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1.
Artigo em Inglês | MEDLINE | ID: mdl-34460936

RESUMO

BACKGROUND: The preventive role of an intraoperative recruitment maneuver plus open lung approach (RM + OLA) ventilation on postoperative pulmonary complications (PPC) remains unclear. We aimed at investigating whether an intraoperative open lung condition reduces the risk of developing a composite of PPCs. METHODS: Post hoc analysis of two randomized controlled trials including patients undergoing abdominal surgery. Patients were classified according to the intraoperative lung condition as "open" (OL) or "non-open" (NOL) if PaO2 /FIO2 ratio was ≥ or <400 mmHg, respectively. We used a multivariable logistic regression model that included potential confounders selected with directed acyclic graphs (DAG) using Dagitty software built with variables that were considered clinically relevant based on biological mechanism or evidence from previously published data. PPCs included severe acute respiratory failure, acute respiratory distress syndrome, and pneumonia. RESULTS: A total of 1480 patients were included in the final analysis, with 718 (49%) classified as OL. The rate of severe PPCs during the first seven postoperative days was 6.0% (7.9% in the NOL and 4.4% in the OL group, p = .007). OL was independently associated with a lower risk for severe PPCs during the first 7 and 30 postoperative days [odds ratio of 0.58 (95% CI 0.34-0.99, p = .04) and 0.56 (95% CI 0.34-0.94, p = .03), respectively]. CONCLUSIONS: An intraoperative open lung condition was associated with a reduced risk of developing severe PPCs in intermediate-to-high risk patients undergoing abdominal surgery. TRIAL REGISTRATION: Registered at clinicaltrials.gov NCT02158923 (iPROVE), NCT02776046 (iPROVE-O2).

2.
Intensive Care Med ; 47(8): 851-866, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34232336

RESUMO

The role of non-invasive respiratory support (high-flow nasal oxygen and noninvasive ventilation) in the management of acute hypoxemic respiratory failure and acute respiratory distress syndrome is debated. The oxygenation improvement coupled with lung and diaphragm protection produced by non-invasive support may help to avoid endotracheal intubation, which prevents the complications of sedation and invasive mechanical ventilation. However, spontaneous breathing in patients with lung injury carries the risk that vigorous inspiratory effort, combined or not with mechanical increases in inspiratory airway pressure, produces high transpulmonary pressure swings and local lung overstretch. This ultimately results in additional lung damage (patient self-inflicted lung injury), so that patients intubated after a trial of noninvasive support are burdened by increased mortality. Reducing inspiratory effort by high-flow nasal oxygen or delivery of sustained positive end-expiratory pressure through the helmet interface may reduce these risks. In this physiology-to-bedside review, we provide an updated overview about the role of noninvasive respiratory support strategies as early treatment of hypoxemic respiratory failure in the intensive care unit. Noninvasive strategies appear safe and effective in mild-to-moderate hypoxemia (PaO2/FiO2 > 150 mmHg), while they can yield delayed intubation with increased mortality in a significant proportion of moderate-to-severe (PaO2/FiO2 ≤ 150 mmHg) cases. High-flow nasal oxygen and helmet noninvasive ventilation represent the most promising techniques for first-line treatment of severe patients. However, no conclusive evidence allows to recommend a single approach over the others in case of moderate-to-severe hypoxemia. During any treatment, strict physiological monitoring remains of paramount importance to promptly detect the need for endotracheal intubation and not delay protective ventilation.


Assuntos
Ventilação não Invasiva , Síndrome do Desconforto Respiratório , Insuficiência Respiratória , Humanos , Hipóxia/terapia , Intubação Intratraqueal , Oxigênio , Respiração com Pressão Positiva , Síndrome do Desconforto Respiratório/terapia , Insuficiência Respiratória/terapia
4.
Chest ; 159(6): 2373-2383, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-34099131

