Metoprolol for prevention of bucking at orotracheal extubation: a double-blind, placebo-controlled randomised trial

Abstract Background: Respiratory responses to extubation can cause serious postoperative complications. Beta-blockers, such as metoprolol, can interfere with the cough pathway. However, whether metoprolol can effectively control respiratory reflexes during extubation remains unclear. The objective of this study is to evaluate the efficacy of intravenous metoprolol in attenuating respiratory responses to tracheal extubation. Methods: Randomized, double-blinded, placebo-controlled trial. Setting: Tertiary referral center located in Brasília, Brazil. Recruitment: June 2021 to December 2021. Sample: 222 patients of both sexes with an American Society of Anesthesiologists (ASA) physical status I-III aged 18-80 years. Patients were randomly assigned to receive intravenous metoprolol 5 mg IV or placebo at the end of surgery. The primary outcome was the proportion of patients who developed bucking secondary to endotracheal tube stimulation of the tracheal mucosa during extubation. Secondary outcomes included coughing, bronchospasm, laryngospasm, Mean Blood Pressure (MAP), and Heart Rate (HR) levels. Results: Two hundred and seven participants were included in the final analysis: 102 in the metoprolol group and 105 in the placebo group. Patients who received metoprolol had a significantly lower risk of bucking (43.1% vs. 64.8%, Relative Risk [RR = 0.66], 95% Confidence Interval [95% CI 0.51-0.87], p = 0.003). In the metoprolol group, 6 (5.9%) patients had moderate/severe coughing compared with 33 (31.4%) in the placebo group (RR = 0.19; 95% CI 0.08-0.43, p < 0.001). Conclusion: Metoprolol reduced the risk of bucking at extubation in patients undergoing general anesthesia compared to placebo.

Association of biomarkers with successful ventilatory weaning in COVID-19 patients: an observational study / Associação entre biomarcadores e sucesso do desmame ventilatório em pacientes com COVID-19: um estudo observacional

ABSTRACT Objective: To evaluate the association of biomarkers with successful ventilatory weaning in COVID-19 patients. Methods: An observational, retrospective, and single-center study was conducted between March 2020 and April 2021. C-reactive protein, total lymphocytes, and the neutrophil/lymphocyte ratio were evaluated during attrition and extubation, and the variation in these biomarker values was measured. The primary outcome was successful extubation. ROC curves were drawn to find the best cutoff points for the biomarkers based on sensitivity and specificity. Statistical analysis was performed using logistic regression. Results: Of the 2,377 patients admitted to the intensive care unit, 458 were included in the analysis, 356 in the Successful Weaning Group and 102 in the Failure Group. The cutoff points found from the ROC curves were −62.4% for C-reactive protein, +45.7% for total lymphocytes, and −32.9% for neutrophil/lymphocyte ratio. These points were significantly associated with greater extubation success. In the multivariate analysis, only C-reactive protein variation remained statistically significant (OR 2.6; 95%CI 1.51 - 4.5; p < 0.001). Conclusion: In this study, a decrease in C-reactive protein levels was associated with successful extubation in COVID-19 patients. Total lymphocytes and the neutrophil/lymphocyte ratio did not maintain the association after multivariate analysis. However, a decrease in C-reactive protein levels should not be used as a sole variable to identify COVID-19 patients suitable for weaning; as in our study, the area under the ROC curve demonstrated poor accuracy in discriminating extubation outcomes, with low sensitivity and specificity.

RESUMO Objetivo: Avaliar a associação de biomarcadores com o sucesso do desmame ventilatório em pacientes com COVID-19. Métodos: Trata-se de estudo observacional, retrospectivo e de centro único realizado entre março de 2020 e abril de 2021. Foram avaliados a proteína C-reativa, os linfócitos totais e a relação neutrófilos/linfócitos durante o atrito e a extubação; mediu-se a variação desses valores de biomarcadores. O desfecho primário foi o sucesso da extubação. As curvas ROC foram desenhadas para encontrar os melhores pontos de corte dos biomarcadores segundo a sensibilidade e a especificidade. A análise estatística foi realizada por meio de regressão logística. Resultados: Dos 2.377 pacientes admitidos na unidade de terapia intensiva, 458 foram incluídos na análise, 356 no Grupo Sucesso do desmame e 102 no Grupo Fracasso do desmame. Os pontos de corte encontrados nas curvas ROC foram −62,4% para proteína C-reativa, +45,7% para linfócitos totais e −32,9% para relação neutrófilo/linfócito. Esses pontos foram significativamente associados ao maior sucesso da extubação. Na análise multivariada, apenas a variação da proteína C-reativa permaneceu estatisticamente significativa (RC 2,6; IC95% 1,51 - 4,5; p < 0,001). Conclusão: Neste estudo, uma diminuição nos níveis de proteína C-reativa foi associada ao sucesso da extubação em pacientes com COVID-19. Os linfócitos totais e a relação neutrófilos/linfócitos não mantiveram a associação após a análise multivariada. No entanto, uma diminuição nos níveis de proteína C-reativa não deve ser usada como única variável para identificar pacientes com COVID-19 adequados para o desmame; como em nosso estudo, a área sob a curva ROC demonstrou baixa precisão na discriminação dos resultados de extubação, com baixas sensibilidade e especificidade.

A Simplified Protocol for Tracheostomy Decannulation in Patients Weaned off Prolonged Mechanical Ventilation

Abstract Introduction The criteria for the removal of the tracheostomy tube (decannulation) vary from center to center. Some perform an endoscopic evaluation under anesthesia or computed tomography, which adds to the cost and discomfort. We use a simple two-part protocol to determine the eligibility and carry out the decannulation: part I consists of airway and swallowing assessment through an office-based flexible laryngotracheoscopy, and part II involves a tracheostomy capping trial. Objective The primary objective was to determine the safety and efficacy of the simplified decannulation protocol followed at our center among the patients who were weaned off the mechanical ventilator and exhibited good swallowing function clinically. Methods Of the patients considered for decannulation between November 1st, 2018, and October 31st, 2020, those who had undergone tracheostomy for prolonged mechanical ventilation were included. The efficacy to predict successful decannulation was calculated by the decannulation rate among patients who had been deemed eligible for decannulation in part I of the protocol, and the safety profile was defined by the protocol's ability to correctly predict the chances of risk-free decannulation among those submitted to part II of the protocol. Results Among the 48 patients included (mean age: 46.5 years; male-to-female ratio: 3:1), the efficacy of our protocol in predicting the successful decannulation was of 87.5%, and it was was safe or reliable in 95.45%. Also, in our cohort, the decannulation success and the duration of tracheotomy dependence were significantly affected by the neurological status of the patients. Conclusion The decannulation protocol consisting of office-based flexible laryngotracheoscopy and capping trial of the tracheostomy tube can safely and effectively aid the decannulation process.

