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Med. infant ; 29(1): 38-43, Marzo 2022. ilus
Article in Spanish | LILACS, BINACIS, UNISALUD | ID: biblio-1367206


La Injuria Pulmonar Autoinducida por el Paciente (p-SILI) es una entidad recientemente reconocida. Clásicamente, el daño producido por la ventilación mecánica (VM) se asoció al uso de presión positiva, y para disminuirlo se crearon distintas estrategias conocidas como parámetros de protección pulmonar. Sin embargo, es importante reconocer los potenciales efectos deletéreos de la ventilación espontánea dependientes de la injuria pulmonar previa que sufra el paciente y del esfuerzo que realice. En este artículo se explican los distintos mecanismos que pueden producir p-SILI y las estrategias descritas en la literatura para prevenirla (AU)

Patient self-inflicted lung injury (p-SILI) is a recently recognized disorder. Classically, damage produced by mechanical ventilation (MV) was associated with the use of positive pressure, and different strategies known as lung protection parameters were created to reduce it. Nevertheless, it is important to recognize the potential deleterious effects of the effort made during spontaneous breathing due to previous lung injury suffered by the patient. This article explains the different mechanisms that may produce p-SILI and the prevention strategies described in the literature. (AU)

Respiration, Artificial/methods , Respiratory Distress Syndrome, Newborn , Intensive Care Units, Pediatric , Tidal Volume , Positive-Pressure Respiration/methods , Lung Injury/physiopathology , Lung Injury/prevention & control
Chinese Medical Journal ; (24): 779-789, 2022.
Article in English | WPRIM | ID: wpr-927568


Neurocritical care (NCC) is not only generally guided by principles of general intensive care, but also directed by specific goals and methods. This review summarizes the common pulmonary diseases and pathophysiology affecting NCC patients and the progress made in strategies of respiratory support in NCC. This review highlights the possible interactions and pathways that have been revealed between neurological injuries and respiratory diseases, including the catecholamine pathway, systemic inflammatory reactions, adrenergic hypersensitivity, and dopaminergic signaling. Pulmonary complications of neurocritical patients include pneumonia, neurological pulmonary edema, and respiratory distress. Specific aspects of respiratory management include prioritizing the protection of the brain, and the goal of respiratory management is to avoid inappropriate blood gas composition levels and intracranial hypertension. Compared with the traditional mode of protective mechanical ventilation with low tidal volume (Vt), high positive end-expiratory pressure (PEEP), and recruitment maneuvers, low PEEP might yield a potential benefit in closing and protecting the lung tissue. Multimodal neuromonitoring can ensure the safety of respiratory maneuvers in clinical and scientific practice. Future studies are required to develop guidelines for respiratory management in NCC.

Humans , Lung , Lung Diseases/etiology , Positive-Pressure Respiration/methods , Respiration, Artificial/adverse effects , Tidal Volume
Rev. Paul. Pediatr. (Ed. Port., Online) ; 39: e2019275, 2021. tab, graf
Article in English, Portuguese | LILACS | ID: biblio-1155475


ABSTRACT Objective: Acute respiratory distress syndrome (ARDS) can be a devastating condition in children with cancer and alveolar recruitment maneuvers (ARMs) can theoretically improve oxygenation and survival. The study aimed to assess the feasibility of ARMs in critically ill children with cancer and ARDS. Methods: We retrospectively analyzed 31 maneuvers in a series of 12 patients (median age of 8.9 years) with solid tumors (n=4), lymphomas (n=2), acute lymphoblastic leukemia (n=2), and acute myeloid leukemia (n=4). Patients received positive end-expiratory pressure from 25 up to 40 cmH20, with a delta pressure of 15 cmH2O for 60 seconds. We assessed blood gases pre- and post-maneuvers, as well as ventilation parameters, vital signs, hemoglobin, clinical signs of pulmonary bleeding, and radiological signs of barotrauma. Pre- and post-values were compared by the Wilcoxon test. Results: Median platelet count was 53,200/mm3. Post-maneuvers, mean arterial pressure decreased more than 20% in two patients, and four needed an increase in vasoactive drugs. Hemoglobin levels remained stable 24 hours after ARMs, and signs of pneumothorax, pneumomediastinum, or subcutaneous emphysema were absent. Fraction of inspired oxygen decreased significantly after ARMs (FiO2; p=0.003). Oxygen partial pressure (PaO2)/FiO2 ratio increased significantly (p=0.0002), and the oxygenation index was reduced (p=0.01), but all these improvements were transient. Recruited patients' 28-day mortality was 58%. Conclusions: ARMs, although feasible in the context of thrombocytopenia, lead only to transient improvements, and can cause significant hemodynamic instability.

RESUMO Objetivo: A síndrome do desconforto respiratório agudo (SDRA) pode ser uma condição devastadora em crianças com câncer e as manobras de recrutamento alveolar (MRA) podem melhorar a oxigenação e a sobrevida. O objetivo foi avaliar a viabilidade das MRA em crianças gravemente doentes com câncer e SDRA. Métodos: Analisamos retrospectivamente 31 manobras em 12 pacientes (idade mediana de 8,9 anos), com tumores sólidos (n=4), linfomas (n=2) e leucemias linfoide (n=2) e mieloide agudas (n=4). Os pacientes receberam pressão expiratória final positiva de 25 a 40 cmH20, com delta de pressão de 15 cmH2O por 60 segundos. Gasometrias foram analisadas pré e pós-manobras, bem como os parâmetros de ventilação, sinais vitais, hemoglobina, sinais clínicos de sangramento pulmonar e sinais radiológicos de barotrauma. Valores foram comparados com o teste de Wilcoxon. Resultados: A contagem mediana de plaquetas era de 53.200/mm3. Após as manobras, em dois pacientes, a pressão arterial média declinou mais de 20%, e quatro necessitaram de aumento de drogas vasoativas. A hemoglobina permaneceu estável 24 horas após a MRA, sem sinais de pneumotórax, pneumomediastino ou enfisema subcutâneo. Houve diminuição significativa nas frações inspiradas de oxigênio (FiO2; p=0,003). A relação pressão arterial de oxigênio (PaO2)/FiO2 aumentou (p=0,002), e o índice de oxigenação caiu (p=0,01), mas essas melhoras foram transitórias. A mortalidade em 28 dias foi de 58%. Conclusões: As MRA, embora viáveis no contexto da trombocitopenia, levam apenas a melhorias transitórias e podem causar instabilidade hemodinâmica significativa.

