Lung Ultrasound in Emergency and Critically Ill Patients: Number of Supervised Exams to Reach Basic Competence.

BACKGROUND: Lung ultrasound is increasingly used in critically ill patients as an alternative to bedside chest radiography, but the best training method remains uncertain. This study describes a training curriculum allowing trainees to acquire basic competence. METHODS: This multicenter, prospective, and educational study was conducted in 10 Intensive Care Units in Brazil, China, France and Uruguay. One hundred residents, respiratory therapists, and critical care physicians without expertise in transthoracic ultrasound (trainees) were trained by 18 experts. The main study objective was to determine the number of supervised exams required to get the basic competence, defined as the trainees' ability to adequately classify lung regions with normal aeration, interstitial-alveolar syndrome, and lung consolidation. An initial 2-h video lecture provided the rationale for image formation and described the ultrasound patterns commonly observed in critically ill and emergency patients. Each trainee performed 25 bedside ultrasound examinations supervised by an expert. The progression in competence was assessed every five supervised examinations. In a new patient, 12 pulmonary regions were independently classified by the trainee and the expert. RESULTS: Progression in competence was derived from the analysis of 7,330 lung regions in 2,562 critically ill and emergency patients. After 25 supervised examinations, 80% of lung regions were adequately classified by trainees. The ultrasound examination mean duration was 8 to 10 min in experts and decreased from 19 to 12 min in trainees (after 5 vs. 25 supervised examinations). The median training duration was 52 (42, 82) days. CONCLUSIONS: A training curriculum including 25 transthoracic ultrasound examinations supervised by an expert provides the basic skills for diagnosing normal lung aeration, interstitial-alveolar syndrome, and consolidation in emergency and critically ill patients.

Respiratory rate as a predictor of weaning failure from mechanical ventilation.

BACKGROUND AND OBJECTIVE: There is not an ideal predictor of weaning from mechanical ventilation (MV). In a large meta-analysis, despite methodological limitations, respiratory rate (RR) was considered a promising predictor. The aim of this study was to evaluate RR as a predictor of weaning failure from MV. METHODS: We prospectively evaluated 166 patients scheduled for weaning from MV. RR and other essential criteria for weaning were evaluated at an early stage of screening. Patients who met the essential screening criteria for weaning underwent spontaneous breathing trial. RR was compared with the following outcomes: weaning success/failure or extubation failure. RESULTS: Weaning success was present in 76.5% and weaning failure in 17.5% of patients. There were 6% of reintubations. The predictive power for RR weaning failure, RR best cut-off point > 24 breaths per minute (rpm), was: sensitivity 100%, specificity 85%, and accuracy 88% (ROC curve, p < 0.0001). Of the patients with weaning failure, 100% were identified by RR during screening (RR cut-off > 24 rpm). There were 15% false positives, weaning successes with RR > 24 rpm. CONCLUSION: RR was an effective predictor of weaning failure. The best cut-off point was RR > 24 rpm, which differed from those reported in the literature (35 and 38 rpm). Only 6% of patients were reintubated, but RR or other weaning criteria did not identify them.

Respiratory rate as a predictor of weaning failure from mechanical ventilation.

BACKGROUND AND OBJECTIVE: There is not an ideal predictor of weaning from mechanical ventilation (MV). In a large meta-analysis, despite methodological limitations, respiratory rate (RR) was considered a promising predictor. The aim of this study was to evaluate RR as a predictor of weaning failure from MV. METHODS: We prospectively evaluated 166 patients scheduled for weaning from MV. RR and other essential criteria for weaning were evaluated at an early stage of screening. Patients who met the essential screening criteria for weaning underwent spontaneous breathing trial. RR was compared with the following outcomes: weaning success/failure or extubation failure. RESULTS: Weaning success was present in 76.5% and weaning failure in 17.5% of patients. There were 6% of reintubations. The predictive power for RR weaning failure, RR best cut-off point > 24 breaths per minute (rpm), was: sensitivity 100%, specificity 85%, and accuracy 88% (ROC curve, p<0.0001). Of the patients with weaning failure, 100% were identified by RR during screening (RR cut-off > 24 rpm). There were 15% false positives, weaning successes with RR > 24 rpm. CONCLUSION: RR was an effective predictor of weaning failure. The best cut-off point was RR > 24 rpm, which differed from those reported in the literature (35 and 38 rpm). Only 6% of patients were reintubated, but RR or other weaning criteria did not identify them.