Outcomes of Minimally Invasive Aortic Valve Replacement in Obese Patients: A Propensity-Matched Study

ABSTRACT Introduction: Obese patients are at risk of complications after cardiac surgery. The aim of this study is to investigate safety and efficacy of a minimally invasive approach via upper sternotomy in this setting. Methods: We retrospectively reviewed 203 obese patients who underwent isolated, elective aortic valve replacement between January 2014 and January 2023 - 106 with minimally invasive aortic valve replacement (MIAVR) and 97 with conventional aortic valve replacement (CAVR). To account for baseline differences, a propensity-matching analysis was performed obtaining two balanced groups of 91 patients each. Results: The 30-day mortality rate was comparable between groups (1.1% MIAVR vs. 0% CAVR, P=0.99). MIAVR patients had faster extubation than CAVR patients (6 ± 2 vs. 9 ± 2 hours, P<0.01). Continuous positive airway pressure therapy was less common in the MIAVR than in the CAVR group (3.3% vs. 13.2%, P=0.03). Other postoperative complications did not differ significantly. Intensive care unit stay (1.8 ± 1.2 vs. 3.2 ± 1.4 days, P<0.01), but not hospital stay (6.7 ± 2.1 vs. 7.2 ± 1.9 days, P=0.09), was shorter for MIAVR than for CAVR patients. Follow-up survival was comparable (logrank P-value = 0.58). Conclusion: MIAVR via upper sternotomy has been shown to be a safe and effective option for obese patients. Respiratory outcome was promising with shorter mechanical ventilation time and reduced need for post-extubation support. The length of stay in the intensive care unit was reduced. These advantages might be important for the obese patient to whom minimally invasive surgery should not be denied.

Postoperative Prognostic Nutritional Index and Fibrinogen Could Well Predict Poor Prognosis of Acute Type A Aortic Dissection Patients After Surgery

ABSTRACT Introduction: Inflammatory and immunological factors play pivotal roles in the prognosis of acute type A aortic dissection. We aimed to evaluate the prognostic values of immune-inflammatory parameters in acute type A aortic dissection patients after surgery. Methods: A total of 127 acute type A aortic dissection patients were included. Perioperative clinical data were collected through the hospital's information system. The outcomes studied were delayed extubation, reintubation, and 30-day mortality. Multivariate logistic regression analysis and receiver operating characteristic analysis were used to screen the risk factors of poor prognosis. Results: Of all participants, 94 were male, and mean age was 51.95±11.89 years. The postoperative prognostic nutritional indexes were lower in delayed extubation patients, reintubation patients, and patients who died within 30 days. After multivariate regression analysis, the postoperative prognostic nutritional index was a protective parameter of poor prognosis. The odds ratios (95% confidence interval) of postoperative prognostic nutritional index were 0.898 (0.815, 0.989) for delayed extubation and 0.792 (0.696, 0.901) for 30-day mortality. Low postoperative fibrinogen could also well predict poor clinical outcomes. The odds ratios (95% confidence interval) of postoperative fibrinogen were 0.487 (0.291, 0.813) for delayed extubation, 0.292 (0.124, 0.687) for reintubation, and 0.249 (0.093, 0.669) for 30-day mortality. Conclusion: Postoperative prognostic nutritional index and postoperative fibrinogen could be two promising markers to identify poor prognosis of acute type A aortic dissection patients after surgery.

CUIDADO DE ENFERMERÍA DURANTE EL PROCESO DE EXTUBACIÓN: DESDE LA TEORÍA DE KRISTEN SWANSON / NURSING CARE DURING THE EXTUBATION PROCESS: FROM THE THEORY OF KRISTEN SWANSON

INTRODUCCIÓN: El creciente aumento de la incidencia del soporte ventilatorio mecánico ha impulsado el interés y desarrollo de estudios para mejorar la conducción de este proceso, sin embargo, conocer las experiencias que han vivido los profesionales de enfermería durante la extubación, puede contribuir a mejorar las prácticas de cuidado para hacer el proceso más humanizado y hacer de la UCI un lugar más ameno para la recuperación. OBJETIVO: Describir la percepción de profesionales de enfermería sobre los cuidados durante el proceso de weaning sustentado en los principios teóricos de Kristen Swanson. MÉTODOS: Estudio descriptivo, en base a un diseño fenomenológico según Husserl. La recogida de datos se realizó a través de una entrevista realizada por Google Meet, grabada en audio y luego transcrita a texto. El proceso de análisis formal estuvo orientado por los 9 pasos de Colaizzi. Para aumentar la credibilidad y precisión de la investigación se utilizaron los criterios de rigor propuestos por Lincoln y Guba. RESULTADOS: Emergieron 15 temas relacionados a los procesos de cuidado de Swanson. Se encontraron hallazgos en relación a cuidados integrales en contexto de extubación; encontrar significado al proceso de destete como experiencia de vida y la relación profesional-paciente en la extubación. CONCLUSIÓN: La experiencia al entregar cuidados durante el proceso de extubación deja en evidencia la importancia que otorgan no solo a aspectos hemodinámicos, fisiológicos y parámetros ventilatorios, sino que también a favorecer que la experiencia del destete sea realizada en un contexto de integralidad, seguridad, calidad, humanismo y respeto por sus derechos.