Humans , Child , Respiratory Distress Syndrome, Newborn/therapy , Positive-Pressure Respiration/methods , Neoplasms/complications , Respiratory Distress Syndrome, Newborn/etiology , Blood Gas Analysis , Feasibility Studies , Retrospective Studies , Positive-Pressure Respiration/adverse effects , Health Services Accessibility
Clinics ; 75: e1894, 2020. graf
Article in English | LILACS | ID: biblio-1101090


This review aims to verify the main epidemiologic, clinical, laboratory-related, and therapeutic aspects of coronavirus disease 2019 (COVID-19) in critically ill pediatric patients. An extensive review of the medical literature on COVID-19 was performed, mainly focusing on the critical care of pediatric patients, considering expert opinions and recent reports related to this new disease. Experts from a large Brazilian public university analyzed all recently published material to produce a report aiming to standardize the care of critically ill children and adolescents. The report emphasizes on the clinical presentations of the disease and ventilatory support in pediatric patients with COVID-19. It establishes a flowchart to guide health practitioners on triaging critical cases. COVID-19 is essentially an unknown clinical condition for the majority of pediatric intensive care professionals. Guidelines developed by experts can help all practitioners standardize their attitudes and improve the treatment of COVID-19.

Humans , Male , Female , Child , Pneumonia, Viral/diagnosis , Pneumonia, Viral/therapy , Coronavirus Infections/diagnosis , Coronavirus Infections/therapy , Betacoronavirus , Time Factors , Severity of Illness Index , Positive-Pressure Respiration/methods , Critical Illness , Coronavirus Infections/metabolism , Clinical Laboratory Techniques , Reverse Transcriptase Polymerase Chain Reaction , Severe Acute Respiratory Syndrome/diagnosis , Severe Acute Respiratory Syndrome/therapy , Diagnosis, Differential , Pandemics , COVID-19 Testing , SARS-CoV-2 , COVID-19
Rev. bras. cir. cardiovasc ; 34(6): 699-703, Nov.-Dec. 2019. tab
Article in English | LILACS | ID: biblio-1057490


Abstract Objective: To evaluate the impact of different levels of positive end-expiratory pressure (PEEP) on gas exchange in patients undergoing coronary artery bypass grafting (CABG). Methods: A randomized clinical trial was conducted with patients undergoing CABG surgery. Patients were randomized into three groups: Group 10, PEEP of 10 cmH2O; Group 12, PEEP of 12 cmH2O; and Group 15, PEEP of 15 cmH2O. After the randomization, all patients underwent gas analysis at three moments: (1) before lung expansion therapy (LET); (2) 30 minutes after LET; and (3) one hour after extubation. Results: Sixty-six patients were studied, of which 61.7% were men, with mean age of 64 ± 8.9 years. Patients allocated to Group 15 showed a significant improvement in gas exchange comparing pre- and post-expansion values (239±21 vs. 301±19, P<0,001) and the increase was maintained after extubation (278±26). Despite the use of high levels of PEEP, no significant hemodynamic change was evidenced. Conclusion: It is concluded that high levels of PEEP (15 cmH2O) are beneficial for the improvement of gas exchange in patients undergoing CABG.

Humans , Male , Female , Middle Aged , Aged , Coronary Artery Bypass/rehabilitation , Positive-Pressure Respiration/methods , Blood Gas Analysis , Respiratory Mechanics , Pulmonary Gas Exchange , Airway Extubation , Hemodynamics
Braz. j. med. biol. res ; 52(7): e8585, 2019. tab, graf
Article in English | LILACS | ID: biblio-1011588


Atelectasis and inadequate oxygenation in lung donors is a common problem during the retrieval of these organs. Nevertheless, the use of high positive end-expiratory pressure (PEEP) is not habitual during procedures of lung retrieval. Twenty-one Sprague-Dawley male consanguineous rats were used in the study. The animals were divided into 3 groups according to the level of PEEP used: low (2 cmH2O), moderate (5 cmH2O), and high (10 cmH2O). Animals were ventilated with a tidal volume of 6 mL/kg. Before lung removal, the lungs were inspected for the presence of atelectasis. When atelectasis was detected, alveolar recruitment maneuvers were performed. Blood gasometric analysis was performed immediately. Finally, the lungs were retrieved, weighed, and submitted to histological analysis. The animals submitted to higher PEEP showed higher levels of oxygenation with the same tidal volumes PO2=262.14 (PEEP 2), 382.4 (PEEP 5), and 477.0 (PEEP 10). The occurrence of atelectasis was rare in animals with a PEEP of 10 cmH2O, which therefore required less frequent recruitment maneuvers (need for recruitment: PEEP 2=100%, PEEP 5 =100%, and PEEP 10=14.3%). There was no change in hemodynamic stability, occurrence of pulmonary edema, or other histological injuries with the use of high PEEP. The use of high PEEP (10 cmH2O) was feasible and probably a beneficial strategy for the prevention of atelectasis and the optimization of oxygenation during lung retrieval. Clinical studies should be performed to confirm this hypothesis.

