Impact of vertical positioning on lung aeration among mechanically ventilated intensive care unit patients: a randomized crossover clinical trial / Impacto do posicionamento vertical na aeração pulmonar em pacientes de unidades de terapia intensiva ventilados mecanicamente: um estudo clínico transversal randomizado

ABSTRACT Objective: To assess the impact of different vertical positions on lung aeration in patients receiving invasive mechanical ventilation. Methods: An open-label randomized crossover clinical trial was conducted between January and July 2020. Adults receiving invasive mechanical ventilation for > 24 hours and < 7 days with hemodynamic, respiratory and neurological stability were randomly assigned at a 1:1 ratio to the sitting position followed by passive orthostasis condition or the passive orthostasis followed by the sitting position condition. The primary outcome was lung aeration assessed using the lung ultrasound score (score ranges from 0 [better] to 36 [worse]). Results: A total of 186 subjects were screened; of these subjects, 19 were enrolled (57.8% male; mean age, 73.2 years). All participants were assigned to receive at least one verticalization protocol. Passive orthostasis resulted in mean lung ultrasound scores that did not differ significantly from the sitting position (11.0 versus 13.7; mean difference, -2.7; [95%CI -6.1 to 0.71; p = 0.11). Adverse events occurred in three subjects in the passive orthostasis group and in one in the sitting position group (p = 0.99). Conclusion: This analysis did not find significant differences in lung aeration between the sitting and passive orthostasis groups. A randomized crossover clinical trial assessing the impact of vertical positioning on lung aeration in patients receiving invasive mechanical ventilation is feasible. Unfortunately, the study was interrupted due to the need to treat COVID-19 patients. ClinicalTrials.gov registry: NCT04176445

RESUMO Objetivo: Avaliar o impacto de diferentes posicionamentos verticais na aeração pulmonar em pacientes em ventilação mecânica invasiva. Métodos: Trata-se de ensaio clínico aberto, randomizado e transversal, realizado entre janeiro e julho de 2020. Adultos em ventilação mecânica invasiva por mais de 24 horas e menos de 7 dias com estabilidade hemodinâmica, respiratória e neurológica foram distribuídos aleatoriamente em uma proporção de 1:1 à postura sentada seguida da condição de ortostatismo passivo ou o ortostatismo passivo seguido de postura sentada. O desfecho primário foi a aeração pulmonar avaliada pelo lung ultrasound score. O escore varia de zero (melhor) a 36 (pior). Resultados: Foram selecionados 186 indivíduos; destes, 19 foram incluídos (57,8% do sexo masculino; média idade de 73,2 anos). Todos os participantes foram selecionados para receber pelo menos um protocolo de verticalização. O ortostatismo passivo resultou em escores médios de aeração pulmonar por ultrassonografia que não diferiram significativamente da postura sentada (11,0 versus 13,7; diferença média, -2,7; IC95% -6,1 a 0,71; p = 0,11). Ocorreram eventos adversos em três indivíduos no grupo ortostatismo passivo e em um no grupo postura sentada (p = 0,99). Conclusão: Esta análise não encontrou diferenças significativas na aeração pulmonar entre os grupos ortostatismo passivo e postura sentada. É factível conduzir um estudo clínico transversal randomizado para avaliar o impacto do posicionamento vertical na aeração pulmonar em pacientes em ventilação mecânica invasiva. Infelizmente, o estudo foi interrompido devido à necessidade de tratar pacientes com COVID-19. Registro ClinicalTrials.gov: NCT04176445

Impact of vertical positioning on lung aeration among mechanically ventilated intensive care unit patients: a randomized crossover clinical trial.

OBJECTIVE: To assess the impact of different vertical positions on lung aeration in patients receiving invasive mechanical ventilation. METHODS: An open-label randomized crossover clinical trial was conducted between January and July 2020. Adults receiving invasive mechanical ventilation for > 24 hours and < 7 days with hemodynamic, respiratory and neurological stability were randomly assigned at a 1:1 ratio to the sitting position followed by passive orthostasis condition or the passive orthostasis followed by the sitting position condition. The primary outcome was lung aeration assessed using the lung ultrasound score (score ranges from 0 [better] to 36 [worse]). RESULTS: A total of 186 subjects were screened; of these subjects, 19 were enrolled (57.8% male; mean age, 73.2 years). All participants were assigned to receive at least one verticalization protocol. Passive orthostasis resulted in mean lung ultrasound scores that did not differ significantly from the sitting position (11.0 versus 13.7; mean difference, -2.7; [95%CI -6.1 to 0.71; p = 0.11). Adverse events occurred in three subjects in the passive orthostasis group and in one in the sitting position group (p = 0.99). CONCLUSION: This analysis did not find significant differences in lung aeration between the sitting and passive orthostasis groups. A randomized crossover clinical trial assessing the impact of vertical positioning on lung aeration in patients receiving invasive mechanical ventilation is feasible. Unfortunately, the study was interrupted due to the need to treat COVID-19 patients.ClinicalTrials.gov registry: NCT04176445.

