Esophageal balloon catheter system identification to improve respiratory effort time features and amplitude determination.

Objective. Understanding a patient's respiratory effort and mechanics is essential for the provision of individualized care during mechanical ventilation. However, measurement of transpulmonary pressure (the difference between airway and pleural pressures) is not easily performed in practice. While airway pressures are available on most mechanical ventilators, pleural pressures are measured indirectly by an esophageal balloon catheter. In many cases, esophageal pressure readings take other phenomena into account and are not a reliable measure of pleural pressure.Approach.A system identification approach was applied to provide accurate pleural measures from esophageal pressure readings. First, we used a closed pressurized chamber to stimulate an esophageal balloon and model its dynamics. Second, we created a simplified version of an artificial lung and tried the model with different ventilation configurations. For validation, data from 11 patients (five male and six female) were used to estimate respiratory effort profile and patient mechanics.Main results.After correcting the dynamic response of the balloon catheter, the estimates of resistance and compliance and the corresponding respiratory effort waveform were improved when compared with the adjusted quantities in the test bench. The performance of the estimated model was evaluated using the respiratory pause/occlusion maneuver, demonstrating improved agreement between the airway and esophageal pressure waveforms when using the normalized mean squared error metric. Using the corrected muscle pressure waveform, we detected start and peak times 130 ± 50 ms earlier and a peak amplitude 2.04 ± 1.46 cmH2O higher than the corresponding estimates from esophageal catheter readings.Significance.Compensating the acquired measurements with system identification techniques makes the readings more accurate, possibly better portraying the patient's situation for individualization of ventilation therapy.

Impact on the ability of healthcare professionals to correctly identify patient-ventilator asynchronies of the simultaneous visualization of estimated muscle pressure curves on the ventilator display: a randomized study (Pmus study).

BACKGROUND: Patient-ventilator asynchronies are usually detected by visual inspection of ventilator waveforms but with low sensitivity, even when performed by experts in the field. Recently, estimation of the inspiratory muscle pressure (Pmus) waveforms through artificial intelligence algorithm has been proposed (Magnamed®, São Paulo, Brazil). We hypothesized that the display of these waveforms could help healthcare providers identify patient-ventilator asynchronies. METHODS: A prospective single-center randomized study with parallel assignment was conducted to assess whether the display of the estimated Pmus waveform would improve the correct identification of asynchronies in simulated clinical scenarios. The primary outcome was the mean asynchrony detection rate (sensitivity). Physicians and respiratory therapists who work in intensive care units were randomized to control or intervention group. In both groups, participants analyzed pressure and flow waveforms of 49 different scenarios elaborated using the ASL-5000 lung simulator. In the intervention group the estimated Pmus waveform was displayed in addition to pressure and flow waveforms. RESULTS: A total of 98 participants were included, 49 per group. The sensitivity per participant in identifying asynchronies was significantly higher in the Pmus group (65.8 ± 16.2 vs. 52.94 ± 8.42, p < 0.001). This effect remained when stratifying asynchronies by type. CONCLUSIONS: We showed that the display of the Pmus waveform improved the ability of healthcare professionals to recognize patient-ventilator asynchronies by visual inspection of ventilator tracings. These findings require clinical validation. TRIAL REGISTRATION: ClinicalTrials.gov: NTC05144607. Retrospectively registered 3 December 2021.

Lung perfusion during veno-venous extracorporeal membrane oxygenation in a model of hypoxemic respiratory failure.

