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1.
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
2.
Respir Care ; 66(5): 705-714, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33653913

RESUMO

BACKGROUND: The efficacy of noninvasive oxygenation strategies (NIOS) in treating COVID-19 disease is unknown. We conducted a prospective observational study to assess the rate of NIOS failure in subjects treated in the ICU for hypoxemic respiratory failure due to COVID-19. METHODS: Patients receiving first-line treatment NIOS for hypoxemic respiratory failure due to COVID-19 in the ICU of a university hospital were included in this study; laboratory data were collected upon arrival, and 28-d outcome was recorded. After propensity score matching based on Simplified Acute Physiology (SAPS) II score, age, [Formula: see text] and [Formula: see text] at arrival, the NIOS failure rate in subjects with COVID-19 was compared to a previously published cohort who received NIOS during hypoxemic respiratory failure due to other causes. RESULTS: A total of 85 subjects received first-line treatment with NIOS. The most frequently used methods were helmet noninvasive ventilation and high-flow nasal cannula; of these, 52 subjects (61%) required endotracheal intubation. Independent factors associated with NIOS failure were SAPS II score (P = .009) and serum lactate dehydrogenase at enrollment (P = .02); the combination of SAPS II score ≥ 33 with serum lactate dehydrogenase ≥ 405 units/L at ICU admission had 91% specificity in predicting the need for endotracheal intubation. In the propensity-matched cohorts (54 pairs), subjects with COVID-19 showed higher risk of NIOS failure than those with other causes of hypoxemic respiratory failure (59% vs 35%, P = .02), with an adjusted hazard ratio of 2 (95% CI 1.1-3.6, P = .01). CONCLUSIONS: As compared to hypoxemic respiratory failure due to other etiologies, subjects with COVID-19 who were treated with NIOS in the ICU were burdened by a 2-fold higher risk of failure. Subjects with a SAPS II score ≥ 33 and serum lactate dehydrogenase ≥ 405 units/L represent the population with the greatest risk.


Assuntos
COVID-19 , Ventilação não Invasiva , Insuficiência Respiratória , Estado Terminal , Humanos , Hipóxia/etiologia , Hipóxia/terapia , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapia , SARS-CoV-2
3.
JAMA ; 325(17): 1731-1743, 2021 05 04.
Artigo em Inglês | MEDLINE | ID: mdl-33764378

RESUMO

Importance: High-flow nasal oxygen is recommended as initial treatment for acute hypoxemic respiratory failure and is widely applied in patients with COVID-19. Objective: To assess whether helmet noninvasive ventilation can increase the days free of respiratory support in patients with COVID-19 compared with high-flow nasal oxygen alone. Design, Setting, and Participants: Multicenter randomized clinical trial in 4 intensive care units (ICUs) in Italy between October and December 2020, end of follow-up February 11, 2021, including 109 patients with COVID-19 and moderate to severe hypoxemic respiratory failure (ratio of partial pressure of arterial oxygen to fraction of inspired oxygen ≤200). Interventions: Participants were randomly assigned to receive continuous treatment with helmet noninvasive ventilation (positive end-expiratory pressure, 10-12 cm H2O; pressure support, 10-12 cm H2O) for at least 48 hours eventually followed by high-flow nasal oxygen (n = 54) or high-flow oxygen alone (60 L/min) (n = 55). Main Outcomes and Measures: The primary outcome was the number of days free of respiratory support within 28 days after enrollment. Secondary outcomes included the proportion of patients who required endotracheal intubation within 28 days from study enrollment, the number of days free of invasive mechanical ventilation at day 28, the number of days free of invasive mechanical ventilation at day 60, in-ICU mortality, in-hospital mortality, 28-day mortality, 60-day mortality, ICU length of stay, and hospital length of stay. Results: Among 110 patients who were randomized, 109 (99%) completed the trial (median age, 65 years [interquartile range {IQR}, 55-70]; 21 women [19%]). The median days free of respiratory support within 28 days after randomization were 20 (IQR, 0-25) in the helmet group and 18 (IQR, 0-22) in the high-flow nasal oxygen group, a difference that was not statistically significant (mean difference, 2 days [95% CI, -2 to 6]; P = .26). Of 9 prespecified secondary outcomes reported, 7 showed no significant difference. The rate of endotracheal intubation was significantly lower in the helmet group than in the high-flow nasal oxygen group (30% vs 51%; difference, -21% [95% CI, -38% to -3%]; P = .03). The median number of days free of invasive mechanical ventilation within 28 days was significantly higher in the helmet group than in the high-flow nasal oxygen group (28 [IQR, 13-28] vs 25 [IQR 4-28]; mean difference, 3 days [95% CI, 0-7]; P = .04). The rate of in-hospital mortality was 24% in the helmet group and 25% in the high-flow nasal oxygen group (absolute difference, -1% [95% CI, -17% to 15%]; P > .99). Conclusions and Relevance: Among patients with COVID-19 and moderate to severe hypoxemia, treatment with helmet noninvasive ventilation, compared with high-flow nasal oxygen, resulted in no significant difference in the number of days free of respiratory support within 28 days. Further research is warranted to determine effects on other outcomes, including the need for endotracheal intubation. Trial Registration: ClinicalTrials.gov Identifier: NCT04502576.


