A Study on the Epidemiological-Molecular Role of Staphylococcus aureus Strains in the Development of Ventilator-Associated Pneumonia in a Tertiary Hospital in Brazil.

This study aimed to explore the molecular epidemiology of Staphylococcus aureus isolated from patients on mechanical ventilation and the participation of virulence factors in the development of ventilator-associated pneumonia (VAP). A prospective cohort study was conducted on patients under mechanical ventilation, with periodic visits for the collection of tracheal aspirates and clinical data. The S. aureus isolates were analyzed regarding resistance profile, virulence, expression of protein A and alpha-toxin using Western blot, clonal profile using PFGE, sequence type using MLST, and characterization and quantification of phenol-soluble modulins. Among the 270 patients in the study, 51 S. aureus strains were isolated from 47 patients. The incidence density of S. aureus and MRSA VAP was 2.35/1000 and 1.96/1000 ventilator days, respectively; of these, 45% (n = 5) were resistant to oxacillin, with 100% (n = 5) harboring SCCmec types II and IV. The most frequent among the tested virulence factors were icaA, hla, and hld. The clonal profile showed a predominance of sequence types originating from the community. Risk factors for VAP were the presence of solid tumors and the sea gene. In conclusion, patient-related risk factors, together with microbiological factors, are involved in the development of S. aureus VAP, which is caused by the patient's own strains.

Sleep and Life Quality in Frail Elderly - A Narrative Review.

Introduction Population aging is a growing reality worldwide, characterized by a rapidly developing event that is not always associated with quality of life. Elderly health stands out, pointing to the need for public health policies that ensure effective and resolutive approaches for this population, and should be applied especially by primary health care, through actions that encourage active aging. The present review aimed to identify whether sleep disorders impact the quality of life in frail elderly. Methods We proceeded with the selection of keywords that led to the search of articles. The search was defined in the Lilacs, PubMed, and Embase databases, conducted from July to November, 2020.We have found a total of 455 articles, of which 9 were included in the present review. Results The studies obtained subjective (self-report and questionnaires) and objective (devices and exams) data that characterized frailty, disorders, and sleep quality in the elderly. Some studies have found a relationship between frailty and sleep disorders in women, others in men, and some have identified the existence of a relationship between these factors and the age of the participants who composed the samples. Conclusion Based in our results, we conclude that disorders and poor sleep quality interfere in the quality of life of frail elderly.

Inflammatory lung injury in rabbits: effects of high-frequency oscillatory ventilation in the prone position.

OBJECTIVE: To compare the effects that prone and supine positioning during high-frequency oscillatory ventilation (HFOV) have on oxygenation and lung inflammation, histological injury, and oxidative stress in a rabbit model of acute lung injury (ALI). METHODS: Thirty male Norfolk white rabbits were induced to ALI by tracheal saline lavage (30 mL/kg, 38°C). The injury was induced during conventional mechanical ventilation, and ALI was considered confirmed when a PaO2/FiO2 ratio < 100 mmHg was reached. Rabbits were randomly divided into two groups: HFOV in the supine position (SP group, n = 15); and HFOV with prone positioning (PP group, n = 15). For HFOV, the mean airway pressure was initially set at 16 cmH2O. At 30, 60, and 90 min after the start of the HFOV protocol, the mean airway pressure was reduced to 14, 12, and 10 cmH2O, respectively. At 120 min, the animals were returned to or remained in the supine position for an extra 30 min. We evaluated oxygenation indices and histological lung injury scores, as well as TNF-α levels in BAL fluid and lung tissue. RESULTS: After ALI induction, all of the animals showed significant hypoxemia, decreased respiratory system compliance, decreased oxygenation, and increased mean airway pressure in comparison with the baseline values. There were no statistically significant differences between the two groups, at any of the time points evaluated, in terms of the PaO2 or oxygenation index. However, TNF-α levels in BAL fluid were significantly lower in the PP group than in the SP group, as were histological lung injury scores. CONCLUSIONS: Prone positioning appears to attenuate inflammatory and histological lung injury during HFOV in rabbits with ALI.