BACKGROUND: Veno-venous extracorporeal membrane oxygenation (ECMO) provides blood oxygenation and carbon dioxide removal in acute respiratory distress syndrome. However, during ECMO support, the native lungs still play an important role in gas exchange, functioning as a second oxygenator in series with ECMO. The hypoxic vasoconstriction mechanism diverts regional blood flow within the lungs away from regions with low oxygen levels, optimizing ventilation/perfusion matching. ECMO support has the potential to reduce this adaptive pulmonary response and worsen the ventilation/perfusion mismatch by raising venous oxygen partial pressure. Thus, the objective of this study was to evaluate the effect of ECMO on regional pulmonary perfusion and pulmonary hemodynamics during unilateral ventilation and posterior lung collapse. METHODS: Five Agroceres pigs were instrumented, monitored and submitted to ECMO. We used the Electrical Impedance Tomography (EIT) to evaluate lung ventilation and perfusion in all protocol steps. Effects of ECMO support on pulmonary hemodynamics and perfusion involving two different scenarios of ventilation/perfusion mismatch: (1) right-lung selective intubation inducing collapse of the normal left lung and (2) dorsal lung collapse after repeated lung lavage. Data including hemodynamics, respiratory, lung perfusion/ventilation, and laboratory data over time were analyzed with a mixed generalized model using the subjects as a random factor. RESULTS: The initiation of ECMO support provided a significant reduction in Mean Pulmonary Artery Pressure (PAPm) in both situations of ventilation/perfusion mismatch. However, distribution of lung perfusion did not change with the use of ECMO support. CONCLUSIONS: We found that the use of ECMO support with consequent increase in venous oxygen pressure induced a significant drop in PAPm with no detectable effect on regional lung perfusion in different scenarios of ventilation/perfusion mismatch.

A Novel Inhalation Mask System to Deliver High Concentrations of Nitric Oxide Gas in Spontaneously Breathing Subjects.

Nitric Oxide (NO) is administered as gas for inhalation to induce selective pulmonary vasodilation. It is a safe therapy, with few potential risks even if administered at high concentration. Inhaled NO gas is routinely used to increase systemic oxygenation in different disease conditions. The administration of high concentrations of NO also exerts a virucidal effect in vitro. Owing to its favorable pharmacodynamic and safety profiles, the familiarity in its use by critical care providers, and the potential for a direct virucidal effect, NO is clinically used in patients with coronavirus disease-2019 (COVID-19). Nevertheless, no device is currently available to easily administer inhaled NO at concentrations higher than 80 parts per million (ppm) at various inspired oxygen fractions, without the need for dedicated, heavy, and costly equipment. The development of a reliable, safe, inexpensive, lightweight, and ventilator-free solution is crucial, particularly for the early treatment of non-intubated patients outside of the intensive care unit (ICU) and in a limited-resource scenario. To overcome such a barrier, a simple system for the non-invasive NO gas administration up to 250 ppm was developed using standard consumables and a scavenging chamber. The method has been proven safe and reliable in delivering a specified NO concentration while limiting nitrogen dioxide levels. This paper aims to provide clinicians and researchers with the necessary information on how to assemble or adapt such a system for research purposes or clinical use in COVID-19 or other diseases in which NO administration might be beneficial.

Protocol for a randomized controlled trial testing inhaled nitric oxide therapy in spontaneously breathing patients with COVID-19.

Introduction: the current worldwide outbreak of Coronavirus disease 2019 (COVID-19) due to a novel coronavirus (SARS-CoV-2) is seriously threatening the public health. The number of infected patients is continuously increasing and the need for Intensive Care Unit admission ranges from 5 to 26%. The mortality is reported to be around 3.4% with higher values for the elderly and in patients with comorbidities. Moreover, this condition is challenging the healthcare system where the outbreak reached its highest value. To date there is still no available treatment for SARS-CoV-2. Clinical and preclinical evidence suggests that nitric oxide (NO) has a beneficial effect on the coronavirus-mediated acute respiratory syndrome, and this can be related to its viricidal effect. The time from the symptoms' onset to the development of severe respiratory distress is relatively long. We hypothesize that high concentrations of inhaled NO administered during early phases of COVID-19 infection can prevent the progression of the disease. Methods and analysis: This is a multicenter randomized controlled trial. Spontaneous breathing patients admitted to the hospital for symptomatic COVID-19 infection will be eligible to enter the study. Patients in the treatment group will receive inhaled NO at high doses (140-180 parts per million) for 30 minutes, 2 sessions every day for 14 days in addition to the hospital care. Patient in the control group will receive only hospital care. The primary outcome is the percentage of patients requiring endotracheal intubation due to the progression of the disease in the first 28 days from enrollment in the study. Secondary outcomes include mortality at 28 days, proportion of negative test for SARS-CoV-2 at 7 days and time to clinical recovery. Ethics and dissemination: The trial protocol has been approved at the Investigation Review Boards of Xijing Hospital (Xi'an, China) and The Partners Human Research Committee of Massachusetts General Hospital (Boston, USA) is pending. Recruitment is expected to start in March 2020. Results of this study will be published in scientific journals, presented at scientific meetings, and on related website or media in fighting this widespread contagious disease.