Assuntos
COVID-19/complicações , Intubação Intratraqueal/estatística & dados numéricos , Ventilação não Invasiva/instrumentação , Oxigenoterapia/métodos , Insuficiência Respiratória/terapia , Idoso , COVID-19/mortalidade , COVID-19/terapia , Feminino , Mortalidade Hospitalar , Humanos , Hipóxia/etiologia , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/métodos , Insuficiência Respiratória/etiologia , Falha de Tratamento
4.
Crit Care ; 24(1): 529, 2020 08 28.
Artigo em Inglês | MEDLINE | ID: mdl-32859264

RESUMO

BACKGROUND: Whether respiratory physiology of COVID-19-induced respiratory failure is different from acute respiratory distress syndrome (ARDS) of other etiologies is unclear. We conducted a single-center study to describe respiratory mechanics and response to positive end-expiratory pressure (PEEP) in COVID-19 ARDS and to compare COVID-19 patients to matched-control subjects with ARDS from other causes. METHODS: Thirty consecutive COVID-19 patients admitted to an intensive care unit in Rome, Italy, and fulfilling moderate-to-severe ARDS criteria were enrolled within 24 h from endotracheal intubation. Gas exchange, respiratory mechanics, and ventilatory ratio were measured at PEEP of 15 and 5 cmH2O. A single-breath derecruitment maneuver was performed to assess recruitability. After 1:1 matching based on PaO2/FiO2, FiO2, PEEP, and tidal volume, COVID-19 patients were compared to subjects affected by ARDS of other etiologies who underwent the same procedures in a previous study. RESULTS: Thirty COVID-19 patients were successfully matched with 30 ARDS from other etiologies. At low PEEP, median [25th-75th percentiles] PaO2/FiO2 in the two groups was 119 mmHg [101-142] and 116 mmHg [87-154]. Average compliance (41 ml/cmH2O [32-52] vs. 36 ml/cmH2O [27-42], p = 0.045) and ventilatory ratio (2.1 [1.7-2.3] vs. 1.6 [1.4-2.1], p = 0.032) were slightly higher in COVID-19 patients. Inter-individual variability (ratio of standard deviation to mean) of compliance was 36% in COVID-19 patients and 31% in other ARDS. In COVID-19 patients, PaO2/FiO2 was linearly correlated with respiratory system compliance (r = 0.52 p = 0.003). High PEEP improved PaO2/FiO2 in both cohorts, but more remarkably in COVID-19 patients (p = 0.005). Recruitability was not different between cohorts (p = 0.39) and was highly inter-individually variable (72% in COVID-19 patients and 64% in ARDS from other causes). In COVID-19 patients, recruitability was independent from oxygenation and respiratory mechanics changes due to PEEP. CONCLUSIONS: Early after establishment of mechanical ventilation, COVID-19 patients follow ARDS physiology, with compliance reduction related to the degree of hypoxemia, and inter-individually variable respiratory mechanics and recruitability. Physiological differences between ARDS from COVID-19 and other causes appear small.


Assuntos
Infecções por Coronavirus/fisiopatologia , Pneumonia Viral/fisiopatologia , Síndrome do Desconforto Respiratório/fisiopatologia , Idoso , Betacoronavirus , COVID-19 , Infecções por Coronavirus/terapia , Feminino , Humanos , Unidades de Terapia Intensiva , Itália , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/terapia , Respiração com Pressão Positiva , Síndrome do Desconforto Respiratório/terapia , Testes de Função Respiratória , Mecânica Respiratória/fisiologia , SARS-CoV-2
5.
Curr Opin Crit Care ; 26(2): 115-121, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32068580