INTRODUCTION: The increasing incidence of mechanical ventilatory support has prompted an interest in and development of studies to improve the process, and knowing the experiences of nursing professionals during extubation can contribute to the improvement of care practices to make it more humanized as well as make the ICU a more pleasant place for recovery. OBJECTIVE: To describe nursing professionals' perception of care during the weaning process based on Kristen Swanson's theoretical principles. METHODS: Descriptive study, based on a phenomenological design according to Husserl. Data collection was done through an interview conducted by Google Meet, audio-recorded and then transcribed to text. The formal analysis process was guided by Colaizzi's 9 steps. To increase the credibility and accuracy of the research, the rigor criteria proposed by Lincoln and Guba were used. RESULTS: Fifteen themes related to Swanson's care processes emerged. Findings related to comprehensive care in the context of extubation were found, including finding meaning in the weaning process as a life experience, and the professional-patient relationship in extubation. CONCLUSION: The experience of providing care during the extubation process shows the importance they attach not only to hemodynamic, physiological and ventilatory parameters, but also to ensuring that the weaning experience is carried out in a context of integrality, safety, quality, humanism and respect for their rights.

Risk factors of self-extubation in intensive care. Retrospective cohort study

Introduction Acute respiratory failure remains one of the three leading causes of admission to the intensive care unit (ICU). Self-extubation is an adverse outcome requiring reintubation in 50% of cases. Objective To assess for determinants (risk factors) of self-extubation and mortality in the ICU by using a generalized estimation equation model (GEE). Methods The data was collected from a retrospective cohort study from 2017-2020 including all patients admitted to the ICU with mechanical ventilation. Univariate and bivariate analyses were performed. Then, a GEE model was conducted to predict the risk of self-extubation and mortality. Results A total of 857 subjects were included, with a mean age of 60.5 +/- 17 years-old. Most of the subjects were males (55.2%). An 8.99-fold risk (95%CI 3.83-21.1, p<0.0i) of self-extubation was identified in patients with agitation. Exposure to infusion of neuromuscular blockade was also found to increase the risk of self-extubation 3.37 times (95%CI 1.31-8.68, p=0.01). No associations were identified between immobilization and self-extubation (OR 1.38 95%CI 0.76-2.51, p=0.29). Finally, light sedation according to the Richmond Sedation Scale (RASS) between 0 to -2 rather than moderate (RASS-3) reduces the risk of mortality (OR 0.57, 95%CI 0.38-0.83, p<0.01). Conclusions The main factors resulting in self-extubation were: agitation, delirium, and infusion of neuromuscular blocking agents. An association was found between light sedation and a lower risk of mortality. No association was found between the use of physical restraint and the desired outcome.

Introducción: La insuficiencia respiratoria aguda continúa siendo una de las tres causas principales de ingreso a la unidad de cuidado intensivo (UCI). La auto-extubación es un desenlace adverso que requiere re-intubación en un 50% de los casos. Objetivo: Evaluar los determinantes (factores de riesgo) de la auto-extubación y la mortalidad en UCI mediante el uso de un modelo de ecuaciones de estimación generalizadas (EEG). Métodos: Estudio de una cohorte retrospectiva realizada durante el periodo 2017-2020 incluyendo a todos los pacientes ingresados a UCI con ventilación mecánica invasiva. Se realizaron análisis univariado y bivariado. Adicionalmente, se utilizó un modelo EEG para predecir el riesgo de auto-extubación y mortalidad. Resultados: Se analizó un total de 857 pacientes con un promedio de edad entre 60,5 +/-17 años, siendo hombres en su mayoría (55,2%). Se encontró un riesgo 8,99 veces mayor (IC95% 3,83-21,1, p<0,01) de auto-extubación en los pacientes con agitación. La infusión de relajación muscular incrementó el riesgo de auto-extubación en 3,37 veces (IC95% 1,318,68, p=0,01). No se encontró asociación entre inmovilización y auto-extubación (OR 1,38 IC95% 0,76-2,51, p=0,29). Finalmente, una sedación ligera según la Escala de Sedación de Richmond (RASS) entre 0 a -2 en lugar de moderada (RASS-3) redujo el riesgo de mortalidad (OR 0,5 IC95% 0,38-0,83, p<0.01). Conclusiones: Los principales factores asociados a auto-extubación fueron agitación, delirium e infusión de relajantes musculares. Se encontró asociación entre una sedación ligera y menor riesgo de mortalidad. No se encontró asociación entre el uso de la restricción física y el desenlace de interés.

Maximal expiratory pressure compared with maximal expiratory pressure during induced cough as a predictor of extubation failure / Comparação da pressão expiratória máxima e da pressão expiratória máxima durante a tosse induzida como preditor de falha na extubação

ABSTRACT Objective: To compare the diagnostic performance of maximal expiratory pressure with maximal expiratory pressure during induced cough for predicting extubation failure within 72 hours in patients who completed a spontaneous breathing trial (SBT). Methods: The study was conducted between October 2018 and September 2019. All patients aged over 18 years admitted to the intensive care unit who required invasive mechanical ventilation for over 48 hours and successfully completed a spontaneous breathing trial were included. The maximal expiratory pressure was assessed with a unidirectional valve for 40 seconds, and verbal encouragement was given. The maximal expiratory pressure during induced cough was measured with slow instillation of 2mL of a 0.9% saline solution. The primary outcome variable was extubation failure. Results: Eighty patients were included, of which 43 (54%) were male. Twenty-two patients [27.5% (95%CI 18.9 - 38.1)] failed extubation within 72 hours. Differences were observed in the maximal expiratory pressure during induced cough between the group who failed extubation, with a median of 0cmH2O (P25-75: 0 - 90), and the group without extubation failure, with a median of 120cmH2O (P25-75: 73 - 120); p < 0.001. Conclusion: In patients who completed a spontaneous breathing trial, the maximal expiratory pressure during induced cough had a higher diagnostic performance for predicting extubation failure within 72 hours. Clinicaltrials.gov Registry:NCT04356625

