Clinimetric properties of the Perme Intensive Care Unit Mobility Score -a multicenter study for minimum important difference and responsiveness analysis.

Background: The use of instruments in clinical practice with measurement properties tested is highly recommended, in order to provide adequate assessment and measurement of outcomes. Objective: To calculate the minimum clinically important difference (MCID) and responsiveness of the Perme Intensive Care Unit Mobility Score (Perme Score). Methods: This retrospective, multicentric study investigated the clinimetric properties of MCID, estimated by constructing the Receiver Operating Characteristic (ROC). Maximizing sensitivity and specificity by Youden's, the ROC curve calibration was performed by the Hosmer and Lemeshow goodness-of-fit test. Additionally, we established the responsiveness, floor and ceiling effects, internal consistency, and predictive validity of the Perme Score. Results: A total of 1.200 adult patients records from four mixed general intensive care units (ICUs) were included. To analyze which difference clinically reflects a relevant evolution we calculated the area under the curve (AUC) of 0.96 (95% CI: 0.95-0.98), and the optimal cut-off value of 7.0 points was established. No substantial floor (8.8%) or ceiling effects (4.9%) were observed at ICU discharge. However, a moderate floor effect was observed at ICU admission (19.3%), in contrast to a very low incidence of ceiling effect (0.6%). The Perme Score at ICU admission was associated with hospital mortality, OR 0.86 (95% CI: 0.82-0.91), and the predictive validity for ICU stay presented a mean ratio of 0.97 (95% CI: 0.96-0.98). Conclusion: Our findings support the establishment of the minimum clinically important difference and responsiveness of the Perme Score as a measure of mobility status in the ICU.

Antecedentes: Se recomienda encarecidamente el uso de instrumentos en la práctica clínica con propiedades de medición probadas, con el fin de proporcionar una evaluación y medición adecuada de los resultados. Objetivo: Calcular la diferencia mínima clínicamente importante (MCID) y la capacidad de respuesta de la puntuación de movilidad de la unidad de cuidados intensivos de Perme (Perme Score). Métodos: Este estudio multicéntrico retrospectivo investigó las propiedades clinimétricas de MCID, estimadas mediante la construcción de la característica operativa del receptor (ROC). Maximizando la sensibilidad y especificidad mediante la prueba de Youden, la calibración de la curva ROC se realizó mediante la prueba de bondad de ajuste de Hosmer y Lemeshow. Además, establecimos la capacidad de respuesta, los efectos suelo y techo, la consistencia interna y la validez predictiva del Perme Score. Resultados: Se incluyeron un total de 1,200 registros de pacientes adultos de cuatro unidades de cuidados intensivos (UCI) generales mixtas. Para analizar qué diferencia refleja clínicamente una evolución relevante calculamos el área bajo la curva (AUC) de 0.96 (95% CI: 0.95-0.98); y se estableció el valor de corte óptimo de 7.0 puntos. No se observaron efectos suelo (8.8%) o techo (4.9%) sustanciales al alta de la UCI. Sin embargo, se observó un efecto suelo moderado al ingreso en la UCI (19.3%), en contraste con una incidencia muy baja del efecto techo (0.6%). El Perme Score al ingreso en UCI se asoció con la mortalidad hospitalaria, OR 0.86 (95% CI: 0.82-0.91), y la validez predictiva de estancia en UCI presentó una relación media de 0.97 (95% CI: 0.96-0.98). Conclusiones: Nuestros hallazgos respaldan el establecimiento de la diferencia mínima clínicamente importante y la capacidad de respuesta de el Perme Score como medida del estado de movilidad en la UCI.

Effects of Combined Tracheal Suctioning and Expiratory Pause: A Crossover Randomized Clinical Trial.

AIMS: Our aim is to compare volume of suctioned secretion, respiratory mechanics, and hemodynamic parameters in intubated patients undergoing closed-system endotracheal suctioning alone (control group) versus closed-system tracheal suctioning with an expiratory pause (intervention group). SETTINGS AND DESIGN: Randomized crossover clinical trial. MATERIALS AND METHODS: Patients who had been on mechanical ventilation for more than 24 hours were randomly assigned to receive closed-system suctioning alone or closed-system suctioning with an expiratory pause on the ventilator. The following variables were evaluated: heart rate, respiratory rate, mean arterial pressure, peripheral arterial oxygen saturation, peak inspiratory pressure, mechanical ventilator circuit pressure during aspiration, exhaled tidal volume, dynamic compliance, resistance, and weight of suctioned secretion. STATISTICAL ANALYSIS: Compared using the paired t-test and general linear model analysis of variance for normally distributed variables (as confirmed by the Kolmogorov-Smirnov test). The Wilcoxon test was used for variables with a nonparametric distribution, while the Chi-square test and Fisher's exact test were used for categorical variables. RESULTS: The sample comprised 31 patients (mean age, 61.1 ± 18.2 years). The amount of secretion suctioned was significantly higher in the intervention group than in the control group (1.6 g vs 0.45 g; p = 0.0001). There were no significant changes in hemodynamic parameters or respiratory mechanics when comparing pre- and postprocedure time points. CONCLUSION: The combination of closed-system endotracheal suctioning and an expiratory pause significantly increased the amount of secretion suctioned compared to conventional suctioning without expiratory pause. KEY MESSAGES: Combination of closed-system endotracheal suctioning and an expiratory pause significantly increased the amount of secretion suctioned. HOW TO CITE THIS ARTICLE: Martins LFG, Naue WS, Skueresky AS, Bianchi T, Dias AS, Forgiarini Junior LA. Effects of Combined Tracheal Suctioning and Expiratory Pause: A Crossover Randomized Clinical Trial. Indian J Crit Care Med 2019;23(10):454-457.

