Functional independence and spirometry in adult post-intensive care unit patients. / Independência funcional e espirometria em pacientes adultos pós-unidade de terapia intensiva.

OBJECTIVE: To relate functional independence to the degree of pulmonary impairment in adult patients 3 months after discharge from the intensive care unit. METHODS: This was a retrospective cohort study conducted in one adult intensive care unit and a multi-professional post-intensive care unit outpatient clinic of a single center. Patients admitted to the intensive care unit from January 2012 to December 2013 who underwent (3 months later) spirometry and answered the Functional Independence Measure Questionnaire were included. RESULTS: Patients were divided into groups according to the classification of functional independence and spirometry. The study included 197 patients who were divided into greater dependence (n = 4), lower dependence (n = 12) and independent (n = 181) groups. Comparing the three groups, regarding the classification of the Functional Independence Measure, patients with greater dependence had higher Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment values at intensive care unit admission with more advanced age, more days on mechanical ventilation, and longer stay in the intensive care unit and hospital. The majority of patients presented with pulmonary impairment, which was the obstructive pattern observed most frequently. When comparing functional independence with pulmonary function, it was observed that the lower the functional status, the worse the pulmonary function, with a significant difference being observed in peak expiratory flow (p = 0.030). CONCLUSION: The majority of patients who returned to the outpatient clinic 3 months after discharge had good functional status but did present with pulmonary impairment, which is related to the degree of functional dependence.

OBJETIVO: Relatar a independência funcional e o grau de comprometimento pulmonar em pacientes adultos 3 meses após a alta da unidade de terapia intensiva. MÉTODOS: Este foi um estudo de coorte retrospectiva conduzido em uma unidade de terapia intensiva multiprofissional para pacientes adultos em um único centro. Incluíram-se pacientes admitidos à unidade de terapia intensiva entre janeiro de 2012 e dezembro de 2013 que, 3 meses mais tarde, foram submetidos à espirometria e responderam ao questionário Medida de Independência Funcional. RESULTADOS: Os pacientes foram divididos em grupos segundo sua classificação de independência funcional e espirometria. O estudo incluiu 197 pacientes, que foram divididos entre os grupos maior dependência (n = 4), menor dependência (n = 12) e independente (n = 181). Na comparação dos três grupos com relação à classificação pela Medida de Independência Funcional, pacientes com maior dependência tinham escores Acute Physiology and Chronic Health Evaluation II e Sequential Organ Failure Assessment mais altos quando da admissão à unidade de terapia intensiva, idade mais avançada, mais dias sob ventilação mecânica e tempo mais longo de permanência na unidade de terapia intensiva e no hospital. A maioria dos pacientes apresentava comprometimento pulmonar, sendo o padrão obstrutivo o mais frequentemente observado. Na comparação da independência funcional com a função pulmonar, observou-se que, quanto pior a condição funcional, pior a função pulmonar, observando-se diferenças significantes em relação ao pico de fluxo expiratório (p = 0,030). CONCLUSÃO: Em sua maioria, os pacientes que retornaram ao ambulatório 3 meses após a alta tinham boa condição funcional, porém apresentavam comprometimento pulmonar relacionado com o grau de dependência funcional.

Effects of Neuromuscular Electrical Stimulation of the Quadriceps and Diaphragm in Critically Ill Patients: A Pilot Study.

BACKGROUND: Deep and respiratory muscle disorders are commonly observed in critically ill patients. Neuromuscular electrical stimulation (NMES) is an alternative to mobilize and to exercise that does not require active patient participation and can be used on bedridden patients. OBJECTIVE: Evaluate the effectiveness of the NMES therapy in quadriceps versus diaphragm subjects in mechanical ventilation (MV). METHODS: Sixty-seven subjects in MV were included, divided into 3 groups: (a) control group (CG, n=26), (b) stimulation of quadriceps (quadriceps group-QG, n=24), and (c) stimulation of diaphragm (diaphragm group-DG, n=17). The QG and DG patients received consecutive daily electrical stimulation sessions at specific points from the first day of randomization until ICU discharge. Respiratory and peripheral muscle strength, MV time, length of hospitalization, and functional independence score (the Functional Status Score-ICU) were recorded. RESULTS: There were studied n=24 (QG), n=17 (DG), and n=26 (CG) patients. Peripheral muscle strength improved significantly in the QG (p=0.030). Functional independence at ICU discharge was significantly better in QG (p=0.013), and the QG presented a better Barthel Index compared to DG and CG (p=0.0049) and also presented better FSS compared to CG (p=0.001). CONCLUSIONS: Electrical stimulation of quadriceps had best outcomes for peripheral muscle strength compared with controls or electrical stimulation of diaphragm among mechanically ventilated critically ill subjects and promoted functional independence and decreased length of hospitalization.