RESUMO Objetivo: Comparar o desempenho diagnóstico da pressão expiratória máxima com a pressão expiratória máxima durante a tosse induzida para prever a falha na extubação em 72 horas em pacientes que completaram o teste de respiração espontânea. Métodos: O estudo foi realizado entre outubro de 2018 e setembro de 2019. Foram incluídos todos os pacientes com mais de 18 anos admitidos à unidade de terapia intensiva que necessitavam de ventilação mecânica invasiva durante mais de 48 horas e completaram com sucesso o teste de respiração espontânea. A pressão expiratória máxima foi avaliada com uma válvula unidirecional durante 40 segundos, e foi dado encorajamento verbal. A pressão expiratória máxima durante a tosse induzida foi medida com instilação lenta de 2mL de solução salina a 0,9%. A variável do desfecho primário foi a falha na extubação. Resultados: Foram incluídos 80 pacientes, dos quais 43 (54%) eram do sexo masculino. Verificou-se falha na extubação de 22 pacientes [27,5% (IC95% 18,9 - 38,1)] em 72 horas. Observou-se diferença entre a pressão expiratória máxima durante a tosse induzida do grupo com falha na extubação, com mediana de 0cmH2O (P25-75 de 0 - 90) e do grupo sem falha na extubação, com mediana de 120cmH2O (P25-75 de 73 - 120), com p < 0,001. Conclusão: Em pacientes que completaram o teste de respiração espontânea, a pressão expiratória máxima durante a tosse induzida apresentou melhor desempenho diagnóstico para prever falha na extubação em 72 horas. Registro Cliniclatrials.gov:NCT04356625

Fitness checklist model for spontaneous breathing tests in pediatrics / Modelo de checklist de, aptidão para teste de respiração espontânea em pediatria

ABSTRACT Objective: To evaluate whether a model of a daily fitness checklist for spontaneous breathing tests is able to identify predictive variables of extubation failure in pediatric patients admitted to a Brazilian intensive care unit. Methods: This was a single-center, cross-sectional study with prospective data collection. The checklist model comprised 20 items and was applied to assess the ability to perform spontaneous breathing tests. Results: The sample consisted of 126 pediatric patients (85 males (67.5%)) on invasive mechanical ventilation, for whom 1,217 daily assessments were applied at the bedside. The weighted total score of the prediction model showed the highest discriminatory power for the spontaneous breathing test, with sensitivity and specificity indices for fitness failure of 89.7% or success of 84.6%. The cutoff point suggested by the checklist was 8, with a probability of extubation failure less than 5%. Failure increased progressively with increasing score, with a maximum probability of predicting extubation failure of 85%. Conclusion: The extubation failure rate with the use of this model was within what is acceptable in the literature. The daily checklist model for the spontaneous breathing test was able to identify predictive variables of failure in the extubation process in pediatric patients.

RESUMO Objetivo: Avaliar se um modelo de checklist diário de aptidão para o teste de respiração espontânea é capaz de identificar variáveis preditivas de falha no processo de extubação em pacientes pediátricos internados em uma unidade de terapia intensiva brasileira. Métodos: Estudo unicêntricotransversal, com coleta prospectiva de dados. O modelo de checklist foi elaborado com 20 itens e aplicado para avaliação de aptidão para o teste de respiração espontânea. Resultados: A amostra foi composta de 126 pacientes pediátricos em ventilação mecânica invasiva, 85 do sexo masculino (67,5%), para os quais foram aplicadas 1.217 avaliações diárias à beira do leito. A pontuação total ponderada do modelo de predição apresentou o maior poder de discriminação para a realização do teste de respiração espontânea, com índices de sensibilidade e especificidade para a falha de aptidão de 89,7% ou sucesso de 84,6%. O ponto de corte sugerido pelo checklist foi 8, com probabilidade de falha de extubação inferior a 5%. Observou-se que a falha aumentou progressivamente com o aumento da pontuação obtida, com probabilidade máxima de predição de falha de extubação de 85%. Conclusão: A taxa de falha de extubação com a utilização desse modelo ficou dentro do que é aceitável na literatura. O modelo de checklist diário para aptidão do teste de respiração espontânea foi capaz de identificar variáveis preditivas de falha no processo de extubação em pacientes pediátricos.

Protocol-directed weaning versus conventional weaning from mechanical ventilation for neurocritical patients in an intensive care unit: a nonrandomized quasi-experimental study / Desmame da ventilação mecânica por protocolo versus desmame convencional em pacientes neurocríticos de uma unidade de terapia intensiva: um estudo quase experimental não randomizado

ABSTRACT Objective: To investigate whether protocol-directed weaning in neurocritical patients would reduce the rate of extubation failure (as a primary outcome) and the associated complications (as a secondary outcome) compared with conventional weaning. Methods: A quasi-experimental study was conducted in a medical-surgical intensive care unit from January 2016 to December 2018. Patients aged 18 years or older with an acute neurological disease who were on mechanical ventilation > 24 hours were included. All patients included in the study were ready to wean, with no or minimal sedation, Glasgow coma score ≥ 9, spontaneous ventilatory stimulus, noradrenaline ≤ 0.2μgr/kg/ minute, fraction of inspired oxygen ≤ 0.5, positive end-expiratory pressure ≤ 5cmH2O, maximal inspiratory pressure < -20cmH2O, and occlusion pressure < 6cmH2O. Results: Ninety-four of 314 patients admitted to the intensive care unit were included (50 in the Intervention Group and 44 in the Control Group). There was no significant difference in spontaneous breathing trial failure (18% in the Intervention Group versus 34% in the Control Group, p = 0.12). More patients in the Intervention Group were extubated than in the Control Group (100% versus 79%, p = 0.01). The rate of extubation failure was not signifiantly diffrent between the groups (18% in the Intervention Group versus 17% in the Control Group; relative risk 1.02; 95%CI 0.64 - 1.61; p = 1.00). The reintubation rate was lower in the Control Group (16% in the Intervention Group versus 11% in the Control Group; relative risk 1.15; 95%CI 0.74 - 1.82; p = 0.75). The need for tracheotomy was lower in the Intervention Group [4 (8%) versus 11 (25%) in the Control Group; relative risk 0.32; 95%CI 0.11 - 0.93; p = 0.04]. At Day 28, the patients in the Intervention Group had more ventilator-free days than those in the Control Group [28 (26 - 28) days versus 26 (19 - 28) days; p = 0.01]. The total duration of mechanical ventilation was shorter in the Intervention Group than in the Control Group [5 (2 - 13) days versus 9 (3 - 22) days; p = 0.01]. There were no diffrences in the length of intensive care unit stay, 28-day free from mechanical ventilation, hospital stay or 90-day mortality. Conclusion: Considering the limitations of our study, the application of a weaning protocol for neurocritical patients led to a high percentage of extubation, a reduced need for tracheotomy and a shortened duration of mechanical ventilation. However, there was no reduction in extubation failure or the 28-day free of from mechanical ventilation compared with the Control Group. ClinicalTrials.gov Registry:NCT03128086