Animals , Male , Rats , Pulmonary Atelectasis/rehabilitation , Pulmonary Gas Exchange/physiology , Tidal Volume/physiology , Positive-Pressure Respiration/methods , Lung Transplantation/methods , Pulmonary Atelectasis/physiopathology , Rats, Sprague-Dawley , Models, Animal
J. bras. pneumol ; 45(3): e20180058, 2019. tab, graf
Article in English | LILACS | ID: biblio-990114


ABSTRACT Objective: To investigate the effects of manual chest compression (MCC) on the expiratory flow bias during the positive end-expiratory pressure-zero end-expiratory pressure (PEEP-ZEEP) airway clearance maneuver applied in patients on mechanical ventilation. The flow bias, which influences pulmonary secretion removal, is evaluated by the ratio and difference between the peak expiratory flow (PEF) and the peak inspiratory flow (PIF). Methods: This was a crossover randomized study involving 10 patients. The PEEP-ZEEP maneuver was applied at four time points, one without MCC and the other three with MCC, which were performed by three different respiratory therapists. Respiratory mechanics data were obtained with a specific monitor. Results: The PEEP-ZEEP maneuver without MCC was enough to exceed the threshold that is considered necessary to move secretion toward the glottis (PEF − PIF difference > 33 L/min): a mean PEF − PIF difference of 49.1 ± 9.4 L/min was achieved. The mean PEF/PIF ratio achieved was 3.3 ± 0.7. Using MCC with PEEP-ZEEP increased the mean PEF − PIF difference by 6.7 ± 3.4 L/min. We found a moderate correlation between respiratory therapist hand grip strength and the flow bias generated with MCC. No adverse hemodynamic or respiratory effects were found. Conclusions: The PEEP-ZEEP maneuver, without MCC, resulted in an expiratory flow bias superior to that necessary to facilitate pulmonary secretion removal. Combining MCC with the PEEP-ZEEP maneuver increased the expiratory flow bias, which increases the potential of the maneuver to remove secretions.

RESUMO Objetivo: Avaliar os efeitos da compressão torácica manual (CTM) sobre o flow bias expiratório durante a manobra positive end-expiratory pressure-zero end-expiratory pressure (PEEP-ZEEP) para a remoção de secreção em pacientes sob ventilação mecânica invasiva. O flow bias, que influencia na remoção de secreção pulmonar, foi avaliado pela razão e diferença entre pico de fluxo expiratório (PFE) e pico de fluxo inspiratório (PFI). Métodos: Estudo cruzado e randomizado no qual participaram 10 pacientes. A manobra PEEP-ZEEP foi aplicada em quatro momentos, sendo um sem CTM e os outros três em associação com a CTM, que foram aplicadas por três fisioterapeutas distintos. Um monitor específico foi utilizado para o registro dos dados de mecânica respiratória. Resultados: A manobra PEEP-ZEEP sem a CTM foi suficiente para ultrapassar o limiar do flow bias expiratório (diferença PFE − PFI > 33 l/min), considerado necessário para deslocar a secreção em direção à glote; a média da diferença PFE − PFI encontrada foi de 49,1 ± 9,4 l/min. A média da razão PFE/PFI alcançada foi de 3,3 ± 0,7. A associação da CTM à PEEP-ZEEP aumentou a média da diferença PFE − PFI em 6,7 ± 3,4 l/min. Foi observada correlação moderada entre a força de preensão manual dos fisioterapeutas e o flow bias gerado durante a CTM. Não foram encontradas alterações hemodinâmicas ou respiratórias adversas ao longo do estudo. Conclusões: A manobra PEEP-ZEEP sem a CTM resultou em um flow bias expiratório superior ao considerado efetivo para auxiliar na remoção de secreção pulmonar. A associação com a CTM aumentou o flow bias expiratório, o que aumenta o potencial da manobra para remover secreções.

Humans , Male , Female , Adult , Middle Aged , Aged , Young Adult , Respiration, Artificial/methods , Positive-Pressure Respiration/methods , Pulmonary Ventilation/physiology , Thoracic Wall/physiopathology , Lung/physiology , Reference Values , Respiration, Artificial/adverse effects , Time Factors , Linear Models , Respiratory Mechanics/physiology , Analysis of Variance , Treatment Outcome , Cross-Over Studies , Bodily Secretions , Arterial Pressure/physiology
Rev. bras. cir. cardiovasc ; 33(3): 250-257, May-June 2018. tab, graf
Article in English | LILACS | ID: biblio-958414


Abstract Objective: To compare the effects of extended- versus short-time noninvasive positive pressure ventilation on pulmonary function, tissue perfusion, and clinical outcomes in the early postoperative period following coronary artery bypass surgery in patients with preserved left ventricular function. Methods: Patients were randomized into two groups according to noninvasive positive pressure ventilation intensity: short-time noninvasive positive pressure ventilation n=20 (S-NPPV) and extended-time noninvasive positive pressure ventilation n=21 (E-NPPV). S-NPPV was applied for 60 minutes during immediate postoperative period and 10 minutes, twice daily, from postoperative days 1-5. E-NPPV was performed for at least six hours during immediate postoperative period and 60 minutes, twice daily, from postoperative days 1-5. As a primary outcome, tissue perfusion was determined by central venous oxygen saturation and blood lactate level measured after anesthetic induction, immediately after extubation and following noninvasive positive pressure ventilation protocols. As a secondary outcome, pulmonary function tests were performed preoperatively and in the postoperative days 1, 3, and 5; clinical outcomes were recorded. Results: Significant drop in blood lactate levels and an improvement in central venous oxygen saturation values in the E-NPPV group were observed when compared with S-NPPV group after study protocol (P<0.01). The E-NPPV group presented higher preservation of postoperative pulmonary function as well as lower incidence of respiratory events and shorter postoperative hospital stay (P<0.05). Conclusion: Prophylactic E-NPPV administered in the early postoperative period of coronary artery bypass surgery resulted in greater improvements in tissue perfusion, pulmonary function and clinical outcomes than S-NPPV, in patients with preserved left ventricular function. Trial Registration: Brazilian Registry of Clinical trial - RBR7sqj78 -

Humans , Male , Female , Middle Aged , Aged , Coronary Artery Bypass/methods , Positive-Pressure Respiration/methods , Noninvasive Ventilation/methods , Lung Diseases/prevention & control , Oxygen/blood , Postoperative Complications/prevention & control , Postoperative Complications/blood , Time Factors , Vital Capacity , Forced Expiratory Volume , Coronary Artery Bypass/adverse effects , Risk Factors , Analysis of Variance , Treatment Outcome , Statistics, Nonparametric , Lactic Acid/blood , Length of Stay , Lung Diseases/etiology , Lung Diseases/blood
Säo Paulo med. j ; 136(3): 266-269, May-June 2018. tab, graf
Article in English | LILACS | ID: biblio-962727