Comparison of Mechanical Insufflation-Exsufflation and Endotracheal Suctioning in Mechanically Ventilated Patients: Effects on Respiratory Mechanics, Hemodynamics, and Volume of Secretions.

CONTEXT: Cough assist (CA) is a device to improve bronchial hygiene of patients with secretion in the airways and ineffective cough. AIMS: To compare the physiological effects and the volume of secretion of mechanical insufflation-exsufflation (CA device) with isolated endotracheal suctioning in mechanically ventilated patients. SETTINGS AND DESIGN: Randomized crossover trial. MATERIALS AND METHODS: The patients were randomly allocated to the first technique, then the following technique was performed in the next day. We collected the variables related to oxygen saturation, hemodynamics (heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure [MAP]), and respiratory mechanics (tidal volume, minute volume, respiratory rate, and lung compliance and resistance), pre- and postimplementation (immediately and after 15 and 30 min), and the aspirated volume of secretion. STATISTICAL ANALYSIS USED: We used two-way analysis of variance followed by the Student-Newman-Keuls t-test to compare the variables at different time points. Student's t-test was used to compare secretion volumes. All data were stored and analyzed in SPSS for Windows Version 19.0. The significance level was set at 5%. RESULTS: Forty-three patients were included in the study. When we compared the results before and after the application of the techniques, we observed no significant difference in lung compliance, pulmonary resistance, MAP, peripheral oxygen saturation, and secretion volume in both groups. CONCLUSIONS: The mechanical insufflation-exsufflation does not alter respiratory mechanics and hemodynamic stability, and it does not improve airway clearance in mechanically ventilated patients.

Clinical attitudes and perceived barriers to early mobilization of critically ill patients in adult intensive care units. / Atitudes clínicas e barreiras percebidas para a mobilização precoce de pacientes graves em unidades de terapia intensiva adulto.

OBJECTIVE: To investigate the knowledge of multi-professional staff members about the early mobilization of critically ill adult patients and identify attitudes and perceived barriers to its application. METHODS: A cross-sectional study was conducted during the second semester of 2016 with physicians, nursing professionals and physical therapists from six intensive care units at two teaching hospitals. Questions were answered on a 5-point Likert scale and analyzed as proportions of professionals who agreed or disagreed with statements. The chi-square and Fisher's exact tests were used to investigate differences in the responses according to educational/training level, previous experience with early mobilization and years of experience in intensive care units. RESULTS: The questionnaire was answered by 98 out of 514 professionals (response rate: 19%). The acknowledged benefits of early mobilization were maintenance of muscle strength (53%) and shortened length of mechanical ventilation (83%). Favorable attitudes toward early mobilization included recognition that its benefits for patients under mechanical ventilation exceed the risks for both patients and staff, that early mobilization should be routinely performed via nursing and physical therapy protocols, and readiness to change the parameters of mechanical ventilation and reduce sedation to facilitate the early mobilization of patients. The main barriers mentioned were the unavailability of professionals and time to mobilize patients, excessive sedation, delirium, risk of musculoskeletal self-injury and excessive stress at work. CONCLUSION: The participants were aware of the benefits of early mobilization and manifested attitudes favorable to its application. However, the actual performance of early mobilization was perceived as a challenge, mainly due to the lack of professionals and time, excessive sedation, delirium, risk of musculoskeletal self-injury and excessive stress at work.