RESUMO

BACKGROUND: Increased pleural pressure affects the mechanics of breathing of people with class III obesity (BMI > 40 kg/m2). RESEARCH QUESTION: What are the acute effects of CPAP titrated to match pleural pressure on cardiopulmonary function in spontaneously breathing patients with class III obesity? STUDY DESIGN AND METHODS: We enrolled six participants with BMI within normal range (control participants, group I) and 12 patients with class III obesity (group II) divided into subgroups: IIa, BMI of 40 to 50 kg/m2; and IIb, BMI of ≥ 50 kg/m2. The study was performed in two phases: in phase 1, participants were supine and breathing spontaneously at atmospheric pressure, and in phase 2, participants were supine and breathing with CPAP titrated to match their end-expiratory esophageal pressure in the absence of CPAP. Respiratory mechanics, esophageal pressure, and hemodynamic data were collected, and right heart function was evaluated by transthoracic echocardiography. RESULTS: The levels of CPAP titrated to match pleural pressure in group I, subgroup IIa, and subgroup IIb were 6 ± 2 cmH2O, 12 ± 3 cmH2O, and 18 ± 4 cmH2O, respectively. In both subgroups IIa and IIb, CPAP titrated to match pleural pressure decreased minute ventilation (IIa, P = .03; IIb, P = .03), improved peripheral oxygen saturation (IIa, P = .04; IIb, P = .02), improved homogeneity of tidal volume distribution between ventral and dorsal lung regions (IIa, P = .22; IIb, P = .03), and decreased work of breathing (IIa, P < .001; IIb, P = .003) with a reduction in both the work spent to initiate inspiratory flow as well as tidal ventilation. In five hypertensive participants with obesity, BP decreased to normal range, without impairment of right heart function. INTERPRETATION: In ambulatory patients with class III obesity, CPAP titrated to match pleural pressure decreased work of breathing and improved respiratory mechanics while maintaining hemodynamic stability, without impairing right heart function. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT02523352; URL: www.clinicaltrials.gov.


Assuntos
Resistência das Vias Respiratórias/fisiologia , Obesidade/fisiopatologia , Cavidade Pleural/fisiopatologia , Respiração , Volume de Ventilação Pulmonar/fisiologia , Esôfago/fisiopatologia , Humanos , Pressão , Troca Gasosa Pulmonar
5.
BMC Pulm Med ; 21(1): 133, 2021 Apr 24.
Artigo em Inglês | MEDLINE | ID: mdl-33894747

RESUMO

BACKGROUND: Among the challenges for personalizing the management of mechanically ventilated patients with coronavirus disease (COVID-19)-associated acute respiratory distress syndrome (ARDS) are the effects of different positive end-expiratory pressure (PEEP) levels and body positions in regional lung mechanics. Right-left lung aeration asymmetry and poorly recruitable lungs with increased recruitability with alternating body position between supine and prone have been reported. However, real-time effects of changing body position and PEEP on regional overdistension and collapse, in individual patients, remain largely unknown and not timely monitored. The aim of this study was to individualize PEEP and body positioning in order to reduce the mechanisms of ventilator-induced lung injury: collapse and overdistension. METHODS: We here report a series of five consecutive mechanically ventilated patients with COVID-19-associated ARDS in which sixteen decremental PEEP titrations were performed in the first days of mechanical ventilation (8 titration pairs: supine position immediately followed by 30° targeted lateral position). The choice of lateral tilt was based on X-Ray. This targeted lateral position strategy was defined by selecting the less aerated lung to be positioned up and the more aerated lung to be positioned down. For each PEEP level, global and regional collapse and overdistension maps and percentages were measured by electrical impedance tomography. Additionally, we present the incidence of lateral asymmetry in a cohort of forty-four patients. RESULTS: The targeted lateral position strategy resulted in significantly smaller amounts of overdistension and collapse when compared with the supine one: less collapse along the PEEP titration was found within the left lung in targeted lateral (P = 0.014); and less overdistension along the PEEP titration was found within the right lung in targeted lateral (P = 0.005). Regarding collapse within the right lung and overdistension within the left lung: no differences were found for position. In the cohort of forty-four patients, ventilation inequality of > 65/35% was observed in 15% of cases. CONCLUSIONS: Targeted lateral positioning with bedside personalized PEEP provided a selective attenuation of overdistension and collapse in mechanically ventilated patients with COVID-19-associated ARDS and right-left lung aeration/ventilation asymmetry. TRIAL REGISTRATION: Trial registration number: NCT04460859.


