Traqueobronquite associada à ventilação mecânica: uma atualização / Ventilator-associated tracheobronchitis: an update

RESUMO As infecções do trato respiratório inferior associadas à ventilação mecânica são uma das complicações mais frequentes em pacientes em ventilação mecânica. Há muitos anos, a traqueobronquite associada à ventilação mecânica tem sido considerada uma doença que não demanda antibioticoterapia. Na última década, diversos estudos demonstraram que a traqueobronquite associada à ventilação mecânica deve ser considerada um processo intermediário que leva à pneumonia associada à ventilação mecânica, uma vez que apesar de ter impacto limitado sobre a mortalidade dos pacientes gravemente enfermos internados nas unidades de terapia intensiva, em contrapartida, demonstra associação significativa com o aumento dos custos hospitalares desses pacientes, assim como do tempo de internação na unidade de terapia intensiva e hospitalar, do uso de antibióticos, e da duração da ventilação mecânica. Embora ainda necessitemos de evidências científicas mais robustas, especialmente no que tange às modalidades terapêuticas, os dados atuais a respeito da traqueobronquite associada à ventilação mecânica salientam que há desfechos suficientemente importantes que exigem vigilância epidemiológica e controle clínico adequados.

ABSTRACT Ventilator-associated lower respiratory tract infection is one of the most frequent complications in mechanically ventilated patients. Ventilator-associated tracheobronchitis has been considered a disease that does not warrant antibiotic treatment by the medical community for many years. In the last decade, several studies have shown that tracheobronchitis could be considered an intermediate process that leads to ventilator-associated pneumonia. Furthermore, ventilator-associated tracheobronchitis has a limited impact on overall mortality but shows a significant association with increased patient costs, length of stay, antibiotic use, and duration of mechanical ventilation. Although we still need clear evidence, especially concerning treatment modalities, the present study on ventilator-associated tracheobronchitis highlights that there are important impacts of including this condition in clinical management and epidemiological and infection surveillance.

Ventilator-associated tracheobronchitis: an update. / Traqueobronquite associada à ventilação mecânica: uma atualização.

Ventilator-associated lower respiratory tract infection is one of the most frequent complications in mechanically ventilated patients. Ventilator-associated tracheobronchitis has been considered a disease that does not warrant antibiotic treatment by the medical community for many years. In the last decade, several studies have shown that tracheobronchitis could be considered an intermediate process that leads to ventilator-associated pneumonia. Furthermore, ventilator-associated tracheobronchitis has a limited impact on overall mortality but shows a significant association with increased patient costs, length of stay, antibiotic use, and duration of mechanical ventilation. Although we still need clear evidence, especially concerning treatment modalities, the present study on ventilator-associated tracheobronchitis highlights that there are important impacts of including this condition in clinical management and epidemiological and infection surveillance.

As infecções do trato respiratório inferior associadas à ventilação mecânica são uma das complicações mais frequentes em pacientes em ventilação mecânica. Há muitos anos, a traqueobronquite associada à ventilação mecânica tem sido considerada uma doença que não demanda antibioticoterapia. Na última década, diversos estudos demonstraram que a traqueobronquite associada à ventilação mecânica deve ser considerada um processo intermediário que leva à pneumonia associada à ventilação mecânica, uma vez que apesar de ter impacto limitado sobre a mortalidade dos pacientes gravemente enfermos internados nas unidades de terapia intensiva, em contrapartida, demonstra associação significativa com o aumento dos custos hospitalares desses pacientes, assim como do tempo de internação na unidade de terapia intensiva e hospitalar, do uso de antibióticos, e da duração da ventilação mecânica. Embora ainda necessitemos de evidências científicas mais robustas, especialmente no que tange às modalidades terapêuticas, os dados atuais a respeito da traqueobronquite associada à ventilação mecânica salientam que há desfechos suficientemente importantes que exigem vigilância epidemiológica e controle clínico adequados.

External validation of SAPS 3 and MPM0-III scores in 48,816 patients from 72 Brazilian ICUs.