ABSTRACT CONTEXT: Mounier-Kuhn syndrome is a rare congenital condition with distinct dilatation and diverticulation of the tracheal wall. The symptoms may vary and the treatment usually consists of support. CASE REPORT: The patient was a 60-year-old male with recurrent hospital admission. He was admitted in this case due to dyspnea, cough and sputum production. An arterial blood sample revealed decompensated respiratory acidosis with moderate hypoxemia. A chest computed tomography (CT) scan showed dilatation of the trachea and bronchi, tracheal diverticula and bronchiectasis. Flexible bronchoscopy was performed, which revealed enlarged airways with expiratory collapse. Furthermore, orifices of tracheal diverticulosis were also detected. Non-invasive positive pressure ventilation (NPPV) was added, along with long-term oxygen therapy. At control visits, the patient's clinical and laboratory findings were found to have improved. CONCLUSION: Flexible bronchoscopy can be advocated for establishing the diagnosis and non-invasive mechanical ventilation can be used with a high success rate, for clinical wellbeing in Mounier-Kuhn syndrome.

RESUMO CONTEXTO: A síndrome de Mounier-Kuhn é uma condição congênita rara com dilatação e diverticulação distintas da parede traqueal. Os sintomas podem ser variáveis ​e o tratamento geralmente é de suporte. RELATO DE CASO: Paciente do sexo masculino, de 60 anos, com internação hospitalar recorrente, foi internado neste caso devido a dispneia, tosse e produção de expectoração. A amostra de sangue arterial revelou acidose respiratória descompensada, com hipoxemia moderada. A tomografia computadorizada de tórax mostrou dilatação da traqueia e brônquios, divertículos traqueais e bronquiectasias. Realizou-se broncoscopia flexível, que revelou aumento das vias aéreas com colapso expiratório. Além disso, também foram detectados orifícios de diverticulose traqueal. Foi adicionada ventilação com pressão positiva não invasiva (NPPV) juntamente com a oxigenoterapia a longo prazo. Foram verificadas melhoras dos resultados clínicos e laboratoriais do doente nas visitas de controle. CONCLUSÃO: A broncoscopia flexível pode ser defendida para estabelecer o diagnóstico, e a ventilação mecânica não invasiva pode ser utilizada com alta taxa de sucesso, para bem-estar clínico, na síndrome de Mounier-Kuhn.

Humans , Male , Middle Aged , Bronchoscopy/methods , Tracheobronchomegaly/therapy , Positive-Pressure Respiration/methods , Diverticulum/therapy , Noninvasive Ventilation/methods , Oxygen Inhalation Therapy/methods , Tomography, X-Ray Computed , Tracheobronchomegaly/diagnostic imaging , Diverticulum/diagnostic imaging
Rev. bras. cir. cardiovasc ; 32(4): 295-300, July-Aug. 2017. tab, graf
Article in English | LILACS | ID: biblio-897926


Abstract Introduction: During and after coronary artery bypass grafting, a decline in multifactor lung function is observed. Due to this fact, some patients may benefit from non-invasive ventilation after extubation targeting lung expansion and consequently improved oxygenation. Objective: To test the hypothesis that higher levels of positive end expiration pressure during non-invasive ventilation improves oxygenation in patients undergoing coronary artery bypass grafting. Methods: A randomized clinical trial was conducted at Instituto Nobre de Cardiologia in Feira de Santana. On the first day after surgery, the patients were randomized: Group PEEP 10, Group PEEP 12 and Group PEEP 15 who underwent non-invasive ventilation with positive end expiration pressure level. All patients were submitted to analysis blood pressure oxygen (PaO2), arterial oxygen saturation (SaO2) and oxygenation index (PaO2/FiO2). Results: Thirty patients were analyzed, 10 in each group, with 63.3% men with a mean age of 61.1±12.2 years. Mean pulmonary expansion pre-therapy PaO2 was generally 121.9±21.6 to 136.1±17.6 without statistical significance in the evaluation among the groups. This was also present in PaO2/FiO2 and SaO2. Statistical significance was only present in pre and post PEEP 15 when assessing the PaO2 and SaO2 (P=0.02). Conclusion: Based on the findings of this study, non-invasive ventilation with PEEP 15 represented an improvement in oxygenation levels of patients undergoing coronary artery bypass grafting.

Humans , Male , Female , Middle Aged , Aged , Oxygen/blood , Pulmonary Gas Exchange/physiology , Coronary Artery Bypass , Positive-Pressure Respiration/methods , Noninvasive Ventilation/methods , Postoperative Period , Time Factors
Rev. bras. ter. intensiva ; 29(2): 142-153, abr.-jun. 2017. tab, graf
Article in Portuguese | LILACS | ID: biblio-899511


RESUMO Fundamentação: O estudo Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) é um ensaio clínico internacional, multicêntrico, randomizado, pragmático e controlado com ocultação da alocação que envolve 120 unidades de terapia intensiva no Brasil, Argentina, Colômbia, Espanha, Itália, Polônia, Portugal, Malásia e Uruguai, com o objetivo primário de determinar se o recrutamento alveolar gradual máximo associado com titulação da pressão positiva expiratória final, ajustada segundo a complacência estática do sistema respiratório (estratégia ART), é capaz de aumentar, quando comparada aos resultados do tratamento convencional (estratégia ARDSNet), a sobrevivência em 28 dias de pacientes com síndrome do desconforto respiratório agudo. Objetivo: Descrever o processo de gerenciamento dos dados e o plano de análise estatística em um ensaio clínico internacional. Métodos: O plano de análise estatística foi delineado pelo comitê executivo e revisado pelo comitê diretivo do ART. Foi oferecida uma visão geral do delineamento do estudo, com foco especial na descrição de desfechos primário (sobrevivência aos 28 dias) e secundários. Foram descritos o processo de gerenciamento dos dados, o comitê de monitoramento de dados, a análise interina e o cálculo do tamanho da amostra. Também foram registrados o plano de análise estatística para os desfechos primário e secundários, e os subgrupos de análise pré-especificados. Detalhes para apresentação dos resultados, inclusive modelos de tabelas para as características basais, adesão ao protocolo e efeito nos desfechos clínicos, foram fornecidos. Conclusão: Em acordo com as melhores práticas em ensaios clínicos, submetemos nossos planos de análise estatística e de gerenciamento de dados para publicação antes do fechamento da base de dados e início das análises. Antecipamos que este documento deve prevenir viés em análises e incrementar a utilidade dos resultados a serem relatados. Registro do estudo: Número no registro NCT01374022.