RESUMO

PURPOSE OF REVIEW: Multimodal monitoring has emerged as a novel paradigm of care in acute brain injury, and in this context the value of noninvasive devices is increasingly under scrutiny. This narrative review summarizes recent clinical investigation focused on the role of automated infrared pupillometry (AIP) and optic nerve sheath diameter (ONSD) ultrasound as novel techniques to monitor and manage neurocritical care patients. RECENT FINDINGS: AIP provides a quantitative measurement of the pupillary light reflex that is more precise and reliable than the traditional examination of the pupillary light reflex using manual flashlight lamps. AIP helps detect raised intracranial pressure (ICP) and brain herniation in patients with intracranial mass lesions. Using an automatically computed scalar index - the neurological pupil index - AIP has great accuracy to predict poor neurological outcome in patients in coma after cardiac arrest. Recent data indicate that ONSD may diagnose intracranial hypertension with better accuracy than other ultrasound-based methods. SUMMARY: Noninvasive AIP and ONSD appear useful complements to multimodality monitoring of acute brain injury, in particular in patients at risk of elevated ICP and for early neuroprognostication following cardiac arrest.


Assuntos
Hipertensão Intracraniana , Pressão Intracraniana , Nervo Óptico , Encéfalo/diagnóstico por imagem , Humanos , Hipertensão Intracraniana/diagnóstico por imagem , Nervo Óptico/diagnóstico por imagem , Estudos Prospectivos , Pupila , Ultrassonografia
6.
Intensive Care Med ; 46(5): 963-972, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32016534

RESUMO

PURPOSE: Post-resuscitation guidelines recommend a multimodal algorithm for outcome prediction after cardiac arrest (CA). We aimed at evaluating the prevalence of indeterminate prognosis after application of this algorithm and providing a strategy for improving prognostication in this population. METHODS: We examined a prospective cohort of comatose CA patients (n = 485) in whom the ERC/ESICM algorithm was applied. In patients with an indeterminate outcome, prognostication was investigated using standardized EEG classification (benign, malignant, highly malignant) and serum neuron-specific enolase (NSE). Neurological recovery at 3 months was dichotomized as good (Cerebral Performance Categories [CPC] 1-2) vs. poor (CPC 3-5). RESULTS: Using the ERC/ESICM algorithm, 155 (32%) patients were prognosticated with poor outcome; all died at 3 months. Among the remaining 330 (68%) patients with an indeterminate outcome, the majority (212/330; 64%) showed good recovery. In this patient subgroup, absence of a highly malignant EEG by day 3 had 99.5 [97.4-99.9] % sensitivity for good recovery, which was superior to NSE < 33 µg/L (84.9 [79.3-89.4] % when used alone; 84.4 [78.8-89] % when combined with EEG, both p < 0.001). Highly malignant EEG had equal specificity (99.5 [97.4-99.9] %) but higher sensitivity than NSE for poor recovery. Further analysis of the discriminative power of outcome predictors revealed limited value of NSE over EEG. CONCLUSIONS: In the majority of comatose CA patients, the outcome remains indeterminate after application of ERC/ESICM prognostication algorithm. Standardized EEG background analysis enables accurate prediction of both good and poor recovery, thereby greatly reducing uncertainty about coma prognostication in this patient population.


Assuntos
Parada Cardíaca , Hipotermia Induzida , Coma/diagnóstico , Coma/etiologia , Eletroencefalografia , Parada Cardíaca/terapia , Humanos , Fosfopiruvato Hidratase , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Incerteza
7.
Chest ; 157(5): 1167-1174, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31870911

RESUMO

BACKGROUND: Venoarterial extracorporeal membrane oxygenation therapy (VA-ECMO) after refractory cardiogenic shock or cardiac arrest has significant morbidity and mortality. Early outcome prediction is crucial in this setting, but data on neuroprognostication are limited. We examined the prognostic value of clinical neurologic examination, using an automated device for the quantitative measurement of pupillary light reactivity. METHODS: An observational cohort of sedated, mechanically ventilated VA-ECMO patients was analyzed during the early phase after ECMO insertion (first 72 h). Using the NPi-200 automated infrared pupillometer, pupillary light reactivity was assessed repeatedly (every 12 h) by calculating the Neurological Pupil index (NPi). Trends of NPi over time were correlated to 90-day mortality, and the prognostic performance of the NPi, alone and in combination with the 12-h PREDICT VA-ECMO score, was evaluated. RESULTS: One hundred consecutive patients were studied (51 with refractory cardiogenic shock and 49 with refractory cardiac arrest; 12-h PREDICT VA-ECMO, 40%; observed 90-day survival, 43%). Nonsurvivors (n = 57) had significantly lower NPi than did survivors at all time points (all P < .01). Abnormal NPi (< 3, at any time from 24 to 72 h) was 100% specific for 90-day mortality, with 0% false positives. Adding the 12-h PREDICT VA-ECMO score to the NPi provided the best prognostic performance (specificity, 100% [95% CI, 92%-100%]; sensitivity, 60% [95% CI, 46%-72%]; area under the receiver operating characteristic curve, 0.82). CONCLUSIONS: Quantitative NPi alone had excellent ability to predict a poor outcome from day 1 after VA-ECMO insertion, with no false positives. Combining NPi and 12-h PREDICT-VA ECMO score increased the sensitivity of outcome prediction, while maintaining 100% specificity.