OBJETIVO: Avaliar o conhecimento dos profissionais da equipe multiprofissional sobre mobilização precoce em pacientes graves adultos, e identificar atitudes e barreiras percebidas para sua realização. MÉTODOS: Estudo transversal realizado com médicos, profissionais de enfermagem e fisioterapeutas de seis unidades de terapia intensiva de dois hospitais de ensino no segundo semestre de 2016. Foram indicadas respostas com uma escala Likert de 5 pontos, as quais foram registradas como proporção de profissionais concordantes e discordantes. Teste do qui quadrado e exato de Fisher foram usados para determinar diferenças nas respostas por nível de formação, experiência prévia com mobilização precoce e anos de experiência em unidade de terapia intensiva. RESULTADOS: Responderam o questionário 98 de 514 profissionais (taxa de resposta de 19%). Os benefícios da mobilização precoce reconhecidos foram manutenção da força muscular (53%) e redução no tempo de ventilação mecânica (83%). Atitudes favoráveis à mobilização precoce foram consentir que seus benefícios em pacientes sob ventilação mecânica superassem os riscos relacionados aos pacientes e à equipe; que a mobilização precoce deveria ocorrer rotineiramente por meio de protocolos de enfermagem e fisioterapia; e em alterar os parâmetros da ventilação mecânica e reduzir a sedação dos pacientes, para facilitar a mobilização precoce. As principais barreiras identificadas foram indisponibilidade de profissionais e tempo para a mobilização precoce, excesso de sedação, delirium, risco de autolesão musculoesquelética e excesso de estresse no trabalho. CONCLUSÃO: Os profissionais conhecem os benefícios da mobilização precoce e reconhecem atitudes que tornam favorável sua realização. Entretanto, aplicar a mobilização precoce foi percebida como desafiador, principalmente pela indisponibilidade de profissionais e tempo para a mobilização precoce, sedação, delirium, risco de autolesão musculoesquelética e excesso de estresse no trabalho.

Cirrhosis affects maximal oxygen consumption, functional capacity, quality of life in patients with hepatitis C.

OBJECTIVE: The aim is assess, compare, and correlate maximal oxygen consumption (VO2max. ), functional capacity and quality of life in cirrhotic patients with hepatitis C virus (HCV) and in healthy individuals. METHODS: This case-control study included 36 participants (18 patients with HCV cirrhosis and 18 healthy individuals) matched for sex and age. VO2max was assessed using ergospirometry with an incremental load test on a cycloergometer. Functional capacity was measured by a 6-min walk test (6WT), and quality of life was assessed using the 36-Item Short-Form Health Survey (SF-36). RESULTS: Both the cirrhotic group and the control group had similar results for sex (44.4% male) and age (55.6 ± 8.31 and 55.2 ± 8.85 years, respectively). The cirrhotic group scored lower in all domains of the SF-36, on the VO2max test (cirrhotic group 16.2 [11.6-18.6] ml/kg/min; control group 19.9 [16.28-26.9]; p = 0.007) and on the 6WT (cirrhotic group 521.5 [476.25-544.75] m; control group 618.0 [570.75-643.75] m; p = 0.0001). Correlations were found between the 6WT and the VO2max (r = 0.801, p < 0.0001) and between the 6WT and quality of life (SF-361-functional capacity domain; r = 0.552, p = 0.018) only in the cirrhotic group. CONCLUSION: Patients with cirrhosis due to HCV show changes in VO2max and in functional capacity, which have a significant impact on their quality of life.

Quality of life in survivors after a period of hospitalization in the intensive care unit: a systematic review. / Qualidade de vida de sobreviventes de um período de internação na unidade de terapia intensiva: uma revisão sistemática.

OBJECTIVE: To assess the long-term, health-related quality of life of intensive care unit survivors by systematic review. METHODS: The search for, and selection and analysis of, observational studies that assessed the health-related quality of life of intensive care unit survivors in the electronic databases LILACS and MEDLINE® (accessed through PubMed) was performed using the indexed MESH terms "quality of life [MeSH Terms]" AND "critically illness [MeSH Terms]". Studies on adult patients without specific prior diseases published in English in the last 5 years were included in this systematic review. The citations were independently selected by three reviewers. Data were standardly and independently retrieved by two reviewers, and the quality of the studies was assessed using the Newcastle-Ottawa scale. RESULTS: In total, 19 observational cohort and 2 case-control studies of 57,712 critically ill patients were included. The follow-up time of the studies ranged from 6 months to 6 years, and most studies had a 6-month or 1-year follow up. The health-related quality of life was assessed using two generic tools, the EuroQol and the Short Form Health Survey. The overall quality of the studies was low. CONCLUSIONS: Long-term, health-related quality of life is compromised among intensive care unit survivors compared with the corresponding general population. However, it is not significantly affected by the occurrence of sepsis, delirium, and acute kidney injury during intensive care unit admission when compared with that of critically ill patient control groups. High-quality studies are necessary to quantify the health-related quality of life among intensive care unit survivors.