Inflammatory lung injury in rabbits: effects of high-frequency oscillatory ventilation in the prone position / Lesão inflamatória pulmonar em coelhos: efeitos da ventilação oscilatória de alta frequência em posição prona

ABSTRACT Objective: To compare the effects that prone and supine positioning during high-frequency oscillatory ventilation (HFOV) have on oxygenation and lung inflammation, histological injury, and oxidative stress in a rabbit model of acute lung injury (ALI). Methods: Thirty male Norfolk white rabbits were induced to ALI by tracheal saline lavage (30 mL/kg, 38°C). The injury was induced during conventional mechanical ventilation, and ALI was considered confirmed when a PaO2/FiO2 ratio < 100 mmHg was reached. Rabbits were randomly divided into two groups: HFOV in the supine position (SP group, n = 15); and HFOV with prone positioning (PP group, n = 15). For HFOV, the mean airway pressure was initially set at 16 cmH2O. At 30, 60, and 90 min after the start of the HFOV protocol, the mean airway pressure was reduced to 14, 12, and 10 cmH2O, respectively. At 120 min, the animals were returned to or remained in the supine position for an extra 30 min. We evaluated oxygenation indices and histological lung injury scores, as well as TNF-α levels in BAL fluid and lung tissue. Results: After ALI induction, all of the animals showed significant hypoxemia, decreased respiratory system compliance, decreased oxygenation, and increased mean airway pressure in comparison with the baseline values. There were no statistically significant differences between the two groups, at any of the time points evaluated, in terms of the PaO2 or oxygenation index. However, TNF-α levels in BAL fluid were significantly lower in the PP group than in the SP group, as were histological lung injury scores. Conclusions: Prone positioning appears to attenuate inflammatory and histological lung injury during HFOV in rabbits with ALI.

RESUMO Objetivo: Comparar os efeitos das posições prona e supina durante ventilação oscilatória de alta frequência (VOAF) sobre oxigenação e inflamação pulmonar, lesão histológica e estresse oxidativo em um modelo de lesão pulmonar aguda (LPA) em coelhos. Métodos: Trinta coelhos Norfolk machos brancos foram submetidos à LPA por meio de lavagem traqueal com salina (30 ml/kg, 38°C). A lesão foi induzida durante a ventilação mecânica convencional, e a LPA foi considerada confirmada na presença de relação PaO2/FiO2 < 100 mmHg. Os coelhos foram aleatoriamente divididos em dois grupos: VOAF em posição supina (grupo PS, n = 15); e VOAF em posição prona (grupo PP, n = 15). Para a VOAF, a pressão média das vias aéreas foi inicialmente estabelecida em 16 cmH2O. No 30º, 60º e 90º min após o início do protocolo de VOAF, a pressão média das vias aéreas foi reduzida para 14, 12 e 10 cmH2O, respectivamente. No 120º min, os animais foram recolocados ou permaneceram na posição supina por mais 30 min. Foram avaliados os índices de oxigenação e escores histológicos de lesão pulmonar, bem como os níveis de TNF-α em lavado broncoalveolar e tecido pulmonar. Resultados: Após a indução da LPA, todos os animais apresentaram hipoxemia significativa, diminuição da complacência do sistema respiratório, diminuição da oxigenação e aumento da pressão média das vias aéreas em comparação aos valores basais. Não houve diferenças estatisticamente significativas entre os dois grupos, em nenhum dos momentos avaliados, quanto a PaO2 e índice de oxigenação. Entretanto, os níveis de TNF-α no lavado broncoalveolar foram significativamente menores no grupo PP que no grupo PS, assim como os escores histológicos de lesão pulmonar. Conclusões: A posição prona parece atenuar a lesão pulmonar inflamatória e histológica durante a VOAF em coelhos com LPA.

Comparison between conventional protective mechanical ventilation and high-frequency oscillatory ventilation associated with the prone position. / Comparação entre ventilação mecânica convencional protetora e ventilação oscilatória de alta frequência associada à posição prona.

OBJECTIVE: To compare the effects of high-frequency oscillatory ventilation and conventional protective mechanical ventilation associated with the prone position on oxygenation, histology and pulmonary oxidative damage in an experimental model of acute lung injury. METHODS: Forty-five rabbits with tracheostomy and vascular access were underwent mechanical ventilation. Acute lung injury was induced by tracheal infusion of warm saline. Three experimental groups were formed: healthy animals + conventional protective mechanical ventilation, supine position (Control Group; n = 15); animals with acute lung injury + conventional protective mechanical ventilation, prone position (CMVG; n = 15); and animals with acute lung injury + high-frequency oscillatory ventilation, prone position (HFOG; n = 15). Ten minutes after the beginning of the specific ventilation of each group, arterial gasometry was collected, with this timepoint being called time zero, after which the animal was placed in prone position and remained in this position for 4 hours. Oxidative stress was evaluated by the total antioxidant performance assay. Pulmonary tissue injury was determined by histopathological score. The level of significance was 5%. RESULTS: Both groups with acute lung injury showed worsening of oxygenation after induction of injury compared with the Control Group. After 4 hours, there was a significant improvement in oxygenation in the HFOG group compared with CMVG. Analysis of total antioxidant performance in plasma showed greater protection in HFOG. HFOG had a lower histopathological lesion score in lung tissue than CMVG. CONCLUSION: High-frequency oscillatory ventilation, associated with prone position, improves oxygenation and attenuates oxidative damage and histopathological lung injury compared with conventional protective mechanical ventilation.