RESUMO Objetivo: Investigar se o desmame por protocolo em pacientes neurocríticos reduz a taxa de falha de extubação (desfecho primário) e as complicações associadas (desfecho secundário) em comparação com o desmame convencional. Métodos: Realizou-se um estudo quase experimental em uma unidade de terapia intensiva médico-cirúrgica de janeiro de 2016 a dezembro de 2018. Foram incluídos pacientes com 18 anos de idade ou mais, com doença neurológica aguda e em ventilação mecânica > 24 horas. Todos os pacientes incluídos no estudo estavam prontos para o desmame, com nenhuma ou mínima sedação, escala de coma de Glasgow ≥ 9, estímulo ventilatório espontâneo, noradrenalina ≤ 0,2μgr/kg/minuto, fração inspirada de oxigênio ≤ 0,5, pressão expiratória positiva final ≤ 5cmH2O, pressão inspiratória máxima < -20cmH2O e pressão de oclusão < 6cmH2O. Resultados: Foram incluídos 94 dos 314 pacientes admitidos à unidade de terapia intensiva, sendo 50 no Grupo Intervenção e 44 no Grupo Controle. Não houve diferença significativa na falha do ensaio respiratório espontâneo (18% no Grupo Intervenção versus 34% no Grupo Controle, p = 0,12). Foram extubados mais pacientes no Grupo Intervenção do que no Controle (100% versus 79%; p = 0,01). A taxa de falha de extubação não foi significativamente diferente entre os grupos (18% no Grupo Intervenção versus 17% no Grupo Controle, risco relativo de 1,02; IC95% 0,64 - 1,61; p = 1,00). A taxa de reintubação foi menor no Grupo Controle (16% no Grupo Intervenção versus 11% no Grupo Controle; risco relativo de 1,15; IC95% 0,74 -1,82; p = 0,75). A necessidade de traqueotomia foi menor no Grupo Intervenção [4 (8%) versus 11 (25%) no Grupo Controle; risco relativo de 0,32; IC95% 0,11 - 0,93; p = 0,04]. Aos 28 dias, os pacientes do Grupo Intervenção tinham mais dias sem ventilador do que os do Grupo Controle [28 (26 - 28) dias versus 26 (19 - 28) dias; p = 0,01]. A duração total da ventilação mecânica foi menor no Grupo Intervenção do que no Controle [5 (2 - 13) dias versus 9 (3 - 22) dias; p = 0,01]. Não houve diferenças no tempo de internação na unidade de terapia intensiva, 28 dias sem ventilação mecânica, internação hospitalar ou mortalidade em 90 dias. Conclusão: Considerando as limitações de nosso estudo, a aplicação de um protocolo de desmame em pacientes neurocríticos levou à maior proporção de extubação, à menor necessidade de traqueotomia e à menor duração da ventilação mecânica. Entretanto, não houve redução na falha de extubação ou 28 dias sem ventilação mecânica em comparação com o Grupo de Controle. Registro ClinicalTrials.gov:NCT03128086

Impact of topical airway anesthesia on immediate postoperative cough/bucking: a systematic review and meta-analysis

Abstract Background Postoperative cough may occur after tracheal intubation, but it is indistinct which drug is best at diminishing these events. Additionally, airway reflexes are commonly accompanied by severe hemodynamics responses during emergence. Objectives To evaluate the role of topical airway anesthesia on immediate post-extubation cough/bucking and extubation time. Methods Randomized clinical trials from MEDLINE, EMBASE, CENTRAL, and LILACS published until December 23, 2020 were included. Our primary outcome was postoperative cough/bucking incidence which was compared between local anesthetics and controls. Extubation times were likewise considered. Predisposition appraisal and subgroup, affectability investigations were likewise performed. Results The pooled analysis found a 45% reduction in cough incidence after treatment with topical airway local anesthetic (RR = 0.55; 95% CI: 0.42 to 0.72; p< 0.001). The number needed to treat (NNT) was 4.61. The intervention showed no differences in reduction of the extubation time (mean difference = -0.07; 95% CI: -0.14 to 0.28; p= 0.49). Conclusion Topical airway anesthesia demonstrated better than placebo or no medication in reducing immediate post-extubation cough/bucking. Further studies could have this objective to combine the different ways to perform better outcomes for patients.

Extubation failure and the use of noninvasive ventilation during the weaning process in critically ill COVID-19 patients / Falha de extubação e uso de ventilação não invasiva durante o processo de desmame em pacientes críticos com COVID-19

ABSTRACT Objective: To assess the outcome of extubation in COVID-19 patients and the use of noninvasive ventilation in the weaning process. Methods: This retrospective, observational, single-center study was conducted in COVID-19 patients aged 18 years or older who were admitted to an intensive care unit between April 2020 and December 2021, placed under mechanical ventilation for more than 48 hours and progressed to weaning. Early extubation was defined as extubation without a spontaneous breathing trial and immediate use of noninvasive ventilation after extubation. In patients who underwent a spontaneous breathing trial, noninvasive ventilation could be used as prophylactic ventilatory assistance when started immediately after extubation (prophylactic noninvasive ventilation) or as rescue therapy in cases of postextubation respiratory failure (therapeutic noninvasive ventilation). The primary outcome was extubation failure during the intensive care unit stay. Results: Three hundred eighty-four extubated patients were included. Extubation failure was observed in 107 (27.9%) patients. Forty-seven (12.2%) patients received prophylactic noninvasive ventilation. In 26 (6.8%) patients, early extubation was performed with immediate use of noninvasive ventilation. Noninvasive ventilation for the management of postextubation respiratory failure was administered to 64 (16.7%) patients. Conclusion: We found that COVID-19 patients had a high rate of extubation failure. Despite the high risk of extubation failure, we observed low use of prophylactic noninvasive ventilation in these patients.