Protocol of a randomized controlled trial testing inhaled Nitric Oxide in mechanically ventilated patients with severe acute respiratory syndrome in COVID-19 (SARS-CoV-2).

Introduction: Severe acute respiratory syndrome due to novel Coronavirus (SARS-CoV-2) related infection (COVID-19) is characterized by severe ventilation perfusion mismatch leading to refractory hypoxemia. To date, there is no specific treatment available for COVID-19. Nitric oxide is a selective pulmonary vasodilator gas used as a rescue therapy in refractory hypoxemia due to acute respiratory distress syndrome (ARDS). In has also shown invitro and clinical evidence that inhaled nitric oxide gas (iNO) has antiviral activity against other strains of coronavirus. The primary aim of this study is to determine whether inhaled NO improves oxygenation in patients with hypoxic COVID-19. This is a multicenter randomized controlled trial with 1:1 individual allocation. Patients will be blinded to the treatment. Methods and analysis: Intubated patients admitted to the intensive care unit with confirmed SARS-CoV-2 infection and severe hypoxemia will be randomized to receive inhalation of NO (treatment group) or not (control group). Treatment will be stopped when patients are free from hypoxemia for more than 24 hours. The primary outcome evaluates levels of oxygenation between the two groups at 48 hours. Secondary outcomes include rate of survival rate at 28 and 90 days in the two groups, time to resolution of severe hypoxemia, time to achieve negativity of SARS-CoV-2 RT-PCR tests. Ethics and dissemination: The study protocol has been approved by the Investigational Review Board of Xijing Hospital (Xi'an, China) and by the Partners Human Research Committee (Boston, USA). Recruitment will start after approval of both IRBs and local IRBs at other enrolling centers. Results of this study will be published in scientific journals, presented at scientific meetings, reported through flyers and posters, and published on related website or media in combating against this widespread contagious disease. Trial registration: Clinicaltrials.gov. NCT04306393.

Síndrome de Burnout: realidade dos fisioterapeutas intensivistas? / El síndrome de Burnout: ¿estará presente entre los fisioterapeutas de cuidados intensivos? / Burnout Syndrome: the Reality of ICU Physiotherapists

RESUMO O objetivo deste trabalho foi avaliar o perfil e a prevalência da síndrome de Burnout em fisioterapeutas intensivistas das redes públicas da cidade do Recife, comparando-os entre unidades adultas, pediátricas e neonatais. Realizou-se um estudo descritivo de corte transversal em cinco hospitais públicos portadores de Unidade de Terapia Intensiva, por meio de um questionário sociodemográfico para fatores estressantes e do Maslach Burnout Inventory (MIB) para avaliar a prevalência da síndrome. Os resultados indicaram um percentual de 48,72% de Burnout para profissionais de UTI de cuidado adulto e 47,06% para unidades pediátricas e neonatais, considerando-se nível grave em apenas uma dimensão. Foram encontrados escores elevados nos indicadores de exaustão emocional, com 56,42% em UTI adulto e 64,71% em unidades pediátricas e neonatais. O indicador despersonalização apresentou 12,82% em UTI adulto e 29,41% nas demais. Já realização profissional obteve valores de 17,65% em UTI pediátricas e neonatais e de 33,33% em cuidado adulto. A prevalência da síndrome de Burnout se mostrou elevada entre os fisioterapeutas avaliados. Diante disso, observa-se a necessidade do desenvolvimento de medidas preventivas e modelos de intervenção para que tal efeito seja minimizado.