Assuntos
Oxigenação por Membrana Extracorpórea , Parada Cardíaca/terapia , Exame Neurológico/métodos , Reflexo Pupilar , Choque Cardiogênico/terapia , Idoso , Coma , Feminino , Parada Cardíaca/mortalidade , Humanos , Pessoa de Meia-Idade , Prognóstico , Sensibilidade e Especificidade , Choque Cardiogênico/mortalidade , Taxa de Sobrevida , Suíça
8.
Am J Respir Crit Care Med ; 201(3): 303-312, 2020 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-31687831

RESUMO

Rationale: High-flow nasal cannula (HFNC) and helmet noninvasive ventilation (NIV) are used for the management of acute hypoxemic respiratory failure.Objectives: Physiological comparison of HFNC and helmet NIV in patients with hypoxemia.Methods: Fifteen patients with hypoxemia with PaO2/FiO2 < 200 mm Hg received helmet NIV (positive end-expiratory pressure ≥ 10 cm H2O, pressure support = 10-15 cm H2O) and HFNC (50 L/min) in randomized crossover order. Arterial blood gases, dyspnea, and comfort were recorded. Inspiratory effort was estimated by esophageal pressure (Pes) swings. Pes-simplified pressure-time product and transpulmonary pressure swings were measured.Measurements and Main Results: As compared with HFNC, helmet NIV increased PaO2/FiO2 (median [interquartile range]: 255 mm Hg [140-299] vs. 138 [101-172]; P = 0.001) and lowered inspiratory effort (7 cm H2O [4-11] vs. 15 [8-19]; P = 0.001) in all patients. Inspiratory effort reduction by NIV was linearly related to inspiratory effort during HFNC (r = 0.84; P < 0.001). Helmet NIV reduced respiratory rate (24 breaths/min [23-31] vs. 29 [26-32]; P = 0.027), Pes-simplified pressure-time product (93 cm H2O ⋅ s ⋅ min-1 [43-138] vs. 200 [168-335]; P = 0.001), and dyspnea (visual analog scale 3 [2-5] vs. 8 [6-9]; P = 0.002), without affecting PaCO2 (P = 0.80) and comfort (P = 0.50). In the overall cohort, transpulmonary pressure swings were not different between treatments (NIV = 18 cm H2O [14-21] vs. HFNC = 15 [8-19]; P = 0.11), but patients exhibiting lower inspiratory effort on HFNC experienced increases in transpulmonary pressure swings with helmet NIV. Higher transpulmonary pressure swings during NIV were associated with subsequent need for intubation.Conclusions: As compared with HFNC in hypoxemic respiratory failure, helmet NIV improves oxygenation, reduces dyspnea, inspiratory effort, and simplified pressure-time product, with similar transpulmonary pressure swings, PaCO2, and comfort.


Assuntos
Hipóxia/fisiopatologia , Hipóxia/terapia , Ventilação não Invasiva/instrumentação , Insuficiência Respiratória/fisiopatologia , Insuficiência Respiratória/terapia , Doença Aguda , Idoso , Cânula , Estudos Cross-Over , Feminino , Humanos , Hipóxia/complicações , Masculino , Pessoa de Meia-Idade , Insuficiência Respiratória/complicações
9.
Anesthesiology ; 131(1): 58-73, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30882475