Assuntos
COVID-19/terapia , Posicionamento do Paciente/métodos , Atelectasia Pulmonar/prevenção & controle , Síndrome do Desconforto Respiratório/terapia , Lesão Pulmonar Induzida por Ventilação Mecânica/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Impedância Elétrica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva/métodos , Estudos Prospectivos , Atelectasia Pulmonar/terapia , Respiração Artificial/métodos , SARS-CoV-2
6.
PLoS One ; 16(3): e0248214, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33730110

RESUMO

The characterization of pulmonary arterial hypertension (PAH) relies mainly on right heart catheterization (RHC). Electrical impedance tomography (EIT) provides a non-invasive estimation of lung perfusion that could complement the hemodynamic information from RHC. To assess the association between impedance variation of lung perfusion (ΔZQ) and hemodynamic profile, severity, and prognosis, suspected of PAH or worsening PAH patients were submitted simultaneously to RHC and EIT. Measurements of ΔZQ were obtained. Based on the results of the RHC, 35 patients composed the PAH group, and eight patients, the normopressoric (NP) group. PAH patients showed a significantly reduced ΔZQ compared to the NP group. There was a significant correlation between ΔZQ and hemodynamic parameters, particularly with stroke volume (SV) (r = 0.76; P < 0.001). At 60 months, 15 patients died (43%) and 1 received lung transplantation; at baseline they had worse hemodynamics, and reduced ΔZQ when compared to survivors. Patients with low ΔZQ (≤154.6%.Kg) presented significantly worse survival (P = 0.033). ΔZQ is associated with hemodynamic status of PAH patients, with disease severity and survival, demonstrating EIT as a promising tool for monitoring patients with pulmonary vascular disease.


Assuntos
Pressão Sanguínea/fisiologia , Composição Corporal/fisiologia , Hemodinâmica/fisiologia , Hipertensão Arterial Pulmonar/fisiopatologia , Adulto , Impedância Elétrica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia , Adulto Jovem
7.
Am J Respir Crit Care Med ; 204(3): 303-311, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-33784486

RESUMO

Rationale: Mortality in acute respiratory distress syndrome (ARDS) has decreased after the adoption of lung-protective strategies. Lower Vt, lower driving pressure (ΔP), lower respiratory rates (RR), and higher end-expiratory pressure have all been suggested as key components of lung protection strategies. A unifying theoretical explanation has been proposed that attributes lung injury to the energy transfer rate (mechanical power) from the ventilator to the patient, calculated from a combination of several ventilator variables.Objectives: To assess the impact of mechanical power on mortality in patients with ARDS as compared with that of primary ventilator variables such as the ΔP, Vt, and RR.Methods: We obtained data on ventilatory variables and mechanical power from a pooled database of patients with ARDS who had participated in six randomized clinical trials of protective mechanical ventilation and one large observational cohort of patients with ARDS. The primary outcome was mortality at 28 days or 60 days.Measurements and Main Results: We included 4,549 patients (38% women; mean age, 55 ± 23 yr). The average mechanical power was 0.32 ± 0.14 J · min-1 · kg-1 of predicted body weight, the ΔP was 15.0 ± 5.8 cm H2O, and the RR was 25.7 ± 7.4 breaths/min. The driving pressure, RR, and mechanical power were significant predictors of mortality in adjusted analyses. The impact of the ΔP on mortality was four times as large as that of the RR.Conclusions: Mechanical power was associated with mortality during controlled mechanical ventilation in ARDS, but a simpler model using only the ΔP and RR was equivalent.


Assuntos
Mortalidade , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/terapia , Adulto , Idoso , Transferência de Energia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pressão , Taxa Respiratória , Lesão Pulmonar Induzida por Ventilação Mecânica
8.
Am J Respir Crit Care Med ; 203(11): 1378-1385, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-33439781

RESUMO

Rationale: If the risk of ventilator-induced lung injury in acute respiratory distress syndrome (ARDS) is causally determined by driving pressure rather than by Vt, then the effect of ventilation with lower Vt on mortality would be predicted to vary according to respiratory system elastance (Ers). Objectives: To determine whether the mortality benefit of ventilation with lower Vt varies according to Ers. Methods: In a secondary analysis of patients from five randomized trials of lower- versus higher-Vt ventilation strategies in ARDS and acute hypoxemic respiratory failure, the posterior probability of an interaction between the randomized Vt strategy and Ers on 60-day mortality was computed using Bayesian multivariable logistic regression. Measurements and Main Results: Of 1,096 patients available for analysis, 416 (38%) died by Day 60. The posterior probability that the mortality benefit from lower-Vt ventilation strategies varied with Ers was 93% (posterior median interaction odds ratio, 0.80 per cm H2O/[ml/kg]; 90% credible interval, 0.63-1.02). Ers was classified as low (<2 cm H2O/[ml/kg], n = 321, 32%), intermediate (2-3 cm H2O/[ml/kg], n = 475, 46%), and high (>3 cm H2O/[ml/kg], n = 224, 22%). In these groups, the posterior probabilities of an absolute risk reduction in mortality ≥ 1% were 55%, 82%, and 92%, respectively. The posterior probabilities of an absolute risk reduction ≥ 5% were 29%, 58%, and 82%, respectively. Conclusions: The mortality benefit of ventilation with lower Vt in ARDS varies according to elastance, suggesting that lung-protective ventilation strategies should primarily target driving pressure rather than Vt.