RESUMEN En este trabajo se propone evaluar el perfil y la prevalencia del síndrome de Burnout entre los fisioterapias de cuidados intensivos en las redes públicas en Recife (Brasil), comparándolos entre las unidades pediátricas, neonatales y de adultos. Se trata de un estudio descriptivo de cohorte transversal, del cual participaron cinco hospitales públicos con Unidades de Cuidados Intensivos, por medio de un cuestionario sociodemográfico para factores de estrés y del Maslach Burnout Inventory (MIB) para evaluar la prevalencia del síndrome. Los resultados desvelan un porcentaje del 48,72 % de Burnout a profesionales de UCI de atención a adultos, y un 47,06 % en unidades pediátricas y neonatales, con nivel grave sólo en una dimensión. Se encontraron puntuaciones más altas en los indicadores de agotamiento emocional, con un 56,42 % en UCI de adultos, y un 64,71 % en unidades pediátricas y neonatales. El indicador despersonalización presentó un 12,82 % en UCI de adultos, y un 29,41 % en las demás. Ya la satisfacción profesional obtuvo valor de un 17,65 % en UCI pediátricas y neonatales, y un 33,33 % en la atención a adultos. La prevalencia del síndrome de Burnout fue elevada entre los fisioterapeutas evaluados. Lo que demuestra la necesidad de desarrollar medidas preventivas y modelos de intervención para minimizar este efecto.

ABSTRACT The objective of this study was to evaluate the profile and prevalence of Burnout syndrome in physical therapists of public hospitals with intensive care units (ICU) in Recife, comparing them between adult, pediatric and neonatal units. A cross-sectional descriptive study was carried out in five public hospitals with intensive care units in the city of Recife. A sociodemographic questionnaire, a questionnaire for stressors and the Maslach Burnout Inventory (MIB) were used to assess the prevalence of the syndrome. The results indicated a percentage of Burnout of 48.72% for adult ICU professionals and 47.06% for pediatric and neonatal ICUs, considering a serious level in only one dimension. High scores were found in the Emotional Exhaustion indicators, with 56.42% in the adult ICU and 64.71% in the pediatric and neonatal ICUs. For Depersonalization 12.82% in adult ICU and 29.41% in other ICUs. As for Professional Realization, values of 17.65% in pediatric and neonatal ICUs and 33.33% in adults. The prevalence of Burnout syndrome was high among the evaluated physiotherapists. Given this, it is observed the need to develop preventive measures and intervention models, so that this effect is minimized.

Implicações da Revascularização do Miocárdiona Qualidade de Vida: Três meses de pós-operatório / Implications of Myocardial Revascularization on Quality Of Life: A Three-Month Postoperative Follow-Up

Verificar as implicações da cirurgia derevascularização do miocárdio (CRVM) na qualidade de vidade pacientes após um período de três meses do procedimentocirúrgico, observando os aspectos físicos, emocionais esociais que podem estar alterados nesses indivíduos.Material e Métodos: Foram estudados 33 pacientes comdoença arterial coronariana, submetidos à CRVM e areabilitação cardiovascular fase I. A análise da qualidade devida dos pacientes ocorreu pela apuração, em dois momentos,do questionário padronizado, o SF-36 que tem o propósito deexaminar a percepção do estado de saúde pelo própriopaciente. Resultados: Quando comparado o momento do précirúrgicocom os três meses após a cirurgia foi observadoque houve melhora em todos os domínios do questionário dequalidade de vida SF-36, exceto no domínio de limitação poraspectos emocionais (p-valor = 0,920). A melhora foiespecialmente observada nos domínios da capacidadefuncional, da dor, do estado geral de saúde e da saúdemental (p-valor < 0,001), sendo também observada nosdomínios da limitação por aspectos físicos (p-valor = 0,020),da vitalidade (p-valor = 0,001) e dos aspectos sociais (0,039).Conclusões: Demonstrou-se que a CRVM cumpre o objetivode melhorar a qualidade de vida dos pacientes, porém nãose pode subestimar a influência da reabilitação fase I nessamelhora...

