > 0,90) em todos os domínios. Constatou-se um baixo viés interobservador na EMU e no Perme Escore (−0,048 ± 0,350 e −0,06 ± 0,73, respectivamente). Os IC95% para os mesmos instrumentos variaram, respectivamente, de −0,73 a 0,64 e de −1,50 a 1,36, respectivamente. Além disso, verificou-se alta correlação positiva entre os dois instrumentos (r = 0,941; p < 0,001). Conclusões: As versões dos dois instrumentos apresentaram alta concordância e confiabilidade interobservador.

Mobility therapy and central or peripheral catheter-related adverse events in an ICU in Brazil / Realização de fisioterapia motora e ocorrência de eventos adversos relacionados a cateteres centrais e periféricos em uma UTI brasileira

OBJECTIVE: To determine whether mobility therapy is associated with central or peripheral catheter-related adverse events in critically ill patients in an ICU in Brazil. METHODS: A retrospective analysis of the daily medical records of patients admitted to the Clinical Emergency ICU of the University of São Paulo School of Medicine Hospital das Clínicas Central Institute between December of 2009 and April of 2011. In addition to the demographic and clinical characteristics of the patients, we collected data related to central venous catheters (CVCs), hemodialysis (HD) catheters and indwelling arterial catheters (IACs): insertion site; number of catheter days; and types of adverse events. We also characterized the mobility therapy provided. RESULTS: Among the 275 patients evaluated, CVCs were used in 49%, HD catheters were used in 26%, and IACs were used in 29%. A total of 1,268 mobility therapy sessions were provided to patients while they had a catheter in place. Catheter-related adverse events occurred in 20 patients (a total of 22 adverse events): 32%, infection; 32%, obstruction; and 32%, accidental dislodgement. We found that mobility therapy was not significantly associated with any catheter-related adverse event, regardless of the type of catheter employed: CVC-OR = 0.8; 95% CI: 0.7-1.0; p = 0.14; HD catheter-OR = 1.04; 95% CI: 0.89-1.21; p = 0.56; or IAC-OR = 1.74; 95% CI: 0.94-3.23; p = 0.07. CONCLUSIONS: In critically ill patients, mobility therapy is not associated with the incidence of adverse events involving CVCs, HD catheters, or IACs. .

OBJETIVO: Verificar se a realização de fisioterapia com foco na reabilitação motora está associada a eventos adversos em cateteres centrais e periféricos em uma UTI brasileira. MÉTODOS: Análise retrospectiva das fichas de evolução diária dos pacientes internados, de dezembro de 2009 a abril de 2011, na UTI de Emergências Clínicas do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Além das características clínicas e demográficas dos pacientes, foram coletados dados referentes aos cateteres venoso central (CVC), de hemodiálise (HD) e de pressão arterial invasiva (PAi), tais como sítio de inserção, tempo de permanência e eventos adversos relacionados, bem como à caracterização da fisioterapia motora realizada. RESULTADOS: De um total de 275 pacientes, 49% utilizaram CVC, 26%, cateter de HD e 29%, cateter de PAi em algum momento da internação. Um total de 1.268 sessões de fisioterapia motora ocorreu enquanto o paciente apresentava algum tipo de cateter inserido. Os eventos adversos relacionados à inserção dos dispositivos ocorreram em 20 pacientes, totalizando 22 ocorrências: 32% de infecção, 32% de obstrução e 32% de retirada acidental. Neste estudo, verificou-se que não existe relação entre eventos adversos nos cateteres e a realização de fisioterapia motora: fisioterapia motora e CVC - OR = 0,8; IC95%: 0,7-1,0; p = 0,14; fisioterapia motora e cateter de HD - OR = 1,04; IC95%: 0,89-1,21; p = 0,56; e fisioterapia motora e cateter de PAi - OR = 1,74; IC95%: 0,94-3,23; p = 0,07. CONCLUSÕES: A realização de fisioterapia motora em pacientes críticos não está relacionada à incidência de eventos adversos em CVC, cateteres de HD e cateteres de PAi. .