Assuntos
Resistência das Vias Respiratórias/fisiologia , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/mortalidade , Síndrome do Desconforto Respiratório/terapia , Teorema de Bayes , Elasticidade , Feminino , Humanos , Modelos Logísticos , Masculino , Síndrome do Desconforto Respiratório/fisiopatologia , Estudos Retrospectivos , Taxa de Sobrevida , Volume de Ventilação Pulmonar , Lesão Pulmonar Induzida por Ventilação Mecânica/prevenção & controle
9.
Am J Respir Crit Care Med ; 203(10): 1266-1274, 2021 05 15.
Artigo em Inglês | MEDLINE | ID: mdl-33406012

RESUMO

Rationale: The physiological basis of lung protection and the impact of positive end-expiratory pressure (PEEP) during pronation in acute respiratory distress syndrome are not fully elucidated. Objectives: To compare pleural pressure (Ppl) gradient, ventilation distribution, and regional compliance between dependent and nondependent lungs, and investigate the effect of PEEP during supination and pronation. Methods: We used a two-hit model of lung injury (saline lavage and high-volume ventilation) in 14 mechanically ventilated pigs and studied supine and prone positions. Global and regional lung mechanics including Ppl and distribution of ventilation (electrical impedance tomography) were analyzed across PEEP steps from 20 to 3 cm H2O. Two pigs underwent computed tomography scans: tidal recruitment and hyperinflation were calculated. Measurements and Main Results: Pronation improved oxygenation, increased Ppl, thus decreasing transpulmonary pressure for any PEEP, and reduced the dorsal-ventral pleural pressure gradient at PEEP < 10 cm H2O. The distribution of ventilation was homogenized between dependent and nondependent while prone and was less dependent on the PEEP level than while supine. The highest regional compliance was achieved at different PEEP levels in dependent and nondependent regions in supine position (15 and 8 cm H2O), but for similar values in prone position (13 and 12 cm H2O). Tidal recruitment was more evenly distributed (dependent and nondependent), hyperinflation lower, and lungs cephalocaudally longer in the prone position. Conclusions: In this lung injury model, pronation reduces the vertical pleural pressure gradient and homogenizes regional ventilation and compliance between the dependent and nondependent regions. Homogenization is much less dependent on the PEEP level in prone than in supine positon.


Assuntos
Posicionamento do Paciente , Respiração com Pressão Positiva , Decúbito Ventral , Síndrome do Desconforto Respiratório/fisiopatologia , Síndrome do Desconforto Respiratório/terapia , Decúbito Dorsal , Animais , Modelos Animais de Doenças , Complacência Pulmonar/fisiologia , Lesão Pulmonar/complicações , Lesão Pulmonar/fisiopatologia , Lesão Pulmonar/terapia , Cavidade Pleural/fisiopatologia , Síndrome do Desconforto Respiratório/etiologia , Mecânica Respiratória/fisiologia , Suínos
10.
Respir Care ; 66(2): 240-247, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33024002

RESUMO

BACKGROUND: Patients with decreased consciousness are prone to prolonged bed rest and respiratory complications. If effective in reducing atelectasis, lung expansion maneuvers could be used to prevent these complications. In comatose, bedridden subjects, we aimed to assess the acute effect on regional lung aeration of 2 lung expansion techniques: expiratory positive airway pressure and the breath-stacking maneuver. Our secondary aim was to evaluate the influence of these lung expansion techniques on regional ventilation distribution, regional ventilation kinetics, respiratory pattern, and cardiovascular system. METHODS: We enrolled 10 subjects status post neurosurgery, unable to follow commands, and with prolonged bed rest. All subjects were submitted to both expansion techniques in a randomized order. Regional lung aeration, ventilation distribution, and regional ventilation kinetics were measured with electrical impedance tomography. RESULTS: Lung aeration increased significantly during the application of both expiratory positive airway pressure and breath-stacking (P < .001) but returned to baseline values seconds afterwards. The posterior lung regions had the largest volume increase (P < .001 for groups). Both maneuvers induced asynchronous inflation and deflation between anterior and posterior lung regions. There were no significant differences in cardiovascular variables. CONCLUSIONS: In comatose subjects with prolonged bed rest, expiratory positive airway pressure and breath-stacking promoted brief increases in lung aeration. (ClinicalTrials.gov registration NCT02613832.).