A influência do delirium no tempo de ventilação mecânica em pacientes críticos: uma revisão sistemática / The influence of delirium in the time of mechanical ventilation in critical patients: a systematic review

O delirium consiste em um estado confusional agudo e de curso flutuante representando uma manifestação da disfunção cerebral que pode estar associado com diferentes manifestações clínicas. Os pacientes com delirium têm sido estudados, pois tem apresentado maior tempo de ventilação mecânica e de internação em unidade de terapia intensiva. O objetivo do estudo foi realizar uma revisão de literatura acerca da influência do delirium no tempo de ventilação mecânica, sedação e na mortalidade de pacientes internados em unidade de terapia intensiva. Foi realizada uma busca por estudos nas bases de dados PubMed e Embase, com os descritores delirium, intensive care unit and mechanical ventilation. Nos resultados foram incluídos oito artigos, um recebeu graduação A e sete receberam graduação B na escala de Oxford. Os principais resultados foram: Os pacientes com delirium apresentaram maior gravidade, maior tempo de ventilação mecânica, maior tempo de sedação e maior mortalidade. Conclui-se que o delirium parece estar associado ao maior tempo da ventilação mecânica, maior dosagem de sedação e de mortalidade nestes pacientes.

Delirium consists of an acute, fluctuating, confusional state, representing a manifestation of cerebral dysfunction that can occur with different clinical manifestations. Patients with delirium have been studied because they have had longer time of mechanical ventilation and hospitalization in the intensive care unit. The objective of the study was to perform a literature review about the influence of delirium on the time of mechanical ventilation, sedation and on the mortality of patients admitted in intensive care units. A search for studies with the keywords delirium, intensive care unit and mechanical ventilation was performed in PubMed and Embase databases. As result eight articles were included, one received level A and seven received level B on the Oxford scale. The main results were: Patients with delirium presented greater severity, longer time of mechanical ventilation, longer sedation time and higher mortality. It is concluded that delirium appears to be associated with longer mechanical ventilation, greater sedation and mortality rates in these patients.

Comparison of Proportional Assist Ventilation Plus, T-Tube Ventilation, and Pressure Support Ventilation as Spontaneous Breathing Trials for Extubation: A Randomized Study.

BACKGROUND: Failure to wean can prolong ICU stay, increase complications associated with mechanical ventilation, and increase morbidity and mortality. The spontaneous breathing trial (SBT) is one method used to assess weaning. The aim of this study was to assess proportional assist ventilation plus (PAV+) as an SBT by comparing its applicability, safety, and efficacy with T-tube and pressure support ventilation (PSV). METHODS: A randomized study was performed involving 160 adult subjects who remained on mechanical ventilation for > 24 h. Subjects were randomly assigned to the PAV+, PSV, or T-tube group. When subjects were ready to perform the SBT, subjects in the PAV+ group were ventilated in PAV+ mode (receiving support of up to 40%), the pressure support was reduced to 7 cm H2O in the PSV group, and subjects in the T-tube group were connected to one T-piece with supplemental oxygen. Subjects were observed for signs of intolerance, whereupon the trial was interrupted. When the trial succeeded, the subjects were extubated and assessed until discharge. RESULTS: The subjects were predominantly male (66.5%), and the leading cause of admission was traumatic brain injury. The groups were similar with respect to baseline characteristics, and no significant difference was observed among the groups regarding extubation success or failure. Analysis of the specificity and sensitivity revealed good sensitivity for all groups; however, the PAV+ group had higher specificity (66.6%) and higher sensitivity (97.6%), with prediction of ∼ 92.1% of the success and failure events. CONCLUSIONS: No significant differences in the groups was observed regarding the rate of extubation failure, duration of mechanical ventilation, and ICU and hospital stay, indicating that PAV+ is an alternative for use as an SBT.

Delirium during Weaning from Mechanical Ventilation.

Background. We compare the incidence of delirium before and after extubation and identify the risk factors and possible predictors for the occurrence of delirium in this group of patients. Methods. Patients weaned from mechanical ventilation (MV) and extubated were included. The assessment of delirium was conducted using the confusion assessment method for the ICU and completed twice per day until discharge from the intensive care unit. Results. Sixty-four patients were included in the study, 53.1% of whom presented with delirium. The risk factors of delirium were age (P = 0.01), SOFA score (P = 0.03), APACHE score (P = 0.01), and a neurological cause of admission (P = 0.01). The majority of the patients began with delirium before or on the day of extubation. Hypoactive delirium was the most common form. Conclusion. Acute (traumatic or medical) neurological injuries were important risk factors in the development of delirium. During the weaning process, delirium developed predominantly before or on the same day of extubation and was generally hypoactive (more difficult to detect). Therefore, while planning early prevention strategies, attention must be focused on neurological patients who are receiving MV and possibly even on patients who are still under sedation.