OBJETIVO: Avaliar a qualidade de vida relacionada com a saúde, em longo prazo, de sobreviventes de um período de internação na unidade de terapia intensiva por revisão sistemática. MÉTODOS: Busca, seleção e análise de estudos observacionais que avaliaram a qualidade de vida relacionada com a saúde de sobreviventes de internação na unidade de terapia intensiva nas bases de dados eletrônicas LILACS e MEDLINE® (acessada pelo PubMed), encontrados por meio dos termos MESH indexados "quality of life [MeSH Terms]" AND "critically ill [MeSH Terms]". Foram incluídos estudos publicados nos últimos 5 anos no idioma inglês realizados em pacientes adultos sem doenças prévias específicas. As citações foram selecionadas independentemente por três revisores. Os dados foram extraídos de forma padronizada e independente por dois revisores, e a qualidade dos estudos foi avaliada utilizando a escala Newcastle-Ottawa. RESULTADOS: Foram incluídos 19 coortes observacionais e 2 estudos caso-controle de 57.712 doentes críticos. O tempo de seguimento dos estudos variou de 6 meses a 6 anos, sendo a maioria dos estudos com 6 meses ou 1 ano de seguimento. A qualidade de vida relacionada com a saúde foi avaliada utilizando duas ferramentas genéricas, o EuroQol e o Short Form Health Survey. A qualidade geral dos estudos foi baixa. CONCLUSÕES: A qualidade de vida relacionada com a saúde, em longo prazo, está comprometida em sobreviventes de internação na unidade de terapia intensiva comparada à da população geral correspondente. Porém, esta não é significativamente afetada pela presença de sepse, delírio e lesão renal aguda durante a internação na unidade de terapia intensiva quando comparada com grupos controle de pacientes críticos. São necessários estudos de alta qualidade para quantificar a qualidade de vida relacionada com a saúde em sobreviventes de internação em unidade de terapia intensiva.

Simple motor tasks independently predict extubation failure in critically ill neurological patients.

OBJECTIVE:: To evaluate the usefulness of simple motor tasks such as hand grasping and tongue protrusion as predictors of extubation failure in critically ill neurological patients. METHODS:: This was a prospective cohort study conducted in the neurological ICU of a tertiary care hospital in the city of Porto Alegre, Brazil. Adult patients who had been intubated for neurological reasons and were eligible for weaning were included in the study. The ability of patients to perform simple motor tasks such as hand grasping and tongue protrusion was evaluated as a predictor of extubation failure. Data regarding duration of mechanical ventilation, length of ICU stay, length of hospital stay, mortality, and incidence of ventilator-associated pneumonia were collected. RESULTS:: A total of 132 intubated patients who had been receiving mechanical ventilation for at least 24 h and who passed a spontaneous breathing trial were included in the analysis. Logistic regression showed that patient inability to grasp the hand of the examiner (relative risk = 1.57; 95% CI: 1.01-2.44; p < 0.045) and protrude the tongue (relative risk = 6.84; 95% CI: 2.49-18.8; p < 0.001) were independent risk factors for extubation failure. Acute Physiology and Chronic Health Evaluation II scores (p = 0.02), Glasgow Coma Scale scores at extubation (p < 0.001), eye opening response (p = 0.001), MIP (p < 0.001), MEP (p = 0.006), and the rapid shallow breathing index (p = 0.03) were significantly different between the failed extubation and successful extubation groups. CONCLUSIONS:: The inability to follow simple motor commands is predictive of extubation failure in critically ill neurological patients. Hand grasping and tongue protrusion on command might be quick and easy bedside tests to identify neurocritical care patients who are candidates for extubation. OBJETIVO:: Avaliar a utilidade de tarefas motoras simples, tais como preensão de mão e protrusão da língua, para predizer extubação malsucedida em pacientes neurológicos críticos. MÉTODOS:: Estudo prospectivo de coorte realizado na UTI neurológica de um hospital terciário em Porto Alegre (RS). Pacientes adultos que haviam sido intubados por motivos neurológicos e que eram candidatos ao desmame foram incluídos no estudo. O estudo avaliou se a capacidade dos pacientes de realizar tarefas motoras simples como apertar as mãos do examinador e pôr a língua para fora seria um preditor de extubação malsucedida. Foram coletados dados referentes ao tempo de ventilação mecânica, tempo de internação na UTI, tempo de internação hospitalar, mortalidade e incidência de pneumonia associada à ventilação mecânica. RESULTADOS:: Foram incluídos na análise 132 pacientes intubados que haviam recebido ventilação mecânica durante pelo menos 24 h e que passaram no teste de respiração espontânea. A regressão logística mostrou que a incapacidade dos pacientes de apertar a mão do examinador (risco relativo = 1,57; IC95%: 1,01-2,44; p < 0,045) e de pôr a língua para fora (risco relativo = 6,84; IC95%: 2,49-18,8; p < 0,001) foram fatores independentes de risco de extubação malsucedida. Houve diferenças significativas entre os pacientes nos quais a extubação foi malsucedida e aqueles nos quais a extubação foi bem-sucedida quanto à pontuação obtida no Acute Physiology and Chronic Health Evaluation II (p = 0,02), pontuação obtida na Escala de Coma de Glasgow no momento da extubação (p < 0,001), abertura dos olhos em resposta ao comando (p = 0,001), PImáx (p < 0,001), PEmáx (p = 0,006) e índice de respiração rápida e superficial (p = 0,03). CONCLUSÕES:: A incapacidade de obedecer a comandos motores simples é preditora de extubação malsucedida em pacientes neurológicos críticos. Preensão de mão e protrusão da língua em resposta ao comando podem ser testes rápidos e fáceis realizados à beira do leito para identificar pacientes neurológicos críticos que sejam candidatos à extubação.