Assuntos
Repouso em Cama , Atelectasia Pulmonar , Coma/etiologia , Coma/terapia , Impedância Elétrica , Humanos , Pulmão , Respiração com Pressão Positiva , Atelectasia Pulmonar/etiologia
11.
Ann Am Thorac Soc ; 18(5): 857-864, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33112644

RESUMO

Rationale: Clinicians commonly use short-term physiologic markers to assess the benefit of ventilator adjustments. Improved arterial oxygen tension/pressure (PaO2)/fraction of inspired oxygen (FiO2) after ventilator adjustment in acute respiratory distress syndrome is associated with lower mortality. However, as driving pressure (ΔP) reflects lung stress and strain, changes in ΔP may more accurately reflect benefits or harms of ventilator adjustments compared with changes in oxygenation.Objectives: We aimed to compare the association between mortality and the changes in PaO2/FiO2 and ΔP following protocolized ventilator changes.Methods: We assessed associations between mortality and changes in PaO2/FiO2 (ΔPaO2/FiO2) and ΔP (ΔΔP) after postrandomization positive end-expiratory pressure (PEEP) and tidal volume adjustment in reanalyses of the ALVEOLI (Assessment of Low Tidal Volume and Elevated End-Expiratory Volume to Obviate Lung Injury) and ExPress (Expiratory Pressure) trials. We included subjects with available pre- and postintervention PaO2/FiO2 and ΔP (372 in ALVEOLI and 596 in ExPress). In each separate trial cohort, we performed multivariable Cox regression testing the association between ΔPaO2/FiO2 and ΔΔP with mortality.Results: In ALVEOLI, when analyzed as separate variables, ΔPaO2/FiO2 was associated with mortality only in subjects in whom PEEP increased, whereas ΔΔP was associated with mortality irrespective of direction of PEEP change. When modeled together, improved ΔPaO2/FiO2 was not associated with mortality, whereas ΔΔP remained associated with mortality (adjusted hazard ratio [aHR], 1.50 per 5 cm H2O increase; 95% confidence interval [95% CI], 1.21-1.85). When modeled together in ExPress, ΔΔP (aHR, 1.42; 95% CI, 1.14-1.78) was more strongly associated with mortality than ΔPaO2/FiO2 (aHR, 0.95 per 25 mm Hg increase; 95% CI, 0.90-1.00).Conclusions: Reduced ΔP following protocolized ventilator changes was more strongly and consistently associated with lower mortality than was increased PaO2/FiO2, making ΔΔP more informative about benefit from ventilator adjustments. Our results reinforce the primacy of ΔP, rather than oxygenation, as the key variable associated with outcome.

12.
Am J Respir Crit Care Med ; 203(8): 969-976, 2021 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-33091317

RESUMO

Rationale: Asymmetrical lung injury is a frequent clinical presentation. Regional distribution of Vt and positive end-expiratory pressure (PEEP) could result in hyperinflation of the less-injured lung. The validity of esophageal pressure (Pes) is unknown.Objectives: To compare, in asymmetrical lung injury, Pes with directly measured pleural pressures (Ppl) of both sides and investigate how PEEP impacts ventilation distribution and the regional driving transpulmonary pressure (inspiratory - expiratory).Methods: Fourteen mechanically ventilated pigs with lung injury were studied. One lung was blocked while the contralateral one underwent surfactant lavage and injurious ventilation. Airway pressure and Pes were measured, as was Ppl in the dorsal and ventral pleural space adjacent to each lung. Distribution of ventilation was assessed by electrical impedance tomography. PEEP was studied through decremental steps.Measurements and Results: Ventral and dorsal Ppl were similar between the injured and the noninjured lung across all PEEP levels. Dorsal Ppl and Pes were similar. The driving transpulmonary pressure was similar in the two lungs. Vt distribution between lungs was different at zero end-expiratory pressure (≈70% of Vt going in noninjured lung) owing to different respiratory system compliance (8.3 ml/cm H2O noninjured lung vs. 3.7 ml/cm H2O injured lung). PEEP at 10 cm H2O with transpulmonary pressure around zero homogenized Vt distribution opening the lungs. PEEP ≥16 cm H2O equalized distribution of Vt but with overdistension for both lungs.Conclusions: Despite asymmetrical lung injury, Ppl between injured and noninjured lungs is equalized and esophageal pressure is a reliable estimate of dorsal Ppl. Driving transpulmonary pressure is similar for both lungs. Vt distribution results from regional respiratory system compliance. Moderate PEEP homogenizes Vt distribution between lungs without generating hyperinflation.