ABSTRACT Background: The Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) is an international multicenter randomized pragmatic controlled trial with allocation concealment involving 120 intensive care units in Brazil, Argentina, Colombia, Italy, Poland, Portugal, Malaysia, Spain, and Uruguay. The primary objective of ART is to determine whether maximum stepwise alveolar recruitment associated with PEEP titration, adjusted according to the static compliance of the respiratory system (ART strategy), is able to increase 28-day survival in patients with acute respiratory distress syndrome compared to conventional treatment (ARDSNet strategy). Objective: To describe the data management process and statistical analysis plan. Methods: The statistical analysis plan was designed by the trial executive committee and reviewed and approved by the trial steering committee. We provide an overview of the trial design with a special focus on describing the primary (28-day survival) and secondary outcomes. We describe our data management process, data monitoring committee, interim analyses, and sample size calculation. We describe our planned statistical analyses for primary and secondary outcomes as well as pre-specified subgroup analyses. We also provide details for presenting results, including mock tables for baseline characteristics, adherence to the protocol and effect on clinical outcomes. Conclusion: According to best trial practice, we report our statistical analysis plan and data management plan prior to locking the database and beginning analyses. We anticipate that this document will prevent analysis bias and enhance the utility of the reported results. Trial registration: number, NCT01374022.

Humans , Pulmonary Alveoli/metabolism , Respiratory Distress Syndrome/therapy , Positive-Pressure Respiration/methods , Research Design , Survival Rate , Data Interpretation, Statistical , Treatment Outcome , Intensive Care Units
Rev. bras. ter. intensiva ; 29(1): 105-110, jan.-mar. 2017. tab, graf
Article in Portuguese | LILACS | ID: biblio-844285


RESUMO A síndrome do desconforto respiratório agudo é caracterizada por lesão pulmonar inflamatória difusa, classificada em leve, moderada e grave. Clinicamente observam-se hipoxemia, opacidades bilaterais na imagem pulmonar e diminuição da complacência pulmonar. A sepse está entre as causas mais prevalentes (30 - 50%). Dentre as causas diretas de síndrome do desconforto respiratório agudo, a inalação de cloro é uma causa incomum, gerando, na maior parte dos casos, irritação de mucosas e vias aéreas. Apresentamos um caso de síndrome do desconforto respiratório agudo grave após inalação acidental de cloro em piscina, sendo utilizada ventilação não invasiva como tratamento com boa resposta neste caso. Classificamos como síndrome do desconforto respiratório agudo grave baseado na relação pressão parcial de oxigênio/fração inspirada de oxigênio < 100, embora a classificação de Berlin seja limitada em considerar pacientes com hipoxemia grave manejados exclusivamente com ventilação não invasiva. A taxa de falha da ventilação não invasiva nos casos de síndrome do desconforto respiratório agudo está em torno de 52%, estando associada à maior mortalidade. As possíveis complicações do uso da ventilação mecânica não invasiva com pressão positiva na síndrome do desconforto respiratório agudo seriam o atraso para a intubação orotraqueal sendo a mesma realizada em uma condição clínica pior e um alto nível de pressões de suporte, somados a esforços inspiratórios profundos, gerando elevados volumes correntes e pressões transpulmonares excessivas, que contribuem para injúria pulmonar associada à ventilação. Apesar disto, alguns estudos mostraram diminuição nas taxas de intubação orotraqueal em pacientes com síndrome do desconforto respiratório Agudo com baixos escores de gravidade, estabilidade hemodinâmica e ausência de outras disfunções orgânicas.

ABSTRACT Acute respiratory distress syndrome is characterized by diffuse inflammatory lung injury and is classified as mild, moderate, and severe. Clinically, hypoxemia, bilateral opacities in lung images, and decreased pulmonary compliance are observed. Sepsis is one of the most prevalent causes of this condition (30 - 50%). Among the direct causes of acute respiratory distress syndrome, chlorine inhalation is an uncommon cause, generating mucosal and airway irritation in most cases. We present a case of severe acute respiratory distress syndrome after accidental inhalation of chlorine in a swimming pool, with noninvasive ventilation used as a treatment with good response in this case. We classified severe acute respiratory distress syndrome based on an oxygen partial pressure/oxygen inspired fraction ratio <100, although the Berlin classification is limited in considering patients with severe hypoxemia managed exclusively with noninvasive ventilation. The failure rate of noninvasive ventilation in cases of acute respiratory distress syndrome is approximately 52% and is associated with higher mortality. The possible complications of using noninvasive positive-pressure mechanical ventilation in cases of acute respiratory distress syndrome include delays in orotracheal intubation, which is performed in cases of poor clinical condition and with high support pressure levels, and deep inspiratory efforts, generating high tidal volumes and excessive transpulmonary pressures, which contribute to ventilation-related lung injury. Despite these complications, some studies have shown a decrease in the rates of orotracheal intubation in patients with acute respiratory distress syndrome with low severity scores, hemodynamic stability, and the absence of other organ dysfunctions.