RESUMO

BACKGROUND: Airway closure causes lack of communication between proximal airways and alveoli, making tidal inflation start only after a critical airway opening pressure is overcome. The authors conducted a matched cohort study to report the existence of this phenomenon among obese patients undergoing general anesthesia. METHODS: Within the procedures of a clinical trial during gynecological surgery, obese patients underwent respiratory/lung mechanics and lung volume assessment both before and after pneumoperitoneum, in the supine and Trendelenburg positions, respectively. Among patients included in this study, those exhibiting airway closure were compared to a control group of subjects enrolled in the same trial and matched in 1:1 ratio according to body mass index. RESULTS: Eleven of 50 patients (22%) showed airway closure after intubation, with a median (interquartile range) airway opening pressure of 9 cm H2O (6 to 12). With pneumoperitoneum, airway opening pressure increased up to 21 cm H2O (19 to 28) and end-expiratory lung volume remained unchanged (1,294 ml [1,154 to 1,363] vs. 1,160 ml [1,118 to 1,256], P = 0.155), because end-expiratory alveolar pressure increased consistently with airway opening pressure and counterbalanced pneumoperitoneum-induced increases in end-expiratory esophageal pressure (16 cm H2O [15 to 19] vs. 27 cm H2O [23 to 30], P = 0.005). Conversely, matched control subjects experienced a statistically significant greater reduction in end-expiratory lung volume due to pneumoperitoneum (1,113 ml [1,040 to 1,577] vs. 1,000 ml [821 to 1,061], P = 0.006). With airway closure, static/dynamic mechanics failed to measure actual lung/respiratory mechanics. When patients with airway closure underwent pressure-controlled ventilation, no tidal volume was inflated until inspiratory pressure overcame airway opening pressure. CONCLUSIONS: In obese patients, complete airway closure is frequent during anesthesia and is worsened by Trendelenburg pneumoperitoneum, which increases airway opening pressure and alveolar pressure: besides preventing alveolar derecruitment, this yields misinterpretation of respiratory mechanics and generates a pressure threshold to inflate the lung that can reach high values, spreading concerns on the safety of pressure-controlled modes in this setting.


Assuntos
Procedimentos Cirúrgicos em Ginecologia , Obesidade/complicações , Pneumoperitônio/complicações , Postura/fisiologia , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/fisiopatologia , Idoso , Anestesia Geral , Estudos de Coortes , Feminino , Decúbito Inclinado com Rebaixamento da Cabeça , Humanos , Pessoa de Meia-Idade , Obesidade/fisiopatologia , Pneumoperitônio/fisiopatologia , Decúbito Dorsal
10.
Sleep Breath ; 20(4): 1245-1253, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27136936

RESUMO

PURPOSE: The aim of our study was to apply the electrical impedance tomography (EIT) technique to the study of ventilation during wake and NREM and REM sleep in patients with obstructive sleep apneas (OSA). METHODS: This is a prospective, observational, monocentric, pilot study in a neurology department with a sleep disorder center. Inclusion criteria were age ≥18 years, both gender, and diagnosis of OSA. Exclusion criteria were the contraindications to the thoracic EIT. All patients underwent laboratory-based polysomnography (PSG) alongside thoracic EIT. Primary endpoint was to compare the global impedance (GI) among the conditions: "Wake" vs "Sleep," "NREM" vs "REM," and "OSA" vs "Non-OSA." Secondary endpoint was to measure the regional distribution of impedance in the four regions of interest (ROIs), in each condition. RESULTS: Of the 17 consecutive patients enrolled, two were excluded because of poor-quality EIT tracings. Fifteen were analyzed, 10 men and 5 women, mean age 51.6 ± 14.4 years. GI was higher in Wake vs Sleep (Wake 13.24 ± 11.23; Sleep 12.56 ± 13.36; p < 0.01), in NREM vs REM (NREM 13.48 ± 13.43; REM 0.59 ± 0.01; p < 0.01), and in Non-OSA vs OSA (Non-OSA 10.50 ± 12.99; OSA 18.98 ± 10.06; p < 0.01). No significant differences were observed in the regional distribution of impedance between Wake and Sleep (χ 2 = 3.66; p = 0.299) and between Non-OSA and OSA (χ 2 = 1.00; p = 0.799); conversely, a significant difference was observed between NREM and REM sleep (χ 2 = 62.94; p < 0.001). CONCLUSIONS: To our knowledge, this is the first study that addresses the issue of regional ventilation in OSA patients during sleep. Thoracic electrical impedance changes through the sleep-wake cycle and during obstructive events. The application of thoracic EIT can prove a valuable additional strategy for the evaluation of OSA patients.


Assuntos
Impedância Elétrica , Polissonografia , Ventilação Pulmonar/fisiologia , Apneia Obstrutiva do Sono/fisiopatologia , Fases do Sono/fisiologia , Tomografia/métodos , Adulto , Idoso , Feminino , Humanos , Interpretação de Imagem Assistida por Computador , Masculino , Pessoa de Meia-Idade , Valores de Referência , Tórax/fisiopatologia , Tomografia/instrumentação
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