RESUMO Objetivo: Avaliar o desfecho da extubação em pacientes com COVID-19 e o uso da ventilação não invasiva no processo de desmame. Métodos: Este estudo retrospectivo, observacional e unicêntrico foi realizado em pacientes com COVID-19 com 18 anos ou mais, internados em uma unidade de terapia intensiva entre abril de 2020 e dezembro de 2021, colocados sob ventilação mecânica por mais de 48 horas com progressão para o desmame. A extubação precoce foi definida como a extubação sem um teste de ventilação espontânea e com uso imediato de ventilação não invasiva após a extubação. Em pacientes submetidos a um teste de ventilação espontânea, a ventilação não invasiva poderia ser usada como assistência ventilatória profilática, quando iniciada imediatamente após a extubação (ventilação não invasiva profilática), ou como terapia de resgate em casos de insuficiência respiratória pós-extubação (ventilação não invasiva terapêutica). O desfecho primário foi falha de extubação durante a internação na unidade de terapia intensiva. Resultados: Foram incluídos 384 pacientes extubados. A falha de extubação foi observada em 107 (27,9%) pacientes. Quarenta e sete (12,2%) pacientes receberam ventilação não invasiva profilática. Em 26 (6,8%) pacientes, a extubação precoce foi realizada com o uso imediato de ventilação não invasiva. A ventilação não invasiva para o manejo da insuficiência respiratória pós-extubação foi administrada em 64 (16,7%) pacientes. Conclusão: Os pacientes com COVID-19 apresentaram alta taxa de falha de extubação. Apesar do alto risco de falha de extubação, observamos baixo uso de ventilação não invasiva profilática nesses pacientes.

Comparison of different methods of obtaining the rapid shallow breathing index

Abstract Objective: To compare the Rapid Shallow Breathing Index (RSBI) obtained by the ventilometer and from mechanical ventilation parameters. Methods: Randomized crossover trial, including 33 intubated patients, on mechanical ventilation for at least 24 hours, undergoing spontaneous breathing test. Patients were submitted to the measurement of RSBI by four methods: disconnected from the ventilator through the ventilometer; in Pressure Support Ventilation (PSV) mode at a pressure of 7 cm H2O; in Continuous Positive Airway Pressure (CPAP) mode at a pressure of 5 cmH2O with flow trigger; in CPAP mode at a pressure of 5 cmH2O with pressure trigger. Results: No significant difference was detected between the RSBI obtained by the ventilometer and in the CPAP mode with flow and pressure triggers, however, in the PSV mode, the values were lower than in the other measurements (p < 0.001). By selecting patients from the sample with higher RSBI (≥ 80 cycles.min−1.L−1), the value of the index obtained by the ventilometer was higher than that obtained in the three options of ventilation methods. Conclusion: The RSBI obtained in the CPAP mode at a pressure of 5 cmH2O, in both triggers types, did not differ from that measured by the ventilometer; it is, therefore, an alternative when obtaining it from mechanical ventilation parameters is necessary. However, in the presence of borderline values, the RSBI measured by ventilometer is recommended, as in this method the values are significantly higher than in the three ventilation modalities investigated.

Transient hypoxemia after endotracheal tube extubation in a patient who received reversal of muscle relaxation using sugammadex after general anesthesia: A case report

Post-operative respiratory depression is common in patients recovering from anesthesia and can result in fatal cardiopulmonary collapse, anoxic brain injury, and mortality. We report a case of a 54-year-old morbidly obese female patient who developed transient hypoxemia after general anesthesia. The patient with obstructive sleep apnea (OSA) underwent breast excision surgery. At the end of the surgery, her muscle function was fully restored using sugammadex. However, the patient developed transient hypoxemia in the post-anesthesia care unit. The clinician should keep in mind that OSA patients are likely to develop hypoxemia due to the residual sedative effects and airway obstruction despite the recovery of muscle function after anesthesia.

Índice de Oxigenação Respiratória prevê falha de pós-extubação com cânula nasal de alto fluxo em pacientes de unidade de terapia intensiva: estudo de coorte retrospectivo / The Respiratory Rate-Oxygenation Index predicts failure of post-extubation high-flow nasal cannula therapy in intensive care unit patients: a retrospective cohort study

RESUMO Objetivo: Investigar a aplicabilidade do Índice de Oxigenação Respiratória para identificar o risco de falha de cânula nasal de alto fluxo em pacientes com pneumonia. Métodos: Este estudo retrospectivo observacional de 2 anos foi realizado em um hospital de referência em Bogotá, na Colômbia. Incluíram-se no estudo todos os pacientes em que foi utilizada cânula nasal de alto fluxo pós-extubação como terapia-ponte para a extubação. O Índice de Oxigenação Respiratória foi calculado para avaliar o risco de falha pós-extubação de cânula nasal de alto fluxo. Resultados: Incluíram-se no estudo 162 pacientes. Destes, 23,5% apresentaram falha de cânula nasal de alto fluxo. O Índice de Oxigenação Respiratória foi significativamente menor em pacientes que tiveram falha de cânula nasal de alto fluxo. A mediana (IQ 25 - 75%) foi de 10,0 (7,7 - 14,4) versus 12,6 (10,1 - 15,6), com p = 0,006. O Índice de Oxigenação Respiratória > 4,88 apresentou razão de chances bruta de 0,23 (IC95% 0,17 - 0,30) e RC ajustada de 0,89 (IC95% 0,81 - 0,98) estratificada por gravidade e comorbidade. Após a análise de regressão logística, o Índice de Oxigenação Respiratória apresentou razão de chances ajustada de 0,90 (IC95% 0,82 - 0,98; p = 0,026). A área sob a curva Receiver Operating Characteristic para falha de extubação foi de 0,64 (IC95% 0,53 - 0,75; p = 0,06). O Índice de Oxigenação Respiratória não apresentou diferenças entre pacientes que sobreviveram e que morreram durante internação na unidade de terapia intensiva. Conclusão: O Índice de Oxigenação Respiratória é uma ferramenta acessível para identificar pacientes em risco de falha no tratamento pós-extubação com cânulas nasais de alto fluxo. Estudos prospectivos são necessários para ampliar a utilidade nesse cenário.