Variable mechanical ventilation. / Ventilação mecânica variável.

OBJECTIVE:: To review the literature on the use of variable mechanical ventilation and the main outcomes of this technique. METHODS:: Search, selection, and analysis of all original articles on variable ventilation, without restriction on the period of publication and language, available in the electronic databases LILACS, MEDLINE®, and PubMed, by searching the terms "variable ventilation" OR "noisy ventilation" OR "biologically variable ventilation". RESULTS:: A total of 36 studies were selected. Of these, 24 were original studies, including 21 experimental studies and three clinical studies. CONCLUSION:: Several experimental studies reported the beneficial effects of distinct variable ventilation strategies on lung function using different models of lung injury and healthy lungs. Variable ventilation seems to be a viable strategy for improving gas exchange and respiratory mechanics and preventing lung injury associated with mechanical ventilation. However, further clinical studies are necessary to assess the potential of variable ventilation strategies for the clinical improvement of patients undergoing mechanical ventilation.

Viability of gait speed test in hospitalized elderly patients.

OBJECTIVE: The gait speed test (GST) is a physical test that can predict falls and aid in the diagnosis of sarcopenia in the elderly. However, to our knowledge, there have been no studies evaluating its reproducibility in hospitalized elderly patients. The objective of this study was to evaluate the safety and reproducibility of the six-meter GST (6GST) in hospitalized elderly patients. METHODS: This repeated measures study involved hospitalized elderly patients (≥ 60 years of age) who underwent the 6GST by the fifth day of hospitalization, were able to walk without assistance, and presented no signs of dyspnea or pain that would prevent them from performing the test. The 6GST was performed three times in sequence, with a rest period between each test, in a level corridor. Gait speed was measured in meters/second. Reproducibility was assessed by comparing the means, intraclass correlation coefficients (ICCs) and Bland-Altman plots. RESULTS: We evaluated 110 elderly patients in a total of 330 tests. All participants completed all of the tests. The comparisons between the speeds obtained during the three tests showed high ICCs and a low mean bias (Bland-Altman plots). The correlation and accuracy were greatest when the mean maximum speed was compared with that obtained in the third test (1.26 ± 0.44 m/s vs. 1.22 ± 0.44 m/s; ICC = 0.99; p = 0.001; mean bias = 0.04; and limits of agreement = -0.27 to 0.15). CONCLUSIONS: The 6GST was proven to be safe and to have good reproducibility in this sample of hospitalized elderly patients. The third measurement seems to correspond to the maximum speed, since the first two measurements underestimated the actual performance. OBJETIVO: O teste de velocidade de marcha (TVM) é um teste físico que pode predizer quedas e auxiliar no diagnóstico de sarcopenia em idosos da comunidade. Entretanto, pelo que sabemos, não há estudos que avaliaram sua reprodutibilidade em idosos hospitalizados. O objetivo deste estudo foi avaliar a segurança e a reprodutibilidade do TVM de seis metros (TVM6) em idosos hospitalizados. MÉTODOS: Estudo com medidas repetidas envolvendo idosos hospitalizados (idade ≥ 60 anos) que realizaram o TVM6 até o quinto dia de hospitalização, sendo capazes de andar sem auxílio e não apresentando dispneia ou dor que os incapacitasse para a realização dos testes. O TVM6 foi realizado sequencialmente três vezes, com período de descanso, em um corredor plano, e a velocidade de marcha foi calculada em metros/segundo. A reprodutibilidade foi avaliada pela comparação das médias, coeficientes de correlação intraclasse (CCI) e disposições gráficas de Bland-Altman. RESULTADOS: Foram avaliados 110 idosos avaliados com um total de 330 testes. Todos os participantes completaram todos os testes. As comparações entre as velocidades obtidas nos três testes realizados indicaram CCIs elevados e viés médio baixo pela disposição gráfica de Bland-Altman. Em relação à maior velocidade aferida, a correlação e a precisão foram maiores quando comparadas à obtida no terceiro teste (1,26 ± 0,44 m/s vs. 1,22 ± 0,44 m/s; CCI = 0,99; p = 0,001; viés médio = 0,04; e limites de concordância = -0,27 a 0,15). CONCLUSÕES: O TVM6 mostrou-se seguro e teve boa reprodutibilidade nessa amostra de idosos hospitalizados. A terceira aferição parece corresponder à velocidade máxima, já que duas primeiras subestimaram o desempenho real.