Out-of-bed extubation: a feasibility study.

OBJECTIVE: In clinical intensive care practice, weaning from mechanical ventilation is accompanied by concurrent early patient mobilization. The aim of this study was to compare the success of extubation performed with patients seated in an armchair compared to extubation with patients in a supine position. METHODS: A retrospective study, observational and non-randomized was conducted in a mixed-gender, 23-bed intensive care unit. The primary study outcome was success of extubation, which was defined as the patient tolerating the removal of the endotracheal tube for at least 48 hours. The differences between the study groups were assessed using Student's t-test and chi-squared analysis. RESULTS: Ninety-one patients were included from December 2010 and June 2011. The study population had a mean age of 71 years ± 12 months, a mean APACHE II score of 21±7.6, and a mean length of mechanical ventilation of 2.6±2 days. Extubation was performed in 33 patients who were seated in an armchair (36%) and in 58 patients in a supine position (64%). There were no significant differences in age, mean APACHE II score or length of mechanical ventilation between the two groups, and a similar extubation success rate was observed (82%, seated group versus 85%, supine group, p>0.05). Furthermore, no significant differences were found between the two groups in terms of post-extubation distress, need for tracheostomy, duration of mechanical ventilation weaning, or intensive care unit stay. CONCLUSION: Our results suggest that the clinical outcomes of patients extubated in a seated position are similar to those of patients extubated in a supine position. This new practice of seated extubation was not associated with adverse events and allowed extubation to occur simultaneously with early mobilization.

Extubação fora do leito: um estudo de viabilidade / Out-of-bed extubation: a feasibility study

Objetivo: O desmame da ventilação mecânica é acompanhado, na prática clínica em terapia intensiva, de concomitante mobilização precoce do paciente. O objetivo deste estudo foi comparar o sucesso da extubação realizada com pacientes sentados em uma poltrona à extubação de pacientes na posição supina. Métodos: Foi realizado um estudo retrospectivo, observacional e não randomizado em uma unidade de terapia intensiva de 23 leitos, que atende pacientes clínicos e cirúrgicos. O desfecho primário do estudo foi o sucesso da extubação, definido como a tolerância da remoção do tubo endotraqueal por, pelo menos, 48 horas. As diferenças entre os grupos do estudo foram avaliadas utilizando-se o teste t de Student e o qui quadrado. Resultados: Foram incluídos 91 pacientes no período compreendido entre dezembro de 2010 e junho de 2011. A população do estudo tinha uma média de idade de 71 anos ± 12 meses, escore APACHE II médio de 21±7,6 e duração média da ventilação mecânica de 2,6±2 dias. A extubação foi realizada em 33 pacientes enquanto permaneciam sentados em uma poltrona (36%) e 58 pacientes mantidos em posição supina (64%). Não houve diferenças significantes entre os grupos em termos de idade, escore médio APACHE II ou duração da ventilação mecânica. Foi observada uma taxa de sucesso da extubação similar entre os grupos sentado (82%) e em posição supina (85%), com p>0,05. Além disso, não se encontraram diferenças significantes entre os dois grupos em termos de disfunção respiratória pós-extubação, necessidade de traqueostomia, duração do desmame da ventilação mecânica, ou tempo de permanência ...

Objective: In clinical intensive care practice, weaning from mechanical ventilation is accompanied by concurrent early patient mobilization. The aim of this study was to compare the success of extubation performed with patients seated in an armchair compared to extubation with patients in a supine position. Methods: A retrospective study, observational and non-randomized was conducted in a mixed-gender, 23-bed intensive care unit. The primary study outcome was success of extubation, which was defined as the patient tolerating the removal of the endotracheal tube for at least 48 hours. The differences between the study groups were assessed using Student's t-test and chi-squared analysis. Results: Ninety-one patients were included from December 2010 and June 2011. The study population had a mean age of 71 years ± 12 months, a mean APACHE II score of 21±7.6, and a mean length of mechanical ventilation of 2.6±2 days. Extubation was performed in 33 patients who were seated in an armchair (36%) and in 58 patients in a supine position (64%). There were no significant differences in age, mean APACHE II score or length of mechanical ventilation between the two groups, and a similar extubation success rate was observed (82%, seated group versus 85%, supine group, p>0.05). Furthermore, no significant differences were found between the two groups in terms of post-extubation distress, need for tracheostomy, duration of mechanical ventilation weaning, or intensive care unit stay. Conclusion: Our results suggest that the clinical outcomes of patients extubated in a seated position are similar to those of patients extubated in a supine position. This new practice of seated extubation was not associated with adverse events and allowed extubation to occur simultaneously with early mobilization. .