ABSTRACT Objective: To investigate the applicability of the Respiratory Rate-Oxygenation Index to identify the risk of high-flow nasal cannula failure in post-extubation pneumonia patients. Methods: This was a 2-year retrospective observational study conducted in a reference hospital in Bogotá, Colombia. All patients in whom post-extubation high-flow nasal cannula therapy was used as a bridge to extubation were included in the study. The Respiratory Rate-Oxygenation Index was calculated to assess the risk of post-extubation high-flow nasal cannula failure. Results: A total of 162 patients were included in the study. Of these, 23.5% developed high-flow nasal cannula failure. The Respiratory Rate-Oxygenation Index was significantly lower in patients who had high-flow nasal cannula failure [median (IQR): 10.0 (7.7 - 14.4) versus 12.6 (10.1 - 15.6); p = 0.006]. Respiratory Rate-Oxygenation Index > 4.88 showed a crude OR of 0.23 (95%CI 0.17 - 0.30) and an adjusted OR of 0.89 (95%CI 0.81 - 0.98) stratified by severity and comorbidity. After logistic regression analysis, the Respiratory Rate-Oxygenation Index had an adjusted OR of 0.90 (95%CI 0.82 - 0.98; p = 0.026). The area under the Receiver Operating Characteristic curve for extubation failure was 0.64 (95%CI 0.53 - 0.75; p = 0.06). The Respiratory Rate-Oxygenation Index did not show differences between patients who survived and those who died during the intensive care unit stay. Conclusion: The Respiratory Rate-Oxygenation Index is an accessible tool to identify patients at risk of failing high-flow nasal cannula post-extubation treatment. Prospective studies are needed to broaden the utility in this scenario.

In-Hospital Outcomes of Right Minithoracotomy vs. Periareolar Access for Minimally Invasive Video-Assisted Mitral Valve Repair

Abstract Introduction: In minimally invasive mitral valve repair, right minithoracotomy is the most widely performed method, providing a good view of the mitral valve. But regarding other techniques and although it offers limited visualization, the periareolar access is a less traumatic alternative. This study's purpose is to compare in-hospital outcomes in patients who underwent video-assisted minimally invasive mitral valve repair via right minithoracotomy and periareolar access. Methods: This is a retrospective observational study including 37 patients (> 18 years old), without previous right thoracic surgery, who underwent their primary mitral valve repair, with indication for minimally invasive video-assisted approach (via right minithoracotomy or periareolar access), between January 2018 and August 2019. Patients' medical records were consulted to collect demographics data, operative details, and in-hospital outcomes. Results: Twenty-one patients underwent right minithoracotomy, and 16 were operated via periareolar access. The mean patients' age was 62±12 years in the right minithoracotomy group and 61±9 years in the periareolar access group (P=0.2). There are no significant differences in incision length, cardiopulmonary bypass time, aortic cross-clamping time, hematocrit, amount of chest tube drainage, and intensive care unit and in-hospital length of stay. Time to extubation presented significant differences between the right minithoracotomy and the periareolar access group (4.85 hours vs. 5.62 hours, respectively) (P=0.04). Conclusion: In this study, we found similar results in the two applied surgical techniques, except for the time to extubation.

Percepção da equipe multiprofissional acerca da extubação paliativa em uma unidade de cuidados pediátricos / Perception of the multiprofessional team about palliative extubation in a pediatric care unit / Percepción del equipo multiprofesional sobre la extubación paliativa en una unidad de cuidados pediátricos

Objetivo: Investigar a percepção dos profissionais que vivenciam o processo de extubação paliativa. Métodos: Estudo qualitativo, exploratório, descritivo e realizado na unidade de cuidados paliativos pediátricos de um hospital público da rede estadual de saúde de Minas Gerais, em 2020. Resultados: Foram entrevistados 11 profissionais de saúde. Emergiram 4 categorias temáticas: Conhecimento prévio a acerca da extubação paliativa; Planejamento da conduta; Comunicação entre equipe e compartilhamento do cuidado e Percepção e entendimento sobre o procedimento. Os profissionais relataram maior conhecimento teórico sobre a extubação paliativa, porém, informaram que compreenderam melhor o procedimento na prática. Algumas classes profissionais não se sentiram incluídas no planejamento assistencial que abrangia conversa prévia com os familiares do paciente e discussão sobre o plano de cuidados. Falhas na comunicação entre os membros da equipe também foram evidenciados por profissionais não médicos. O procedimento foi entendido por todos os profissionais como necessário em virtude do prognóstico clínico da criança. Conclusão: Faz necessário realizar novas pesquisas relacionados as percepções da equipe multiprofissional frente às estratégias assistenciais em unidades de cuidados paliativos para que as condutas sejam alinhadas e haja maior envolvimento de toda equipe. (AU)

Objective: To investigate the perception of professionals who experience the palliative extubation process. Methods: Qualitative, exploratory, descriptive study carried out in the pediatric palliative care unit of a public hospital in the state health network of Minas Gerais, in 2020. Results: Eleven health professionals were interviewed. Four thematic categories emerged: Knowledge prior to palliative extubation; Conduct planning; Communication between the team and sharing of care and Perception and understanding of the procedure. Professionals reported greater theoretical knowledge about palliative extubation, however, they stated that they understood the procedure better in practice. Some professional classes did not feel included in the care planning, which included a previous conversation with the patient's family members and discussion about the care plan. Failures in communication between team members were also evidenced by non-medical professionals. The procedure was understood by all professionals as necessary due to the child's clinical prognosis. Conclusion: It is necessary to carry out further research related to the perceptions of the multidisciplinary team regarding care strategies in palliative care units so that the conducts are aligned and there is greater involvement of the entire team. (AU)

Objetivo: Investigar la percepción de los profesionales que viven el proceso de extubación paliativa. Métodos: Estudio cualitativo, exploratorio, descriptivo realizado en la unidad de cuidados paliativos pediátricos de un hospital público de la red estatal de salud de Minas Gerais, en 2020. Resultados: se entrevistó a once profesionales de la salud. Surgieron cuatro categorías temáticas: conocimiento previo a la extubación paliativa; Llevar a cabo la planificación; Comunicación entre el equipo e intercambio de cuidados y Percepción y comprensión del procedimiento. Los profesionales refirieron un mayor conocimiento teórico sobre la extubación paliativa, sin embargo, manifestaron comprender mejor el procedimiento en la práctica. Algunas clases profesionales no se sintieron incluidas en la planificación de la atención, que incluyó una conversación previa con los familiares del paciente y una discusión sobre el plan de atención. Los profesionales no médicos también evidenciaron fallas en la comunicación entre los miembros del equipo. El procedimiento fue entendido por todos los profesionales como necesario por el pronóstico clínico del niño. Conclusión: Es necesario realizar más investigaciones relacionadas con las percepciones del equipo multidisciplinar sobre las estrategias de atención en las unidades de cuidados paliativos para que las conductas estén alineadas y exista una mayor implicación de todo el equipo. (AU)