Influence of prone positioning on premature newborn infant stress assessed by means of salivary cortisol measurement: pilot study.

OBJECTIVE: This study sought to assess the influence of prone positioning on the stress of newborn premature infants through the measurement of the salivary cortisol concentration and the evaluation of physiological and behavioral responses before and after changes in body positioning. METHODS: Saliva samples were collected from newborn infants at two different times: the first (corresponding to the baseline) after a period of 40 minutes during which the infants were not subjected to any manipulation and were placed in the lateral or supine position, and the second 30 minutes after placement in the prone position. Variables including heart rate, respiratory rate, peripheral oxygen saturation, and the Brazelton sleep score were recorded before, during, and at the end of the period in the prone position. RESULTS: The sample comprised 16 newborn premature infants (56.3% male) with a gestational age between 26 and 36 weeks, postnatal age between 1 and 33 days, birth weight of 935 to 3,050g, and weight at the time of intervention of 870 to 2,890g. During the intervention, six participants breathed room air, while the remainder received oxygen therapy. The median salivary cortisol concentration was lower in the prone position compared to baseline (0.13 versus 0.20; p=0.003), as was the median Brazelton sleep score (p=0.02). The average respiratory rate was lower after the intervention (54.88±7.15 versus 60±7.59; p=0.0004). The remainder of the investigated variables did not exhibit significant variation. CONCLUSION: Prone positioning significantly reduced the salivary cortisol level, respiratory rate, and Brazelton sleep score, suggesting a correlation between prone positioning and reduction of stress in preterm infants.

Influência do posicionamento em prona sobre o estresse no recém-nascido prematuro avaliada pela dosagem de cortisol salivar: um estudo piloto / Influence of prone positioning on premature newborn infant stress assessed by means of salivary cortisol measurement: pilot study

Objetivo: Avaliar a influência da postura em prona sobre o estresse no recém-nascido prematuro por meio da dosagem do cortisol salivar e da avaliação das respostas fisiológicas e comportamentais, antes e após o posicionamento. Métodos: Foi realizada a coleta de saliva em cada recém-nascido em dois momentos: o primeiro (correspondente ao basal), sem manipulação prévia por 40 minutos, em decúbito lateral ou supino; e o segundo, 30 minutos após o posicionamento em prona. A frequência cardíaca e respiratória, saturação periférica de oxigênio e escala de sono de Brazelton foram registradas antes, durante e ao final do posicionamento em prona. Resultados: Participaram do estudo 16 recém-nascidos prematuros (56,3% masculino) com idade gestacional de 26 a 36 semanas, com 1 a 33 dias de vida, e peso variando de 935 a 3.050g ao nascimento e de 870 a 2.890g no dia da intervenção. Durante o posicionamento, seis recém-nascidos estavam em ar ambiente e os demais recebiam oxigênio suplementar. A mediana dos níveis de cortisol salivar foi menor durante o posicionamento em prona comparativamente ao basal (0,13 e 0,20; p=0,003), assim como a do escore de sono de Brazelton (p=0,02). A média da frequência respiratória foi menor após a intervenção (54,88±7,15 e 60±7,59; p=0,0004). As demais variáveis analisadas não apresentaram variação significativa. Conclusão: O posicionamento em prona diminuiu significativamente os níveis de cortisol salivar, da frequência respiratória e do escore de sono de Brazelton, sugerindo a correlação entre essa postura e a diminuição do estresse nesses recém-nascidos. .

Objective: This study sought to assess the influence of prone positioning on the stress of newborn premature infants through the measurement of the salivary cortisol concentration and the evaluation of physiological and behavioral responses before and after changes in body positioning. Methods: Saliva samples were collected from newborn infants at two different times: the first (corresponding to the baseline) after a period of 40 minutes during which the infants were not subjected to any manipulation and were placed in the lateral or supine position, and the second 30 minutes after placement in the prone position. Variables including heart rate, respiratory rate, peripheral oxygen saturation, and the Brazelton sleep score were recorded before, during, and at the end of the period in the prone position. Results: The sample comprised 16 newborn premature infants (56.3% male) with a gestational age between 26 and 36 weeks, postnatal age between 1 and 33 days, birth weight of 935 to 3,050g, and weight at the time of intervention of 870 to 2,890g. During the intervention, six participants breathed room air, while the remainder received oxygen therapy. The median salivary cortisol concentration was lower in the prone position compared to baseline (0.13 versus 0.20; p=0.003), as was the median Brazelton sleep score (p=0.02). The average respiratory rate was lower after the intervention (54.88±7.15 versus 60±7.59; p=0.0004). The remainder of the investigated variables did not exhibit significant variation. Conclusion: Prone positioning significantly reduced the salivary cortisol level, respiratory rate, and Brazelton sleep score, suggesting a correlation between prone positioning and reduction of stress in preterm infants. .