OBJETIVO: Comparar os efeitos da ventilação oscilatória de alta frequência e da ventilação mecânica convencional protetora associadas à posição prona quanto à oxigenação, à histologia e ao dano oxidativo pulmonar em modelo experimental de lesão pulmonar aguda. MÉTODOS: Foram instrumentados com traqueostomia, acessos vasculares e ventilados mecanicamente 45 coelhos. A lesão pulmonar aguda foi induzida por infusão traqueal de salina aquecida. Foram formados três grupos experimentais: animais sadios + ventilação mecânica convencional protetora, em posição supina (Grupo Controle; n = 15); animais com lesão pulmonar aguda + ventilação mecânica convencional protetora, posição prona (GVMC; n = 15); animais com lesão pulmonar aguda + ventilação oscilatória de alta frequência, posição prona (GVAF; n = 15). Após 10 minutos do início da ventilação específica de cada grupo, foi coletada gasometria arterial, sendo este momento denominado tempo zero, após o qual o animal foi colocado em posição prona, permanecendo assim por 4 horas. O estresse oxidativo foi avaliado pelo método de capacidade antioxidante total. A lesão tecidual pulmonar foi determinada por escore histopatológico. O nível de significância adotado foi de 5%. RESULTADOS: Ambos os grupos com lesão pulmonar aguda apresentaram piora da oxigenação após a indução da lesão comparados ao Grupo Controle. Após 4 horas, houve melhora significante da oxigenação no grupo GVAF comparado ao GVMC. A análise da capacidade antioxidante total no plasma mostrou maior proteção no GVAF. O GVAF apresentou menor escore de lesão histopatológica no tecido pulmonar que o GVMC. CONCLUSÃO: A ventilação oscilatória de alta frequência, associada à posição prona, melhora a oxigenação, e atenua o dano oxidativo e a lesão pulmonar histopatológica, comparada com ventilação mecânica convencional protetora.

Comparação entre ventilação mecânica convencional protetora e ventilação oscilatória de alta frequência associada à posição prona / Comparison between conventional protective mechanical ventilation and high-frequency oscillatory ventilation associated with the prone position

RESUMO Objetivo: Comparar os efeitos da ventilação oscilatória de alta frequência e da ventilação mecânica convencional protetora associadas à posição prona quanto à oxigenação, à histologia e ao dano oxidativo pulmonar em modelo experimental de lesão pulmonar aguda. Métodos: Foram instrumentados com traqueostomia, acessos vasculares e ventilados mecanicamente 45 coelhos. A lesão pulmonar aguda foi induzida por infusão traqueal de salina aquecida. Foram formados três grupos experimentais: animais sadios + ventilação mecânica convencional protetora, em posição supina (Grupo Controle; n = 15); animais com lesão pulmonar aguda + ventilação mecânica convencional protetora, posição prona (GVMC; n = 15); animais com lesão pulmonar aguda + ventilação oscilatória de alta frequência, posição prona (GVAF; n = 15). Após 10 minutos do início da ventilação específica de cada grupo, foi coletada gasometria arterial, sendo este momento denominado tempo zero, após o qual o animal foi colocado em posição prona, permanecendo assim por 4 horas. O estresse oxidativo foi avaliado pelo método de capacidade antioxidante total. A lesão tecidual pulmonar foi determinada por escore histopatológico. O nível de significância adotado foi de 5%. Resultados: Ambos os grupos com lesão pulmonar aguda apresentaram piora da oxigenação após a indução da lesão comparados ao Grupo Controle. Após 4 horas, houve melhora significante da oxigenação no grupo GVAF comparado ao GVMC. A análise da capacidade antioxidante total no plasma mostrou maior proteção no GVAF. O GVAF apresentou menor escore de lesão histopatológica no tecido pulmonar que o GVMC. Conclusão: A ventilação oscilatória de alta frequência, associada à posição prona, melhora a oxigenação, e atenua o dano oxidativo e a lesão pulmonar histopatológica, comparada com ventilação mecânica convencional protetora.