Achados fonoaudiológicos na avaliação hospitalar à beira-leito do paciente grande queimado: Relato de caso / Speech therapy findings in the hospital evaluation of a major burn patient: Case report

OBJETIVO: Relatar achados fonoaudiológicos em período hospitalar, bem como, de forma breve, intervenções multiprofissionais na assistência a um paciente com queimaduras internado em um hospital da região norte do Rio Grande do Sul (Brasil). RELATO DO CASO: Paciente, do sexo feminino, com 30 anos de idade, teve 39% da superfície corporal queimada por fogo durante acidente doméstico, apresentando queimaduras de segundo e terceiro graus em membros superiores, tórax anterior, face e cervical. Apresentou limitação e prejuízo nos movimentos oromiofuncionais e alterações de deglutição, além de lesão em pregas vocais pós-extubação, com impacto na qualidade vocal. CONSIDERAÇÕES FINAIS: Foi possível identificar danos relativos à motricidade orofacial, deglutição e fonação decorrentes das queimaduras e do uso prolongado de tubo orotraqueal.

OBJECTIVE: To report multiprofessional interventions in the care of burn patients admitted to a hospital in the northern region of Rio Grande do Sul (Brazil). CASE REPORT: A female patient, 30 years old, had 39% of the body surface burned by fire during a domestic accident, presenting second and third degree burns on upper limbs, anterior chest, face and cervical. The patient presented limitation and impairment in oromyofunctional movements, changes in swallowing, and injuries in vocal folds after extubation with an impact on vocal quality. FINAL CONSIDERATIONS: It was possible to identify damages associated with orofacial motricity, deglutition, and secondary phonation caused by the burns and the prolonged use of orotracheal tube.

Análise descritiva das extubações realizadas em um serviço de emergência / Descriptive analysis of extubations performed in an Emergency Service

Introdução: A extubação no serviço de emergência não é realizada com frequência, mas pode ser segura em pacientes selecionados sendo que sua falha e subsequente reintubação é associada com aumento do tempo de ventilação mecânica e mortalidade. Objetivo: Estabelecer as variáveis preditivas de insucesso da extubação na sala de emergência para a identificação dos pacientes potencialmente elegíveis para o procedimento com maior assertividade. Métodos: Estudo retrospectivo através da análise de prontuário de pacientes que foram extubados no serviço de emergência do Hospital de Base de São José de Rio Preto/SP no período de julho de 2018 a julho de 2021. Dados clínicos e demográficos foram coletados, como idade, sexo, causa da intubação e doenças associadas. Os demais dados analisados após a extubação do paciente foram necessidade de reintubação, tempo de internação hospitalar, necessidade de terapia intensiva, alta hospitalar e óbito. Resultados: Os preditores de reintubação orotraqueal avaliados foram idade, sexo masculino, duração da intubação, doenças cardíacas, pulmonares, gastrointestinais e infecciosas, traumatismo cranioencefálico, ventilação não invasiva pós-extubação e estridor. Os preditores com maior Odds Ratio foram estridor, doenças infecciosas e ventilação não invasiva pós-extubação, com aumento da chance de reintubação comparado aos outros pacientes. Conclusão: A análise conjunta das variáveis clínicas mais a identificação dos fatores de insucesso apresentados estimulam a equipe assistencial a buscar a extubação de pacientes selecionáveis dentro da sala de emergência com maior assertividade

Introduction: Extubation in the emergency department is not performed frequently, but it can be safe in selected patients, and its failure and subsequent reintubation is associated with increased duration of mechanical ventilation and mortality. Objective: To establish predictive variables of extubation failure in the emergency room to identify patients potentially eligible for the procedure with greater assertiveness. Methods: Retrospective study by analyzing the medical records of patients who were extubated in the emergency department of the Hospital de Base de São José de Rio Preto/SP from July 2018 to July 2021. Clinical and demographic data were collected, such as age, sex, cause of intubation and associated diseases. The other data analyzed after extubation of the patient were need for reintubation, length of hospital stay, need for intensive care, hospital discharge and death. Results: The predictors of orotracheal reintubation evaluated were age, male gender, duration of intubation, cardiac, pulmonary, gastrointestinal and infectious diseases, traumatic brain injury, non-invasive post-extubation ventilation and stridor. The predictors with the highest Odds Ratio were stridor, infectious diseases and post-extubation noninvasive ventilation, with an increased chance of reintubation compared to other patients. Conclusion: The joint analysis of clinical variables plus the identification of failure factors presented encourage the care team to seek the extubation of selectable patients within the emergency room with greater assertiveness.

Delayed chest closure for oversized lung allograft in lung transplantation: a retrospective analysis from turkey

Abstract Introduction: The aim of this study was to evaluate the delayed chest closure (DCC) results in patients who underwent lung transplantation. Methods: Sixty patients were evaluated retrospectively. Only bilateral lung transplantations and DCC for oversized lung allograft (OLA) were included in the study. Six patients who underwent single lung transplantation, four patients who underwent lobar transplantation, two patients who underwent retransplantation, and four patients who underwent DCC due to bleeding risk were excluded from the study. Forty-four patients were divided into groups as primary chest closure (PCC) (n=28) and DCC (n=16). Demographics, donor characteristics, and operative features and outcomes of the patients were compared. Results: The mean age was 44.5 years. There was no significant difference between the demographics of the groups (P>0.05). The donor/recipient predicted total lung capacity ratio was significantly higher in the DCC group than in the PCC group (1.06 vs. 0.96, P=0.008). Extubation time (4.3 vs. 3.1 days, P=0.002) and intensive care unit length of stay (7.6 vs. 5.2 days, P=0.016) were significantly higher in the DCC group than in the PCC group. In the DCC group, postoperative wound infection was significantly higher than in the PCC group (18.6% vs. 0%, P=0.19). Median survival was 14 months in all patients and there was no significant difference in survival between the groups (16 vs. 13 months, P=0.300). Conclusion: DCC is a safe and effective method for the management of OLA in lung transplantation.