Humans , Male , Respiratory Distress Syndrome/therapy , Chlorine/poisoning , Positive-Pressure Respiration/methods , Noninvasive Ventilation/methods , Oxygen , Partial Pressure , Respiratory Distress Syndrome/chemically induced , Severity of Illness Index , Tidal Volume , Treatment Outcome , Middle Aged
J. bras. pneumol ; 42(6): 404-408, Nov.-Dec. 2016. tab, graf
Article in English | LILACS | ID: biblio-841245


ABSTRACT Objective: To evaluate the effects of positive expiratory pressure (PEP) on pulmonary epithelial membrane permeability in healthy subjects. Methods: We evaluated a cohort of 30 healthy subjects (15 males and 15 females) with a mean age of 28.3 ± 5.4 years, a mean FEV1/FVC ratio of 0.89 ± 0.14, and a mean FEV1 of 98.5 ± 13.1% of predicted. Subjects underwent technetium-99m-labeled diethylenetriaminepentaacetic acid (99mTc-DTPA) radioaerosol inhalation lung scintigraphy in two stages: during spontaneous breathing; and while breathing through a PEP mask at one of three PEP levels-10 cmH2O (n = 10), 15 cmH2O (n = 10), and 20 cmH2O (n = 10). The 99mTc-DTPA was nebulized for 3 min, and its clearance was recorded by scintigraphy over a 30-min period during spontaneous breathing and over a 30-min period during breathing through a PEP mask. Results: The pulmonary clearance of 99mTc-DTPA was significantly shorter when PEP was applied-at 10 cmH2O (p = 0.044), 15 cmH2O (p = 0.044), and 20 cmH2O (p = 0.004)-in comparison with that observed during spontaneous breathing. Conclusions: Our findings indicate that PEP, at the levels tested, is able to induce an increase in pulmonary epithelial membrane permeability and lung volume in healthy subjects.

RESUMO Objetivo: Avaliar os efeitos da pressão expiratória positiva (PEP) na permeabilidade da membrana epitelial pulmonar em indivíduos saudáveis. Métodos: Foi avaliada uma coorte de 30 indivíduos saudáveis (15 homens e 15 mulheres), com média de idade de 28,3 ± 5,4 anos, média da relação VEF1/CVF de 0,89 ± 0,14 e média de VEF1 de 98,5 ± 13,1% do previsto. Os indivíduos foram submetidos a cintilografia pulmonar por inalação de radioaerossol de ácido dietilenotriaminopentacético marcado com tecnécio-99m (99mTc-DTPA em inglês) em dois estágios: durante respiração espontânea e durante respiração com uma máscara de PEP de 10 cmH2O (n = 10), 15 cmH2O (n = 10) ou 20 cmH2O (n = 10). O 99mTc-DTPA foi nebulizado por 3 min, e sua depuração foi registrada por cintilografia por um período de 30 min durante respiração espontânea e por um período de 30 min durante a respiração com uma máscara de PEP. Resultados: A depuração pulmonar do 99mTc-DTPA foi significativamente menor quando PEP foi aplicada a 10 cmH2O (p = 0,044), 15 cmH2O (p = 0,044) e 20 cmH2O (p = 0,004), em comparação com a observada durante a respiração espontânea. Conclusões: Nossos achados indicam que o uso de PEP nos níveis testados pode induzir um aumento na permeabilidade da membrana epitelial pulmonar e no volume pulmonar em indivíduos saudáveis.

Humans , Female , Adult , Lung/metabolism , Positive-Pressure Respiration/methods , Radiopharmaceuticals/pharmacokinetics , Technetium Tc 99m Pentetate/pharmacokinetics , Lung/physiology , Metabolic Clearance Rate , Permeability , Pulmonary Alveoli/metabolism , Radiopharmaceuticals/administration & dosage , Technetium Tc 99m Pentetate/administration & dosage
Rev. bras. ter. intensiva ; 28(3): 341-347, jul.-set. 2016. tab, graf
Article in Portuguese | LILACS | ID: lil-796163


RESUMO Objetivo: Avaliar as repercussões da hiperinsuflação manual, realizada com ressuscitador manual com e sem válvula de pressão positiva expiratória final, sobre a função respiratória de recém-nascidos pré-termo em ventilação mecânica. Métodos: Estudo transversal com recém-nascidos pré-termo com idade gestacional inferior a 32 semanas, em ventilação mecânica e dependentes desta aos 28 dias de vida, estáveis hemodinamicamente. A hiperinsuflação manual foi aplicada de forma randomizada, alternando o uso ou não uso da válvula de pressão positiva expiratória final, seguida de aspiração intratraqueal finalizando a manobra. Para os dados nominais, foi aplicado o teste de Wilcoxon com hipótese bilateral ao nível de significância de 5% e poder de teste de 80%. Resultados: Foram estudados 28 recém-nascidos pré-termo com peso médio de nascimento 1.005,71 ± 372.16g, idade gestacional média 28,90 ± 1,79 semanas, idade corrigida média de 33,26 ± 1,78 semanas, tempo médio de ventilação mecânica de 29,5 (15 - 53) dias. Ocorreu aumento dos volumes inspiratório e expiratório entre os momentos A5 (antes da manobra) e C1 (imediatamente após aspiração intratraqueal) tanto na manobra com válvula (p = 0,001 e p = 0,009) como sem válvula (p = 0,026 e p = 0,001), respectivamente. Também houve aumento da resistência expiratória entre os momentos A5 e C1 com p = 0,044. Conclusão: Os volumes pulmonares aumentaram na manobra com e sem válvula, havendo diferença significativa no primeiro minuto após a aspiração. Houve diferença significativa na resistência expiratória entre os momentos A5 (antes da manobra) e C1 (imediatamente após aspiração intratraqueal) no primeiro minuto após a aspiração dentro de cada manobra.