O elogio da transversalidade / Eulogy of transversality

Refletindo sobre a relação entre cidadania e subjetividade e as formas de intervir nesta relação, os autores sustentam que ao lado do reconhecimento das diferenças, é também necessário superar as barreiras identitárias construídas por cada movimento de defesa de direitos, tais como os relacionados a gênero e etnia, para abrir o diálogo entre os grupos que afirmam suas diferenças, no sentido de melhor vir a esclarecer suas particularidades e transversalidades. Os autores baseiam a discussão em dados de pesquisa-ação desenvolvida com grupos sociais diversos, envolvendo os conceitos de gênero e de etnia. Comparam a questão de gênero e a questão étnica para argumentar que o conceito de identidade deve ser utilizado sempre em articulação com os conceitos de alteridade e de transversalidade, buscando-se superar uma suposta dicotomia entre o reconhecimento da diferença e a universalidade de direitos. Advogam considerar nem identidades isoladas nem a pretensão de um universalismo que não considere as diferenças, mas a busca de uma transversalidade onde as trocas entre os grupos e movimentos sociais possam esclarecer a sua dialética entre identidade/alteridade e suas questões em comum no contexto sóciohistórico(AU)

The authors reflect on the relationship between citizenship and subjectivity as well as the ways of working out this relationship. They argue that, side by side the recognition of differences, it is essential to go beyond the identity barriers each social movement constructs in the defense of its rights. Examples are those movements related to gender and ethnia. It is important to open the dialogue among these groups, to better understand its particularities and transversalities. The discussion is based on data from action-research with different groups, involving the issues of gender and ethnia. The authors compare the question of gender and that of ethnia and maintain that the concept of identity shall be intertwined with those of alterity and transversality. This is aimed to surpass the alleged dichotomy between difference and universality. The authors propose neither to consider isolated identities nor to accept a “universalism” that effaces differences. Instead, they propose to search for the transversality dimension through which groups and social movements could enlighten the dialectics between identity and alterity, as well as their common issues inthe social-historical context. (AU)

O elogio da transversalidade / Eulogy of transversality

Refletindo sobre a relação entre cidadania e subjetividade e as formas de intervir nesta relação, os autores sustentam que ao lado do reconhecimento das diferenças, é também necessário superar as barreiras identitárias construídas por cada movimento de defesa de direitos, tais como os relacionados a gênero e etnia, para abrir o diálogo entre os gruposque afirmam suas diferenças, no sentido de melhor vir a esclarecer suas particularidades e transversalidades.Os autores baseiam a discussão em dados de pesquisa-ação desenvolvida com grupos sociais diversos, envolvendo os conceitos de gênero e de etnia. Comparam a questão de gênero e a questão étnica para argumentar que o conceito de identidade deve serutilizado sempre em articulação com os conceitos de alteridade e de transversalidade, buscando-se superar uma suposta dicotomia entre o reconhecimento da diferença e auniversalidade de direitos. Advogam considerar nem identidades isoladas nem a pretensão de um universalismo que não considere as diferenças, mas a busca de uma transversalidade onde as trocas entre os grupos e movimentos sociais possam esclarecer a sua dialética entre identidade/alteridade e suas questões em comum no contexto sóciohistórico

The authors reflect on the relationship between citizenship and subjectivity as well as the ways of working out this relationship. They argue that, side by side the recognition of differences, it is essential to go beyond the identity barriers each social movementconstructs in the defense of its rights. Examples are those movements related to gender and ethnia. It is important to open the dialogue among these groups, in order to better understand its particularities and transversalities.The discussion is based on data from action-research with different groups, involving the issues of gender and ethnia. The authors compare the question of gender and that ofethnia and maintain that the concept of identity shall be intertwined with those of alterity and transversality. This is aimed to surpass the alleged dichotomy between difference and universality. The authors propose not to consider isolated identities nor to accept a“universalism” that effaces differences. Instead, they propose to search for thetransversality dimension through which groups and social movements could enlighten the dialectics between identity and alterity, as well as their common issues in the socialhistorical context