Assuntos
Lesão Pulmonar/fisiopatologia , Lesão Pulmonar/terapia , Respiração com Pressão Positiva/métodos , Respiração Artificial/métodos , Mecânica Respiratória/fisiologia , Suínos , Animais , Modelos Animais
13.
Crit Care ; 24(1): 678, 2020 12 07.
Artigo em Inglês | MEDLINE | ID: mdl-33287864

RESUMO

RATIONALE: Patients with coronavirus disease-19-related acute respiratory distress syndrome (C-ARDS) could have a specific physiological phenotype as compared with those affected by ARDS from other causes (NC-ARDS). OBJECTIVES: To describe the effect of positive end-expiratory pressure (PEEP) on respiratory mechanics in C-ARDS patients in supine and prone position, and as compared to NC-ARDS. The primary endpoint was the best PEEP defined as the smallest sum of hyperdistension and collapse. METHODS: Seventeen patients with moderate-to-severe C-ARDS were monitored by electrical impedance tomography (EIT) and evaluated during PEEP titration in supine (n = 17) and prone (n = 14) position and compared with 13 NC-ARDS patients investigated by EIT in our department before the COVID-19 pandemic. RESULTS: As compared with NC-ARDS, C-ARDS exhibited a higher median best PEEP (defined using EIT as the smallest sum of hyperdistension and collapse, 12 [9, 12] vs. 9 [6, 9] cmH2O, p < 0.01), more collapse at low PEEP, and less hyperdistension at high PEEP. The median value of the best PEEP was similar in C-ARDS in supine and prone position: 12 [9, 12] vs. 12 [10, 15] cmH2O, p = 0.59. The response to PEEP was also similar in C-ARDS patients with higher vs. lower respiratory system compliance. CONCLUSION: An intermediate PEEP level seems appropriate in half of our C-ARDS patients. There is no solid evidence that compliance at low PEEP could predict the response to PEEP.


Assuntos
COVID-19/fisiopatologia , Respiração com Pressão Positiva/métodos , Síndrome do Desconforto Respiratório/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Tomografia Computadorizada por Raios X/normas , Adulto , COVID-19/diagnóstico por imagem , Impedância Elétrica/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva/instrumentação , Síndrome do Desconforto Respiratório/fisiopatologia , Mecânica Respiratória/fisiologia , Tomografia Computadorizada por Raios X/instrumentação
14.
Rev Soc Bras Med Trop ; 53: e20190481, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33027412

RESUMO

INTRODUCTION: Patients with acute respiratory failure due to influenza require ventilatory support. However, mechanical ventilation itself can exacerbate lung damage and increase mortality. METHODS: The aim of this study was to describe a feasible and protective ventilation protocol, with limitation of the tidal volume to ≤6 mL/kg of the predicted weight and a driving pressure ≤15 cmH2O after application of the alveolar recruitment maneuver and PEEP titration. RESULTS: Initial improvement in oxygenation and respiratory mechanics were observed in the four cases submitted to the proposed protocol. CONCLUSIONS: Our results indicate that the mechanical ventilation strategy applied could be optimized.


Assuntos
Influenza Humana , Síndrome do Desconforto Respiratório , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva , Respiração Artificial , Volume de Ventilação Pulmonar
15.
Anaesth Crit Care Pain Med ; 39(6): 825-831, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-33080407