ABSTRACT Objective: To assess the effects of manual hyperinflation, performed with a manual resuscitator with and without the positive end-expiratory pressure valve, on the respiratory function of preterm newborns under mechanical ventilation. Methods: Cross-sectional study of hemodynamically stable preterm newborns with gestational age of less than 32 weeks, under mechanical ventilation and dependent on it at 28 days of life. Manual hyperinflation was applied randomly, alternating the use or not of the positive end-expiratory pressure valve, followed by tracheal aspiration for ending the maneuver. For nominal data, the two-tailed Wilcoxon test was applied at the 5% significance level and 80% power. Results: Twenty-eight preterm newborns, with an average birth weight of 1,005.71 ± 372.16g, an average gestational age of 28.90 ± 1.79 weeks, an average corrected age of 33.26 ± 1.78 weeks, and an average mechanical ventilation time of 29.5 (15 - 53) days, were studied. Increases in inspiratory and expiratory volumes occurred between time-points A5 (before the maneuver) and C1 (immediately after tracheal aspiration) in both the maneuver with the valve (p = 0.001 and p = 0.009) and without the valve (p = 0.026 and p = 0.001), respectively. There was also an increase in expiratory resistance between time-points A5 and C1 (p = 0.044). Conclusion: Lung volumes increased when performing the maneuver with and without the valve, with a significant difference in the first minute after aspiration. There was a significant difference in expiratory resistance between the time-points A5 (before the maneuver) and C1 (immediately after tracheal aspiration) in the first minute after aspiration within each maneuver.

Humans , Male , Female , Infant, Newborn , Respiration, Artificial/methods , Respiratory Therapy/methods , Positive-Pressure Respiration/methods , Lung/metabolism , Time Factors , Infant, Premature , Cross-Sectional Studies , Prospective Studies , Statistics, Nonparametric , Lung Volume Measurements
Medicina (B.Aires) ; 76(4): 235-241, Aug. 2016. ilus, tab
Article in Spanish | LILACS | ID: biblio-841583


El síndrome de distrés respiratorio agudo (SDRA) es una insuficiencia respiratoria aguda secundaria a edema pulmonar inflamatorio, con aumento de permeabilidad capilar, inundación alveolar e hipoxemia profunda subsiguiente. El trastorno subyacente es la presencia de shunt intrapulmonar, característicamente refractario a las FIO2 elevadas. El SDRA se manifiesta dentro de la semana de la exposición a un factor de riesgo, habitualmente neumonía, shock, sepsis, aspiración de contenido gástrico, trauma, y otros. En la tomografía axial computarizada (TAC) la enfermedad frecuentemente aparece como no homogénea, con infiltrados gravitacionales coexistiendo con áreas normalmente aireadas y otras hiperinsufladas. La mortalidad es elevada (30-60%), especialmente en el SDRA secundario a shock séptico e injuria cerebral aguda. El tratamiento es el del factor de riesgo, junto con la ventilación mecánica que, inapropiadamente utilizada, puede también inducir injuria. El uso de un volumen corriente ≤ 6 ml/kg de peso corporal ideal como para mantener una presión de fin de inspiración (plateau) ≤ 30 cm H2O ("ventilación protectora") se asocia a una disminución de la mortalidad. Niveles de presión positiva de fin de espiración (PEEP) moderados-altos son frecuentemente necesarios para tratar la hipoxemia, pero no existe un único valor predeterminado o un método específico de titular PEEP para disminuir la mortalidad. Recientemente, la utilización precoz del decúbito prono en pacientes con PaO2/FIO2 ≤150 se asoció a un aumento de supervivencia. En la hipoxemia grave, pueden utilizarse adyuvantes de la ventilación mecánica como maniobras de reclutamiento, bloqueantes neuromusculares y oxigenación por membrana extracorpórea. La restricción en los fluidos resulta beneficiosa.

Acute respiratory distress syndrome (ARDS) is an acute respiratory failure produced by an inflammatory edema secondary to increased lung capillary permeability. This causes alveolar flooding and subsequently deep hypoxemia, with intrapulmonary shunt as its most important underlying mechanism. Characteristically, this alteration is unresponsive to high FIO2 and only reverses with end-expiratory positive pressure (PEEP). Pulmonary infiltrates on CXR and CT are the hallmark, together with decreased lung compliance. ARDS always occurs within a week of exposition to a precipitating factor; most frequently pneumonia, shock, aspiration of gastric contents, sepsis, and trauma. In CT scan, the disease is frequently inhomogeneous, with gravitational infiltrates coexisting with normal-density areas and also with hyperaerated parenchyma. Mortality is high (30-60%) especially in ARDS associated with septic shock and neurocritical diseases. The cornerstone of therapy lies in the treatment of the underlying cause and in the use mechanical ventilation which, if inappropriately administered, can lead to ventilator-induced lung injury. Tidal volume ≤ 6 ml/kg of ideal body weight to maintain an end-inspiratory (plateau) pressure ≤ 30 cm H2O ("protective ventilation") is the only variable consistently associated with decreased mortality. Moderate-to-high PEEP levels are frequently required to treat hypoxemia, yet no specific level or titration strategy has improved outcomes. Recently, the use of early prone positioning in patients with PaO2/FIO2 ≤ 150 was associated with increased survival. In severely hypoxemic patients, it may be necessary to use adjuvants of mechanical ventilation as recruitment maneuvers, pressure-controlled modes, neuromuscular blocking agents, and extracorporeal-membrane oxygenation. Fluid restriction appears beneficial.

Humans , Respiratory Distress Syndrome, Newborn/therapy , Prognosis , Respiration, Artificial/methods , Respiratory Distress Syndrome, Newborn/etiology , Respiratory Distress Syndrome, Newborn/mortality , Respiratory Distress Syndrome, Newborn/diagnostic imaging , Extracorporeal Membrane Oxygenation , Tomography, X-Ray Computed , Risk Factors , Positive-Pressure Respiration/methods , Prone Position , Adrenal Cortex Hormones/therapeutic use , Patient Positioning/methods , Neuromuscular Blocking Agents/therapeutic use
Braz. j. phys. ther. (Impr.) ; 19(6): 451-456, Nov.-Dec. 2015. tab
Article in English | LILACS | ID: lil-767065


BACKGROUND: Positive expiratory pressure (PEP) is regularly used as a self-administered airway clearance technique. OBJECTIVE: The aim of this study was to evaluate the need to teach the correct use of the PEP device and to measure the progress of the success rate of the maneuver after training. METHOD: A PEP system (PariPEP-S Sytem) was used to generate PEP in 30 healthy volunteers. They were instructed by a qualified physical therapist to breathe correctly through the PEP device. Then they were evaluated during a set of ten expirations. Two other evaluations were performed at day 2 and day 8 (before and after feedback). The mean PEP and the success rate were calculated for each set of expirations. The number of maneuvers needed to obtain a correct use was calculated on the first session. RESULTS: An optimal PEP was reached after 7.5 SD 2.7 attempts by all subjects. Success rates and mean pressures were similar between the different sets of expirations (p=0.720 and p=0.326, respectively). Pressure variability was around 10%. After one week, 30% of subjects generated more than two non-optimal pressures in the set of ten expirations. No difference in success rate was observed depending on the evaluations. CONCLUSION: This study demonstrates that good initial training on the use of the PEP device and regular follow-up are required for the subject to reach optimal expiratory pressure.