N-acetylcysteine administration confers lung protection in different phases of lung ischaemia-reperfusion injury.

OBJECTIVES: To verify the effects of N-acetylcysteine (NAC) administered before and after ischaemia in an animal model of lung ischaemia-reperfusion (IR) injury. METHODS: Twenty-four Wistar rats were subjected to an experimental model of selective left pulmonary hilar clamping for 45 min followed by 2 h of reperfusion. The animals were divided into four groups: control group (SHAM), ischaemia-reperfusion, N-acetylcysteine-preischaemia (NAC-Pre) and NAC-postischaemia (NAC-Post). We recorded the haemodynamic parameters, blood gas analysis and histology. We measured the thiobarbituric acid reactive substances concentration; the expression of superoxide dismutase (SOD), inducible nitric oxide synthase (iNOS), nitrotyrosine, cleaved caspase 3, nuclear factor κB (NF-κB), NF-kappa-B inhibitor alpha (IκB-α), tumour necrosis factor alpha (TNF-α) and interleukin-1 beta (IL-1ß); myeloperoxidase activity (MPO). RESULTS: No significant differences were observed in the haemodynamic parameters, blood gas analysis and SOD activity among the groups. Lipid peroxidation was significantly higher in the IR and NAC-Pre groups (P < 0.01). The expression of nitrotyrosine, cleaved caspase 3, NF-κB, IκB-α, TNF-α and IL-1ß were significantly higher in the IR group when compared with the SHAM and NAC groups (P < 0.01). The NAC-Pre group showed a significantly higher expression of these proteins when compared with the SHAM and NAC-Post groups (P < 0.05). After reperfusion, the expression of iNOS increased almost uniformly in all groups when compared with the SHAM group (P < 0.01). The histological analysis showed fewer inflammatory cells in the NAC groups. CONCLUSIONS: The intravenous administration of NAC demonstrated protective properties against lung IR injury. The use of NAC immediately after reperfusion potentiates its protective effects.

Effect of the systemic administration of methylprednisolone on the lungs of brain-dead donor rats undergoing pulmonary transplantation.

OBJECTIVE: Most lung transplants are obtained from brain-dead donors. The physiopathology of brain death involves hemodynamics, the sympathetic nervous system, and inflammatory mechanisms. Administering methylprednisolone 60 min after inducing brain death in rats has been shown to modulate pulmonary inflammatory activity. Our objective was to evaluate the effects of methylprednisolone on transplanted rat lungs from donors treated 60 min after brain death. METHODS: Twelve Wistar rats were anesthetized, and brain death was induced. They were randomly divided into two groups (n=6), namely a control group, which was administered saline solution, and a methylprednisolone group, which received the drug 60 min after the induction of brain death. All of the animals were observed and ventilated for 2 h prior to being submitted to lung transplantation. We evaluated the hemodynamic and blood gas parameters, histological score, lung tissue levels of thiobarbituric acid-reactive substances, level of superoxide dismutase, level of tumor necrosis factor-alpha, and level of interleukin-1 beta. RESULTS: After transplantation, a significant reduction in the levels of tumor necrosis factor-alpha and IL-1ß was observed in the group that received methylprednisolone (p=0.0084 and p=0.0155, respectively). There were no significant differences in tumor necrosis factor-alpha and superoxide dismutase levels between the control and methylprednisolone groups (p=0.2644 and p=0.7461, respectively). There were no significant differences in the blood gas parameters, hemodynamics, and histological alterations between the groups. CONCLUSION: The administration of methylprednisolone after brain death in donor rats reduces inflammatory activity in transplanted lungs but has no influence on parameters related to oxidative stress.

Effect of the systemic administration of methylprednisolone on the lungs of brain-dead donor rats undergoing pulmonary transplantation