Frequência respiratória como preditor de falha de desmame da ventilação mecânica / Respiratory rate as a predictor of weaning failure from mechanical ventilation / Frecuencia respiratoria como predictor de fallo de destete de la ventilación mecánica

OBJETIVOS E JUSTIFICATIVAS: Não existe um preditor de desmame da ventilação mecânica (VM) ideal. Numa grande metanálise, apesar de limitações metodológicas, a frequência respiratória (FR) foi considerada um preditor promissor. O objetivo deste estudo foi avaliar a FR como um preditor de falha de desmame da VM. MÉTODO: Avaliamos prospectivamente 166 pacientes destinados ao desmame da VM. A FR e outros parâmetros essenciais para desmame foram avaliados numa fase inicial de triagem. Os pacientes que apresentaram na triagem os parâmetros essenciais para desmame foram submetidos ao teste de respiração espontânea. A FR foi comparada com os desfechos: sucesso, falha de desmame ou falha de extubação. RESULTADOS: Sucesso de desmame em 76,5% e falha de desmame em 17,5% dos pacientes. Seis por cento de reintubações. O poder preditivo para falha de desmame da FR, melhor ponto de corte FR > 24 respirações por minuto (rpm), foi: sensibilidade de 100%, especificidade de 85% e acurácia de 88% (curva ROC, p < 0,0001). Dos pacientes com falha de desmame, 100% foram identificados pela FR na fase de triagem (corte FR > 24 rpm). Houve 15% de falsos positivos, sucessos de desmame com FR > 24 rpm. CONCLUSÃO: A FR foi um preditor eficiente de falha de desmame. Encontrou-se como melhor ponto de corte FR > 24 rpm, diferentemente daqueles referidos pela literatura (35 e 38 rpm). Apenas 6% dos pacientes foram reintubados e tanto a FR quanto os outros parâmetros para desmame não tiveram capacidade de identificá-los. © 2013 Sociedade Brasileira de Anestesiologia.

BACKGROUND AND OBJECTIVE: There is not an ideal predictor of weaning from mechanical ventilation (MV). In a large meta-analysis, despite methodological limitations, respiratory rate (RR) was considered a promising predictor. The aim of this study was to evaluate RR as a predictor of weaning failure from MV. METHODS: We prospectively evaluated 166 patients scheduled for weaning from MV. RR and other essential criteria for weaning were evaluated at an early stage of screening. Patients who met the essential screening criteria for weaning underwent spontaneous breathing trial. RR was compared with the following outcomes: weaning success/failure or extubation failure. RESULTS: Weaning success was present in 76.5% and weaning failure in 17.5% of patients. There were 6% of reintubations. The predictive power for RR weaning failure, RR best cut-off point > 24 breaths per minute (rpm), was: sensitivity 100%, specificity 85%, and accuracy 88% (ROC curve, p < 0.0001). Of the patients with weaning failure, 100% were identified by RR during screening (RR cut-off > 24 rpm). There were 15% false positives, weaning successes with RR > 24 rpm. CONCLUSION: RR was an effective predictor of weaning failure. The best cut-off point was RR > 24 rpm, which differed from those reported in the literature (35 and 38 rpm). Only 6% of patients were reintubated, but RR or other weaning criteria did not identify them.

OBJETIVOS Y JUSTIFICATIVAS: No existe un predictor de destete de la ventilación mecánica (VM) ideal. En un gran metaanálisis, y pese a las limitaciones metodológicas, la Frecuencia Respiratoria (FR) fue considerada como un predictor promisorio. El objetivo de este estudio fue evaluar la FR como un predictor de fallo de destete de la VM. MÉTODO: Evaluamos prospectivamente 166 pacientes destinados al destete de la VM. La FR y otros parámetros esenciales para el destete se calcularon en una fase inicial de selección. Los pacientes que en la selección inicial tenían los parámetros esenciales para el destete, fueron sometidos al test de respiración espontánea. La FR se comparó con los resultados: éxito, fallo de destete o fallo de extubación. RESULTADOS: Se comprobó el éxito del destete en un 76,5% y el fallo del destete en un 17,5% de los pacientes. Hubo un seis por ciento de nuevas intubaciones. El poder predictivo para el fallo de destete de la FR, mejor punto de corte FR > 24 respiraciones por minuto (rpm) fue: sensibilidad del 100%, especificidad del 85% y exactitud del 88% (curva ROC, p < 0,0001). De los pacientes con fallo de destete, un 100% fueron identificados por la FR en la fase de selección (corte FR > 24 rpm). Hubo un 15% de falsos positivos, éxitos de destete con FR > 24 rpm. CONCLUSIONES: La FR fue un predictor eficiente de fallo de destete. Encontramos como mejor punto de corte FR > 24 rpm, a diferencia de aquellos referidos por la literatura (35 y 38 rpm). Solamente un 6% de los pacientes fueron reintubados y tanto la FR como los otros parámetros para el destete no tuvieron capacidad para identificarlos.

Contusão Cardíaca / Blunt cardiac injury

A contusão cardíaca e uma entidade clinica, cujo diagnostico necessita de um alto grau de suspeição a de sistematização, uma vez que possui apresentação clínica variada, cujo espectro e de lesões miocardias assintomáticas a ruptura cardíaca com indicação para toracotomia na emergência. O autor apresenta um caso de Contusão cardíaca, diagnosticado e tratado na Unidade de Terapia Intensiva do Hospital HGU, em Petrolina - PE