Humans , Forced Expiratory Volume/physiology , Positive-Pressure Respiration/instrumentation , Pressure , Respiration , Positive-Pressure Respiration/methods , Physical Therapy Modalities/standards
Rev. bras. ter. intensiva ; 27(4): 406-411, out.-dez. 2015. graf
Article in English | LILACS | ID: lil-770043


RESUMO A tomografia por impedância elétrica torácica constitui ferramenta de monitorização não invasiva, em tempo real, da distribuição regional da ventilação pulmonar. Sua utilização à beira do leito em pacientes com síndrome do desconforto respiratório agudo tem o potencial de auxiliar na condução de manobras de recrutamento alveolar, frequentemente necessárias em casos de hipoxemia refratária. Neste relato de caso, apresentamos os resultados e a interpretação da monitorização da tomografia por impedância elétrica torácica em um paciente com síndrome do desconforto respiratório agudo, durante manobras de recrutamento alveolar, com aplicação transitória de altas pressões alveolares e titulação da pressão positiva ao final da expiração ideal. Adicionalmente, apresentamos uma breve revisão da literatura a respeito do uso de manobras de recrutamento alveolar e monitorização com tomografia por impedância elétrica torácica em pacientes com síndrome do desconforto respiratório agudo.

ABSTRACT Thoracic electrical impedance tomography is a real-time, noninvasive monitoring tool of the regional pulmonary ventilation distribution. Its bedside use in patients with acute respiratory distress syndrome has the potential to aid in alveolar recruitment maneuvers, which are often necessary in cases of refractory hypoxemia. In this case report, we describe the monitoring results and interpretation of thoracic electrical impedance tomography used during alveolar recruitment maneuvers in a patient with acute respiratory distress syndrome, with transient application of high alveolar pressures and optimal positive end-expiratory pressure titration. Furthermore, we provide a brief literature review regarding the use of alveolar recruitment maneuvers and monitoring using thoracic electrical impedance tomography in patients with acute respiratory distress syndrome.

Humans , Male , Respiratory Distress Syndrome/therapy , Tomography/methods , Electric Impedance , Pulmonary Alveoli/metabolism , Respiratory Distress Syndrome/diagnostic imaging , Positive-Pressure Respiration/methods , Middle Aged
Rev. chil. pediatr ; 86(5): 309-317, oct. 2015. ilus
Article in Spanish | LILACS | ID: lil-771643


A pesar de los avances en el desarrollo de las terapias de reemplazo renal, la mortalidad de la falla renal aguda permanece elevada, especialmente, cuando se manifiesta simultáneamente con fallas orgánicas distantes, como es en el caso del síndrome de distrés respiratorio agudo. Se revisa la relación bidireccional deletérea entre pulmón y riñón, en el escenario de disfunción orgánica, la cual presenta aspectos clínicos relevantes de conocer. Se discuten los efectos renales del síndrome de distrés respiratorio agudo y del uso de la ventilación mecánica a presión positiva, siendo el daño inducido por este (ventilator induced lung injury) uno de los modelos utilizado frecuentemente para el estudio de la interacción pulmón-riñón. Se enfatiza el rol de la falla renal inducida por la ventilación mecánica (ventilator-induced kidney injury) en la patogenia de la falla renal aguda. Asimismo se analizan las repercusiones pulmonares de la falla renal aguda, reconociéndose que esta condición patológica induce un incremento en la permeabilidad vascular pulmonar, inflamación y alteración de los canales de sodio y agua del epitelio alveolar, entre otros efectos. Este modelo conceptual puede ser la base para el desarrollo de nuevas estrategias terapéuticas a utilizar en el paciente con síndrome de disfunción orgánica múltiple.

Despite advances in the development of renal replacement therapy, mortality of acute renal failure remains high, especially when occurring simultaneously with distant organic failure as it is in the case of the acute respiratory distress syndrome. In this update, birideccional deleterious relationship between lung and kidney on the setting of organ dysfunction is reviewed, which presents important clinical aspects of knowing. Specifically, the renal effects of acute respiratory distress syndrome and the use of positive-pressure mechanical ventilation are discussed, being ventilator induced lung injury one of the most common models for studying the lung-kidney crosstalk. The role of renal failure induced by mechanical ventilation (ventilator-induced kidney injury) in the pathogenesis of acute renal failure is emphasized. We also analyze the impact of the acute renal failure in the lung, recognizing an increase in pulmonary vascular permeability, inflammation, and alteration of sodium and water channels in the alveolar epithelial. This conceptual model can be the basis for the development of new therapeutic strategies to use in patients with multiple organ dysfunction syndrome.

Humans , Respiration, Artificial/methods , Respiratory Distress Syndrome, Newborn/therapy , Acute Kidney Injury/therapy , Multiple Organ Failure/therapy , Respiration, Artificial/adverse effects , Respiratory Distress Syndrome, Newborn/physiopathology , Positive-Pressure Respiration/methods , Critical Illness , Renal Replacement Therapy/methods , Ventilator-Induced Lung Injury/physiopathology , Acute Kidney Injury/physiopathology , Acute Kidney Injury/mortality , Kidney/physiopathology , Lung/physiopathology , Multiple Organ Failure/physiopathology