Chemical composition modulates the adverse effects of particles on the mucociliary epithelium

OBJECTIVE:We compared the adverse effects of two types of real ambient particles; i.e., total suspended particles from an electrostatic precipitator of a steel mill and fine air particles from an urban ambient particulate matter of 2.5 µm, on mucociliary clearance.METHOD:Mucociliary function was quantified by mucociliary transport, ciliary beating frequency and the amount of acid and neutral mucous in epithelial cells through morphometry of frog palate preparations. The palates were immersed in one of the following solutions: total suspended particles (0.1 mg/mL), particulate matter 2.5 µm 0.1 mg/mL (PM0.1) or 3.0 mg/mL (PM3.0) and amphibian Ringer’s solution (control). Particle chemical compositions were determined by X-ray fluorescence and gas chromatography/mass spectrometry.RESULTS:Exposure to total suspended particles and PM3.0 decreased mucociliary transport. Ciliary beating frequency was diminished by total suspended particles at all times during exposure, while particulate matter of 2.5 µm did not elicit changes. Particulate matter of 2.5 µm reduced epithelial mucous and epithelium thickness, while total suspended particles behaved similarly to the control group. Total suspended particles exhibited a predominance of Fe and no organic compounds, while the particulate matter 2.5 µm contained predominant amounts of S, Fe, Si and, to a lesser extent, Cu, Ni, V, Zn and organic compounds.CONCLUSION:Our results showed that different compositions of particles induced different airway epithelial responses, emphasizing that knowledge of their individual characteristics may help to establish policies aimed at controlling air pollution.

Ineficácia da técnica de alívio de pressão por meio de válvula em insuflar o cuff / Ineffectiveness of using the pressure relief valve technique during cuff inflation

Objetivo: Testar a eficácia da técnica de alívio de pressão de cuff por meio de uma válvula em manter níveis de pressão de cuff dentro da normalidade in vitro (Fase 1) e em pacientes internados em unidade de terapia intensiva (Fase 2), bem como testar a reprodutibilidade da técnica utilizando diferentes seringas. Métodos: Na Fase 1, uma cânula orotraqueal foi inserida em um modelo de traqueia. Seringas de 10 e 20mL foram utilizadas para insuflar o cuff da cânula. O cuff foi insuflado lenta e progressivamente até que o êmbolo da seringa se deslocasse em direção contrária da aplicação. Após a pausa do êmbolo, as pressões do balonete foram registradas. Na Fase 2, a mesma manobra de insuflação do cuff foi realizada em 20 pacientes, utilizando-se seringas de 5, 10 e 20mL, e foi comparada com as medidas de um manômetro. O índice de correlação intraclasse e a análise de Bland-Altman foram realizados para verificar a reprodutibilidade e a concordância entre as seringas. Os dados foram expressos como mediana (intervalo interquartil). Resultados: A reprodutibilidade entre as seringas foi nula, com índice de correlação intraclasse variando entre -0,33 e 0,8 (p>0,05). As pressões geradas com as seringas foram superiores à pressão obtida com o manômetro padrão: seringa de 5mL teve 105cmH2O (82,5-120cmH2O); seringa de 10mL teve ...

Objective: To test the effectiveness of using a cuff pressure relief valve technique to maintain cuff pressure levels within the normal in vitro range (Phase 1) in patients admitted to the intensive care unit (Phase 2) and to test the reproducibility of the technique using different syringes. Methods: In Phase 1, a tracheal tube was inserted into a trachea model. Ten- and 20mL syringes were used to inflate the cuff through the tracheal tube. The cuff was slowly and steadily inflated until the syringe plunger would move in the opposite direction of the application. After the plunger stopped, the cuff pressures were recorded. In Phase 2, the same maneuvers for inflating the cuff were performed on 20 patients using 5, 10, and 20mL syringes and were compared with manometer measurements. The intraclass correlation coefficient and Bland-Altman analysis were employed to determine the reproducibility and agreement between syringes. Data were expressed as medians (interquartile range). Results: There was no reproducibility between syringes with an intraclass correlation coefficient ranging between -0.33 and 0.8 (p>0.05). The pressures generated with the syringes were higher than the pressures generated using a standard manometer: the 5mL syringe pressure was 105cmH2O (82.5-120cmH2O), the 10mL syringe pressure was 69cmH2O (47.5-111.3cmH2O), and the 20mL syringe pressure was 45cmH2O (35-59.5cmH2O). The Bland-Altman analysis confirmed the large bias and variability between the ...