RESUMO

INTRODUCTION: Transthoracic lung ultrasound can assess atelectasis reversal and is considered as unable to detect associated hyperdistention. In this study, we describe an ultrasound pattern highly suggestive of pulmonary hyperdistention. METHODS: Eighteen patients with normal lungs undergoing lower abdominal surgery were studied. Electrical impedance tomography was calibrated, followed by anaesthetic induction, intubation and mechanical ventilation. To reverse posterior atelectasis, a recruitment manoeuvre was performed. Positive-end expiratory pressure (PEEP) titration was then obtained during a descending trial - 20, 18, 16, 14, 12, 10, 8, 6 and 4cmH2O. Ultrasound and electrical impedance tomography data were collected at each PEEP level and interpreted by two independent observers. Spearman correlation test and receiving operating characteristic curve were used to compare lung ultrasound and electrical impedance tomography data. RESULTS: The number of horizontal A lines increased linearly with PEEP: from 3 (0, 5) at PEEP 4cmH2O to 10 (8, 13) at PEEP 20cmH2O. The increase number of A lines was associated with a parallel and significant decrease in intercostal space thickness (p=0.001). The lung ultrasound threshold for detecting pulmonary hyperdistention was defined as the number of A lines counted at the PEEP preceding the PEEP providing the best respiratory compliance. Six A lines was the median threshold for detecting pulmonary hyperdistention. The area under the receiving operating characteristic curve was 0.947. CONCLUSIONS: Intraoperative transthoracic lung ultrasound can detect lung hyperdistention during a PEEP descending trial. Six or more A lines detected in normally aerated regions can be considered as indicating lung hyperdistention. TRIAL REGISTRATION: NCT02314845 Registered on ClinicalTrials.gov.

17.
Rev Bras Ortop (Sao Paulo) ; 55(4): 415-418, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32904845

RESUMO

Objective To determine time period for hospital discharge and pain and function improvement in patients submitted to percutaneous endoscopic lumbar discectomy (PELD). Methods Retrospective evaluation of length of stay and visual analog scale (VAS), Oswestry disability index (ODI), and Roland-Morris questionnaire results in 32 patients undergoing PELD at the preoperative period and at 2 days and 1, 2, 4, 6 and 12 postoperative weeks. Results All patients were discharged in less than 6 hours. There was a statistically significant improvement between the results obtained before the procedure and 2 days postsurgery: the mean VAS for axial pain went from 6.63 to 3.31, the VAS for irradiated pain went from 6.66 to 2.75, the Oswestry score went from 44.59 to 33.17%, and the Roland-Morris score went from 14.03 to 10.34. This difference progressively improved up to 12 weeks in all questionnaires. Regarding the Oswestry score, minimum disability values (19.39%) were observed at 6 weeks. Conclusion All 32 patients were discharged within 6 hours. Pain and function improved significantly after 48 hours, with further significant and progressive improvement until the 3 rd month.

18.
Artigo em Inglês | MEDLINE | ID: mdl-32876469

RESUMO

Rationale: Obesity is characterized by elevated pleural pressure (PPL) and worsening atelectasis during mechanical ventilation in patients with acute respiratory distress syndrome (ARDS). Objectives: To determine the effects of lung recruitment maneuver (LRM) in the presence of elevated PPL on hemodynamics, left and right ventricular pressures and pulmonary vascular resistance. We hypothesized that elevated PPL protects the cardiovascular system against high airway pressures and prevents lung overdistension. Methods: First, an interventional crossover trial in adult subjects with ARDS and BMI ≥35 kg/m2 (n=21) was performed to explore the hemodynamic consequences of LRM. Second, cardiovascular function was studied during low/high PEEPs in a model of swine with ARDS and high PPL (n=9) versus healthy swine with normal PPL (n=6). Measurements and Main Results: Subjects with ARDS and obesity (BMI=57±12 kg/m2), following LRM, required an increase in PEEP of 8[7, 10] cmH2O above traditional ARDSnet settings to improve lung function, oxygenation and ventilation/perfusion matching, without impairment of hemodynamics or right heart function. ARDS swine with high PPL demonstrated unchanged transmural left ventricle pressure and systemic blood pressure after LRM protocol. Pulmonary artery hypertension decreased 8[13, 4] mmHg, as did vascular resistance 1.5[2.2, 0.9] WU, and transmural right ventricle pressure 10[15, 6] mmHg during exhalation. LRM and PEEP decreased pulmonary vascular resistance and normalized ventilation/perfusion ratio. Conclusions: High airway pressure is required to recruit lung atelectasis in patients with ARDS and class III obesity but causes minimal overdistension. Additionally, patients with ARDS and class III obesity tolerate hemodynamically LRM with high airway pressure.