BACKGROUND: The performance of severity-of-illness scores varies in different scenarios and must be validated prior of being used in a specific settings and geographic regions. Moreover, models' calibration may deteriorate overtime and performance of such instruments should be reassessed regularly. Therefore, we aimed at to validate the SAPS 3 in a large contemporary cohort of patients admitted to Brazilian ICUs. In addition, we also compared the performance of the SAPS 3 with the MPM0-III. METHODS: This is a retrospective cohort study in which 48,816 (medical admissions = 67.9%) adult patients are admitted to 72 Brazilian ICUs during 2013. We evaluated models' discrimination using the area under the receiver operating characteristic curve (AUROC). We applied the calibration belt to evaluate the agreement between observed and expected mortality rates (calibration). RESULTS: Mean SAPS 3 score was 44.3 ± 15.4 points. ICU and hospital mortality rates were 11.0 and 16.5%. We estimated predicted mortality using both standard (SE) and Central and South American (CSA) customized equations. Predicted mortality rates were 16.4 ± 19.3% (SAPS 3-SE), 21.7 ± 23.2% (SAPS 3-CSA) and 14.3 ± 14.0% (MPM0-III). Standardized mortality ratios (SMR) obtained for each model were: 1.00 (95% CI, 0.98-0.102) for the SAPS 3-SE, 0.75 (0.74-0.77) for the SAPS 3-CSA and 1.15 (1.13-1.18) for the MPM0-III. Discrimination was better for SAPS 3 models (AUROC = 0.85) than for MPM0-III (AUROC = 0.80) (p < 0.001). We applied the calibration belt to evaluate the agreement between observed and expected mortality rates (calibration): the SAPS 3-CSA overestimated mortality throughout all risk classes while the MPM0-III underestimated it uniformly. The SAPS 3-SE did not show relevant deviations from ideal calibration. CONCLUSIONS: In a large contemporary database, the SAPS 3-SE was accurate in predicting outcomes, supporting its use for performance evaluation and benchmarking in Brazilian ICUs.

Novos marcadores biológicos na pneumonia comunitária grave / Novel biomarkers in severe community-acquired pneumonia

A pneumonia adquirida na comunidade é a doença infecciosa que mais comumente exige internação em unidades de terapia intensiva e o diagnóstico precoce e preciso da pneumonia adquirida na comunidade ainda é um desafio. Os biomarcadores desempenham um importante papel auxiliando no julgamento clínico no Serviço de Emergência e são adjuvantes na avaliação da resposta terapêutica. Novos biomarcadores como cortisol, proadrenomedulina e endotelina-1 demonstraram estar associados a gravidade da doença e a evolução em curto prazo. Este artigo de revisão irá se basear no uso clínico de novos biomarcadores, na sua capacidade de predizer gravidade e de monitorar a resposta ao tratamento empregado.

Community-acquired pneumonia (CAP) is the most common infectious disease requiring admission to intensive care units (ICUs), and achieving an early and precise diagnosis of CAP remains a challenge. Biomarkers play an important role in improving clinical judgment in the emergency room and are adjuvant in evaluating treatment responses. Novel biomarkers, such as cortisol, pro-adrenomedullin and endothelin-1, have been shown to be associated with disease severity and short-term outcomes. This review article focuses on the clinical use of novel biomarkers, severity prediction and treatment monitoring as well as future directions of the field.

Novel biomarkers in severe community-acquired pneumonia. / Novos marcadores biológicos na pneumonia comunitária grave.

Community-acquired pneumonia (CAP) is the most common infectious disease requiring admission to intensive care units (ICUs), and achieving an early and precise diagnosis of CAP remains a challenge. Biomarkers play an important role in improving clinical judgment in the emergency room and are adjuvant in evaluating treatment responses. Novel biomarkers, such as cortisol, pro-adrenomedullin and endothelin-1, have been shown to be associated with disease severity and short-term outcomes. This review article focuses on the clinical use of novel biomarkers, severity prediction and treatment monitoring as well as future directions of the field.