OBJECTIVE: Most lung transplants are obtained from brain-dead donors. The physiopathology of brain death involves hemodynamics, the sympathetic nervous system, and inflammatory mechanisms. Administering methylprednisolone 60 min after inducing brain death in rats has been shown to modulate pulmonary inflammatory activity. Our objective was to evaluate the effects of methylprednisolone on transplanted rat lungs from donors treated 60 min after brain death. METHODS: Twelve Wistar rats were anesthetized, and brain death was induced. They were randomly divided into two groups (n = 6), namely a control group, which was administered saline solution, and a methylprednisolone group, which received the drug 60 min after the induction of brain death. All of the animals were observed and ventilated for 2 h prior to being submitted to lung transplantation. We evaluated the hemodynamic and blood gas parameters, histological score, lung tissue levels of thiobarbituric acid-reactive substances, level of superoxide dismutase, level of tumor necrosis factor-alpha, and level of interleukin-1 beta. RESULTS: After transplantation, a significant reduction in the levels of tumor necrosis factor-alpha and IL-1β was observed in the group that received methylprednisolone (p = 0.0084 and p = 0.0155, respectively). There were no significant differences in tumor necrosis factor-alpha and superoxide dismutase levels between the control and methylprednisolone groups (p = 0.2644 and p = 0.7461, respectively). There were no significant differences in the blood gas parameters, hemodynamics, and histological alterations between the groups. CONCLUSION: The administration of methylprednisolone after brain death in donor rats reduces inflammatory activity in transplanted lungs but has no influence on parameters related to oxidative stress. .

Lung and liver changes due to the induction of cirrhosis in two experimental models.

CONTEXT: To evaluate lung and liver changes in two experimental models using intraperitoneal carbon tetrachloride (CCl4) and bile duct ligation (BDL). methods: Twenty-four male Wistar rats were divided into a control group (CO) and an experimental group (EX). We evaluated the liver transaminases (AST, ALT, AP), arterial blood gases (PaO2, PCO2 and SpO2) and lipid peroxidation by TBARS (substances that react to thiobarbituric acid) and chemiluminescence. We also evaluated the antioxidant enzyme superoxide dismutase (SOD) and histology of lung tissue and liver. RESULTS: There were significant differences in AST, ALT, ALP and PaO2 between CO group and EX group (P<0.05). The levels of TBARS, chemiluminescence and activity of enzyme superoxide dismutase were increased to different degrees in the CCl4 groups: CO and in the BDL -EX (P<0.05, respectively). In the lung histology, an increase in the wall thickness of the pulmonary artery and a diameter reduction in the CCl4 animal model were observed: comparing CO group with EX group, we observed a reduction in thickness and an increase in the diameter of the artery wall lung. CONCLUSION: Both experimental models have caused liver damage and alterations in the artery wall that are associated with major changes in pulmonary gas exchange.

Effect of exercise performed during hemodialysis: strength versus aerobic.

RATIONAL: Patients under regular dialysis can also present alterations in the cardiovascular, musculoskeletal, and metabolic systems. OBJECTIVES: The aim of this study is to compare the effects of strength and aerobic exercises performed during hemodialysis (HD) in individuals with chronic renal disease. MATERIALS AND METHODS: Randomized clinical trial. It was developed as a program of exercises three times a week, in the first 2 h of HD for 8 weeks. The patients were divided into three groups: control (Group 1, n: 11), strength (Group 2, n: 11), and aerobic (Group 3, n: 10). G1 has not developed any type of physical training; G2 utilized a training load of 40% of one repetition maximum (1RM) with anklets, and developed three series of 15 repetitions. G3 pedaled seated in the dialysis seat, during 20 min, in an ergometric bicycle, with intensity regulated by the perceived effort scale. Before and after 8 weeks, the following variables were evaluated: respiratory muscular strength, pulmonary function, functional capacity, blood biochemistry, and quality of life. MAIN FINDINGS: In the pre- and post-training comparison, there was statistically significant improvement (p < 0.05) in the maximal inspiratory pressure (MIP), number of steps achieved (NSA), and quality of life (QoL) in the trained groups, as compared to the non-exercised group (G1). CONCLUSIONS: The strength and aerobic exercises developed during HD can improve the respiratory muscular strength, functional performance, and quality of life, when compared to individuals presenting the disease who have not developed any type of physical training.

Endobronchial perfluorocarbon administration decreases lung injury in an experimental model of ischemia and reperfusion.

OBJECTIVE: To verify the effects of liquid endobronchial perfluorocarbon (PFC) administered before reperfusion in an animal model of lung ischemia-reperfusion injury. METHODS: Eighteen Wistar rats were subjected to an experimental model of selective left pulmonary artery clamping for 45 min followed by reperfusion for 2 h. The animals were divided into three groups: the ischemia-reperfusion (IR) group, the sham group, and the PFC group. We recorded the hemodynamic parameters, blood gas analysis, and histology. A Western blot assay was used to measure the inducible nitric oxide synthase, caspase 3, and nuclear factor қB (subunit p65) activities. Lipid peroxidation was assessed by the thiobarbituric acid reactive substances assay and the activity of the antioxidant enzyme superoxide dismutase. RESULTS: No significant differences were observed in lipid peroxidation among the groups. The superoxide dismutase activity was increased (P < 0.05) in the PFC-treated group. The expressions of nuclear factor қB, inducible nitric oxide synthase, and caspase 3 were significantly lower in the PFC group than in the IR group (P < 0.05). The histologic analysis showed a reduction in lung injuries in the PFC group compared with the sham and IR groups. CONCLUSION: The use of endobronchial PFC reduces the inflammatory response, preserves the alveolar structure, and protects the lungs against the hazardous effects of ischemia-reperfusion injuries.