19.
Rev. bras. ortop ; 55(4): 415-418, Jul.-Aug. 2020. tab, graf
Artigo em Inglês | LILACS | ID: biblio-1138046

RESUMO

Abstract Objective To determine time period for hospital discharge and pain and function improvement in patients submitted to percutaneous endoscopic lumbar discectomy (PELD). Methods Retrospective evaluation of length of stay and visual analog scale (VAS), Oswestry disability index (ODI), and Roland-Morris questionnaire results in 32 patients undergoing PELD at the preoperative period and at 2 days and 1, 2, 4, 6 and 12 postoperative weeks. Results All patients were discharged in less than 6 hours. There was a statistically significant improvement between the results obtained before the procedure and 2 days postsurgery: the mean VAS for axial pain went from 6.63 to 3.31, the VAS for irradiated pain went from 6.66 to 2.75, the Oswestry score went from 44.59 to 33.17%, and the Roland-Morris score went from 14.03 to 10.34. This difference progressively improved up to 12 weeks in all questionnaires. Regarding the Oswestry score, minimum disability values (19.39%) were observed at 6 weeks. Conclusion All 32 patients were discharged within 6 hours. Pain and function improved significantly after 48 hours, with further significant and progressive improvement until the 3rd month.


Resumo Objetivo Determinar o tempo de alta hospitalar e o período de melhora funcional e da dor dos pacientes submetidos a discectomia endoscópica percutânea lombar (DEPL). Métodos Avaliação retrospectiva do tempo de internação e dos questionários escala visual análoga (EVA), índice de incapacidade Oswestry (IIO), e Roland-Morris de 32 pacientes submetidos a DEPL nos períodos pré-operatório e com 2 dias, e 1, 2, 4, 6, e 12 semanas pós-operatórias. Resultados Todos os pacientes receberam alta em menos de 6 horas houve melhora estatística entre o período pré-operatório e 2 dias pós-operatório , sendo o valor médio do questionário EVA axial de 6,63 para 3,31, do EVA irradiado de 6,66 para 2,75, do IIO de 44,59% para 33,17% e do Roland-Morris de 14,03 para 10,34. Tal diferença apresentou melhora progressiva até 12 semanas em todos os questionários. O IIO atingiu valores de incapacidade mínima (19,39%) com 6 semanas de avaliação. Conclusão Todos os 32 pacientes receberam alta hospitalar em até 6 horas. Houve melhora significativa dos sintomas funcionais e de dor já com 48 horas, apresentando ainda melhora adicional significativa e progressiva até o 3º mês.


Assuntos
Humanos , Dor , Coluna Vertebral , Discotomia , Período Pré-Operatório , Tempo de Internação
20.
J Appl Physiol (1985) ; 129(3): 492-499, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32702276

RESUMO

Subjects with severe and very severe chronic obstructive pulmonary disease (COPD) present thoracoabdominal asynchrony (TAA) that reduces ventilatory efficiency and exercise capacity. However, no therapeutic intervention has focused on reducing TAA. The purpose of this study was to evaluate the effects of elastic tape (ET) on thoracoabdominal mechanics, dyspnea symptoms, exercise capacity, and physical activity level in nonobese male subjects with severe-to-very severe COPD. This crossover, randomized trial included nonobese males with severe to very severe COPD. ET was placed on the chest wall and abdomen to reduce TAA. Subjects were evaluated at three hospital visits, each 7 days apart. At visit 1, thoracoabdominal kinematic and pulmonary ventilation were evaluated by optoelectronic plethysmography and electrical impedance tomography, respectively, both at rest and during isoload exercise testing. At visit 2, a cardiopulmonary exercise test (CPET; 10 W/min) was performed until exhaustion. Between the visits, subjects used a physical activity monitor (PAM) (at least 5 days of measurement; 10 h/day). At visit 3, all the tests were repeated in the opposite order of the previous randomization. During the isoload exercise, subjects with ET presented lower tidal and minute volumes (P = 0.01) and reduced TAA (P = 0.02) and dyspnea (P = 0.04). During the CPET, subjects with ET presented an increase in peak oxygen consumption (V̇o2peak; L/min and mL·kg-1·min-1; P = 0.01), test duration (P = 0.009), and maximal load (P = 0.03). Moderate and vigorous physical activity (MVPA), which was evaluated by the PAM, was also increased in subjects with ET (P = 0.01). ET reduced TAA and dyspnea and increased exercise capacity and the duration of MVPA in nonobese male subjects with severe-to-very severe COPDNEW & NOTEWORTHY Elastic tape can be used as a new and low-cost intervention to reduce thoracoabdominal asynchrony and sedentary behavior as well as improve exercise capacity and physical activity level in nonobese male subjects with severe-to-very severe chronic obstructive pulmonary disease.


Assuntos
Tolerância ao Exercício , Doença Pulmonar Obstrutiva Crônica , Dispneia , Exercício Físico , Teste de Esforço , Humanos , Masculino
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