Caracterização do uso do cicloergômetro para auxiliar no atendimento fisioterapêutico em pacientes críticos / Characterization of the use of a cycle ergometer to assist in the physical therapy treatment of critically ill patients

OBJETIVO: Analisar as alterações cardiorrespiratórias de pacientes durante o exercício ativo com um cicloergômetro e verificar a aceitação dos pacientes para realizar esse tipo de atividade. MÉTODOS: Foi realizada uma única intervenção de exercício ativo de membros inferiores no cicloergômetro (sem carga) durante 5 minutos. As variáveis frequência cardíaca, pressão arterial, frequência respiratória, saturação periférica de oxigênio e escala de dispneia de Borg foram avaliadas em três momentos: antes, durante e imediatamente após o exercício. Ao final, o paciente respondia um questionário avaliando sua satisfação em relação a esse tipo de atividade. RESULTADOS: Participaram do estudo 38 pacientes (65% masculino) com 48±16 anos e SOFA=2 (0-5). Durante o exercício, 55% estavam em ar ambiente e 16% utilizaram algum tipo de suporte ventilatório. Comparando-se os valores iniciais e finais das variáveis analisadas, verificou-se um aumento apenas nas variáveis frequência cardíaca (92±17 e 95±18; p<0,05), frequência respiratória (19±8 e 23±8; p<0,05) e Borg (1,3±1,8 e 2,8±2,2; p<0,05). Além disso, 85% dos pacientes gostaram muito de realizar esse tipo de atividade. Apenas 25% dos pacientes relataram algum tipo de desconforto, entretanto 100% dos pacientes gostariam de repetir esse tipo de atividade em um próximo atendimento. CONCLUSÃO: Nos pacientes estudados, verificaram-se pequenas alterações cardiorrespiratórias durante o exercício com o cicloergômetro. Os pacientes avaliados relataram alta satisfação com esse tipo de atividade.

OBJECTIVE: The objective of this study was to use a cycle ergometer to assess cardiorespiratory changes during active exercise and to verify patients' satisfaction with this type of activity. METHODS: A single intervention involving active lower limb exercise was performed with a cycle ergometer (without load) for 5 minutes. The following variables were measured before, during and immediately after exercise: heart rate, blood pressure, respiratory rate, peripheral oxygen saturation and the Borg dyspnea scale score. Following the exercise, the patients answered a questionnaire to evaluate their satisfaction with this type of activity. RESULTS: A total of 38 patients (65% male) with a mean age of 48 ± 16 years old participated in the study. Enrolled patients presented a sequential organ failure assessment (SOFA) score of 2 (0 - 5 scale). During the exercise, 16% of the patients used ventilation support and 55% of them were breathing at room air. A comparison of the initial and final values of the variables indicated increases in the heart rate (92±17 beats/min vs. 95±18 beats/min; p<0.05), the respiratory rate (19 ± 8 breaths/min vs. 23±8 breaths/min; p<0.05) and the Borg dyspnea scale score (1.3±1.8 vs. 2.8±2.2; p<0.05). In addition, 85% of the patients reported enjoying the activity. Only 25% of the patients reported some discomfort, and 100% of the patients wanted to repeat this type of activity in future treatments. CONCLUSION: During the cycle ergometer exercises, minor cardiorespiratory changes were observed in the patients. The evaluated patients reported high satisfaction with this type of activity.