Objective: To verify the implications of myocardialrevascularization surgery (MRS) on patients’ quality of lifeafter a three-month postoperative follow-up, with a focus onphysical, emotional and social factors that may be altered inthese individuals. Material and Methods: A total of 33 patientswith coronary artery disease who underwent MRS and phaseI cardiovascular rehabilitation, were included in the study.The analysis of patients’ quality of life was carried out in twostages according to a standardized questionnaire (SF-36),which aims to examine the perception of patients on theirown health status. Results: When the preoperative periodwas compared to that of three months after surgery, therewas an improvement in all domains covered by the SF-36questionnaire, excepting for the incapability due to emotionalaspects (p-value = 0.920). The improvement was observedparticularly in the fields of functional capacity, pain, generalhealth and mental health (p-value < 0.001). Furthermore, therewas an improvement in the fields of incapability due tophysical aspects (p-value = 0.020), vitality (p-value = 0.001)and social aspects (p-value = 0.039). Conclusions: It wasdemonstrated that myocardial revascularization surgeryimproves patients’ quality of life. However, one cannotunderestimate the influence of phase I rehabilitation on suchimprovements...

Avaliação da Capacidade Funcional e daLimitação Física em SujeitosPós-Revascularização Miocárdica / Assessment of Functional Capacity and Physical Limitation in Subjects Submitted to Myocardial Revascularization

Objetivo: Avaliar a capacidade funcional e a limitação física,em pacientes submetidos à cirurgia de revascularização domiocárdio (CRVM) com seis meses do pós-operatório.Material e Métodos: Foram estudados 28 pacientes comdoença arterial coronariana, submetidos à CRVM entrenovembro de 2008 e abril de 2009. Foram avaliadas acapacidade funcional e a limitação por aspectos físicos pelaapuração dos respectivos domínios presentes noquestionário padronizado Medical Outcomes Study - shortform 36 (MOS-SF), e o nível de atividade física, por meio doInternational Physical Activity Questionnaire (IPAQ).Resultados: Houve diferenças significantes entre o pré e opós-operatório para os domínios “capacidade funcional”(41,79 vs. 70,18; p < 0,001) e “limitação por aspectos físicos”(3,57 vs. 35,71; p < 0,001). Foi evidenciado que os pacientesclassificados como “ativos” pelo IPAQ tiveram pontuaçãosignificativamente maior do que o classificado com“sedentário” para o domínio “capacidade funcional” (81,07vs. 45,00; p = 0,012) e que os classificados como“insuficientemente ativo” (58,93 vs. 11,11; p = 0,006) e“sedentário” (58,93 vs. 15,00; p = 0,006) no domínio “limitaçãopor aspectos físicos”. Conclusão: Foi observado acréscimona pontuação dos domínios “capacidade funcional” e“limitação por aspectos físicos” após seis meses da CRVM,o que traduz em aumento da capacidade de realizar atividadesque no pré-operatório não eram possíveis. A melhora destesdomínios foi mais expressiva em indivíduos que praticaramatividade física regularmente após o procedimento cirúrgico...

Objective: To evaluate the functional capacity and physicallimitation in patients submitted to coronary artery bypass graft(CABG) at six months after surgery. Material and Methods:28 patients with coronary artery disease who underwentCABG between November 2008 and April 2009 were includedin this study. Their functional capacity and physical limitationwere approached considering the respective domains presentin the standardized questionnaire Medical Outcomes StudyShort Form (MOS-SF), as well as the level of physical activitythrough the International Physical Activity Questionnaire(IPAQ), in the period of six months after the CABG. Results:There were significant differences before and after surgeryfor the domains “functional capacity” (41.79 vs. 70.18; p<0.001) and “limited by physical aspects” (3.57 vs. 35.71 p<0.001). It was shown that patients classified as “active” byIPAQ had significantly higher scores than those rated as“sedentary” for the domain “functional capacity” (81.07 vs.45.00; p = 0.012) and also higher than those classified as“insufficiently active” (58.93 vs. 11.11; p = 0.006) and“sedentary” (58.93 vs. 15.00; p = 0.006) for the domain “limitedby physical aspects.” Conclusion: There was an increase inthe scores of the domains “functional capacity” and “limitationby physical aspects” six months after CABG, which translatesinto increased ability to perform activities that could not beperformed preoperatively. The improvement of these areaswas more significant in subjects who practiced regularphysical activity after surgery...