Effect of positive end-expiratory pressure after porcine unilateral left lung transplant.

OBJECTIVES: To evaluate the effects of 2 different levels of positive end-expiratory pressure on pigs who had unilateral lung transplants. MATERIALS AND METHODS: A left lung transplant was performed in 12 pigs. The animals were randomized into 2 groups based on positive end-expiratory pressure: group 1 (5 cm H(2)O) and group 2 (10 cm H(2)O). Hemodynamics, gas exchange, and respiratory mechanics were measured before and after surgery. Cytokines, oxidative stress, and histologic scores were assessed in the lung tissue of each pig. RESULTS: Pigs in group 2 exhibited a significantly higher mean heart rate (P = .006), static compliance (P = .001), lower mean arterial pressure (P = .003), and airway resistance (P = .001) than did pigs in group 1. There were no postoperative differences between the groups in concentrations of thiobarbituric acid reactive substances, superoxide dismutase, and interleukin 8. At the end of the observation period, pigs in group 2 had higher levels of thiobarbituric acid reactive substances (P = .001) and interleukin 8 (P = .05), and pigs in group 1 had higher levels of superoxide dismutase (P = .05) than they did at baseline. CONCLUSIONS: After unilateral lung transplant, higher positive end-expiratory pressure was associated with improved respiratory mechanics, a negative effect on hemodynamics, a stronger inflammatory response, and increased production of reactive oxygen species, but no effect on gas exchange.

Early respiratory therapy reduces postoperative atelectasis in children undergoing lung resection.

BACKGROUND: Early physiotherapy reduces pulmonary complications after lung resection in adult patients. However, the effectiveness and the techniques used in postoperative physiotherapy in children undergoing lung resection have not been well described. Therefore, the standardization of a physiotherapeutic attendance after lung resection in children is necessary. METHODS: This was a retrospective and prospective, interventional, descriptive, and quantitative study. We evaluated 123 pediatric subjects undergoing lung resection. Fifty-two children were prospectively submitted to a standardized physiotherapy protocol that included a mask with a positive expiratory pressure of 10 cm H2O, expiratory rib cage compression, coughing, lifting the upper limbs, and ambulation, starting within the first 4 hours after surgery and continuing 3 times each day. A historical control group of 71 subjects received physiotherapeutic techniques without specific standardization and with variability in the start date and number of days attended. We recorded the presence of postoperative complications, prolonged air leak, postoperative bronchoscopy, the time of chest tube removal, and hospital stay following surgery. RESULTS: The group that received a standardized protocol of physiotherapy had fewer instances of atelectasis than the control group (15.4% vs 7.6%, P = .01). Subjects in the control group were more likely than those in the intervention group to require fiberoptic bronchoscopy for bronchial toilet (n = 14 [19.7%] vs n = 5 [9.6%], P ≤ .001). There was no difference in the time of drainage or hospital stay between the groups. CONCLUSIONS: Implementation of a standardized physiotherapeutic protocol after lung resection in children decreases atelectasis but does not reduce the time of chest tube removal or the duration of hospital stay.

When is injury potentially reversible in a lung ischemia-reperfusion model?

OBJECTIVE: To verify the impact of ischemic time on lung cell viability in an experimental model of lung ischemia-reperfusion (IR) injury and its repercussion on lung performance after reperfusion. METHODS: Twenty-four animals were subjected to selective clamping of the left pulmonary artery and divided into four groups (n = 6) according to ischemic time: 15 (IR15), 30 (IR30), 45 (IR45), and 60 min (IR60). All animals were observed for 120 min after reperfusion. The hemodynamics, arterial blood gases measurements, and histologic changes were analyzed. Immunofluorescence assays for caspase 3 and annexin V were performed. Lipid peroxidation was assessed by thiobarbituric acid-reactive substances, and caspase 3 activity was assessed by colorimetric extract. RESULTS: The partial pressure of arterial oxygen significantly decreased at the end of the observation period in the IR30, IR45, and IR60 groups (P < 0.05). The final mean arterial pressure significantly decreased in the IR60 group (P < 0.05). We observed a significant increase in caspase 3 activity and caspase 3-positive cells by immunofluorescence in the IR45 group compared with the other groups (P < 0.05). Additionally, there was an increase in necrotic cells assessed by annexin V in the IR60 group. The histologic score did not show differences among the different groups. CONCLUSIONS: The degree of cell damage had a negative impact on lung performance. Sixty minutes of lung ischemia and posterior reperfusion resulted in an increased number of necrotic cells, suggesting that these cells may not be able to reverse the effects of the IR injury because of the lack of viable cells.