Entendendo o conceito PIRO: da teoria à prática clínica: parte 2: [revisão] / Understanding the PIRO concept: from theory to clinical practice: part 2: [review]

Um sistema de estadiamento da sepse com foco na predisposição, no insulto, na resposta do hospedeiro e na falência orgânica pode fornecer uma base útil para a estratificação do risco. O conhecimento das interações entre os fatores predisponentes, características do insulto e resposta do hospedeiro pode nos ajudar a melhorar a compreensão sobre a fisiopatologia da sepse e permitir uma abordagem terapêutica mais individualizada. Estudos clínicos recentes documentaram a relevância da abordagem PIRO na estratificação da gravidade de pacientes sépticos na unidade de terapia intensiva, e também para condições específicas como pneumonia adquirida na comunidade e pneumonia associada a ventilação mecânica, com bom desempenho para previsão do desfecho. Nesta revisão, descrevemos como este novo conceito pode ser utilizado na prática clínica e fornecemos algumas compreensões sobre a sua utilidade para facilitar a estratificação e potencial para inclusão em estudos clínicos de tratamentos da sepse.

A sepsis staging system focused on predisposition, insult, host response and organ failure may provide a useful basis for risk stratification. Knowledge on interactions among predisposing factors, insult characteristics and host response might help us to improve our understanding on sepsis pathophysiology and allow more individual therapeutic approach. Recent clinical studies documented the clinical importance of PIRO approach for severity stratification in septic patients in intensive care unit, and also for specific conditions such as community acquired pneumonia and ventilator associated pneumonia , with a good performance for outcome prediction. In this review we describe how this new concept can be used in clinical practice and provide some insights on its usefulness to facilitate the stratification and potential for enrollment in clinical trials of sepsis therapies.

Understanding the PIRO concept: from theory to clinical practice - part 2. / Entendendo o conceito PIRO: da teoria à prática clínica - parte 2.

A sepsis staging system focused on predisposition, insult, host response and organ failure may provide a useful basis for risk stratification. Knowledge on interactions among predisposing factors, insult characteristics and host response might help us to improve our understanding on sepsis pathophysiology and allow more individual therapeutic approach. Recent clinical studies documented the clinical importance of PIRO approach for severity stratification in septic patients in intensive care unit, and also for specific conditions such as community acquired pneumonia and ventilator associated pneumonia , with a good performance for outcome prediction. In this review we describe how this new concept can be used in clinical practice and provide some insights on its usefulness to facilitate the stratification and potential for enrollment in clinical trials of sepsis therapies.

Entendendo o conceito PIRO: da teoria à prática clínica - Parte 1 / Understanding the PIRO concept: from theory to clinical practice - Part 1

Apesar dos avanços recentes no diagnóstico e manejo de pacientes criticamente enfermos, a taxa de mortalidade relacionada à sepse continua inaceitavelmente alta. Assim, são necessários novos métodos de avaliação para proporcionar uma caracterização mais precoce e precisa de pacientes sépticos. Com base no sistema TNM (oncológico), o conceito PIRO foi apresentado como um novo sistema de estadiamento para sepse com a finalidade de avaliar o risco e predizer o prognóstico, com potencial de auxiliar na inclusão de pacientes em estudos clínicos e estimar a probabilidade de resposta a intervenções terapêuticas específicas.

Despite recent advances in diagnosis and care of critically ill patients sepsis related mortality rate remains unacceptably high. Therefore, new methods of evaluation are necessary to provide an earlier and more accurate characterization of septic patients. Based on the (oncologic) TNM system, the PIRO concept was introduced as a new staging system for sepsis in order to assess risk and predict prognosis, with potential to assist in inclusion of patients in clinical studies and estimate the probability of response of patients to specific therapeutic interventions.

Understanding the PIRO concept: from theory to clinical practice - Part 1. / Entendendo o conceito PIRO: da teoria à prática clínica - Parte 1.

Despite recent advances in diagnosis and care of critically ill patients sepsis related mortality rate remains unacceptably high. Therefore, new methods of evaluation are necessary to provide an earlier and more accurate characterization of septic patients. Based on the (oncologic) TNM system, the PIRO concept was introduced as a new staging system for sepsis in order to assess risk and predict prognosis, with potential to assist in inclusion of patients in clinical studies and estimate the probability of response of patients to specific therapeutic interventions.