ABSTRACT Objective: To compare the effects of high-frequency oscillatory ventilation and conventional protective mechanical ventilation associated with the prone position on oxygenation, histology and pulmonary oxidative damage in an experimental model of acute lung injury. Methods: Forty-five rabbits with tracheostomy and vascular access were underwent mechanical ventilation. Acute lung injury was induced by tracheal infusion of warm saline. Three experimental groups were formed: healthy animals + conventional protective mechanical ventilation, supine position (Control Group; n = 15); animals with acute lung injury + conventional protective mechanical ventilation, prone position (CMVG; n = 15); and animals with acute lung injury + high-frequency oscillatory ventilation, prone position (HFOG; n = 15). Ten minutes after the beginning of the specific ventilation of each group, arterial gasometry was collected, with this timepoint being called time zero, after which the animal was placed in prone position and remained in this position for 4 hours. Oxidative stress was evaluated by the total antioxidant performance assay. Pulmonary tissue injury was determined by histopathological score. The level of significance was 5%. Results: Both groups with acute lung injury showed worsening of oxygenation after induction of injury compared with the Control Group. After 4 hours, there was a significant improvement in oxygenation in the HFOG group compared with CMVG. Analysis of total antioxidant performance in plasma showed greater protection in HFOG. HFOG had a lower histopathological lesion score in lung tissue than CMVG. Conclusion: High-frequency oscillatory ventilation, associated with prone position, improves oxygenation and attenuates oxidative damage and histopathological lung injury compared with conventional protective mechanical ventilation.

Interactive effects of mechanical ventilation, inhaled nitric oxide and oxidative stress in acute lung injury.

To compare conventional mechanical ventilation (CMV) and high-frequency oscillatory ventilation (HFOV), with/without inhaled nitric oxide (iNO), for oxygenation, inflammation, antioxidant/oxidative stress status, and DNA damage in a model of acute lung injury (ALI). Lung injury was induced by tracheal infusion of warm saline. Rabbits were ventilated at [Formula: see text] 1.0 and randomly assigned to one of five groups. Overall antioxidant defense/oxidative stress was assessed by total antioxidant performance assay, and DNA damage by comet assay. Ventilatory and hemodynamic parameters were recorded every 30min for 4h. ALI groups showed worse oxygenation than controls after lung injury. After 4h of mechanical ventilation, HFOV groups presented significant improvements in oxygenation. HFOV with and without iNO, and CMV with iNO showed significantly increased antioxidant defense and reduced DNA damage than CMV without iNO. Inhaled nitric oxide did not beneficially affect HFOV in relation to antioxidant defense/oxidative stress and pulmonary DNA damage. Overall, lung injury was reduced using HFOV or CMV with iNO.

Association of pre and intraoperative variables with postoperative complications in coronary artery bypass graft surgery / Associação de variáveis pré e intraoperatórias com complicações pós-operatórias em cirurgia de revascularização do miocárdio

OBJECTIVE: To associate the pre- and intraoperative variables with postoperative complications of patients undergoing coronary artery bypass graft surgery. METHODS: The pre- and intraoperative risk factors of individuals of both genders with diagnosis of coronary insufficiency undergoing coronary artery bypass graft have been studied. RESULTS: Fifty-eight individuals with median age 62 ± 10 year-old were included in the study, 67% of whom were male. Fourteen (24.1%) patients were smokers, 39 (67.2%) had previous myocardial infarction history, 11 (19%) had undergone coronary angioplasty, 74% had hypertension, 27% had diabetes mellitus, 64% had dyslipidemia and 15.5% had chronic obstructive pulmonary disease. Eighteen (31%) patients presented postoperative complications, most frequent being: infection in surgical incision, difficulties in deambulation, dyspnea, urinary infection and generalized weakness. Male patients had fewer complications than females (P=0.005). Patients with chronic obstructive pulmonary disease remained hospitalized for longer time periods (P=0.019). Postoperative complications occurred in 50% of the patients with creatinine increased, while only 27.1% of the patients with normal value of creatinine had complications (P=0.049). In addition, complications occurred in 50% of the patients with diabetes mellitus, while only 23.8% of patients without diabetes mellitus had complications (P=0.032). The intraoperative factors showed no statistically significant differences. CONCLUSION: The preoperative factors are associated with postoperative complications in patients undergoing coronary artery bypass graft surgery.

OBJETIVO: Associar variáveis pré e intraoperatórias com as complicações pós-operatórias de pacientes submetidos à cirurgia de revascularização miocárdica. MÉTODOS: Foram estudados os fatores de risco pré e intraoperatórios de indivíduos de ambos os sexos, com diagnóstico de insuficiência coronariana, submetidos à cirurgia de revascularização do miocárdio. RESULTADOS: Participaram do estudo 58 indivíduos, com idade média de 62 ± 10 anos e 67% eram do sexo masculino. Catorze (24,1%) pacientes eram fumantes, 39 (67,2%) apresentavam história de infarto do miocárdio prévia, 11 (19%) tinham realizado angioplastia coronariana, 74% apresentavam hipertensão arterial, 27% diabetes mellitus, 64% dislipidemia e 15,5% doença pulmonar obstrutiva crônica. Dezoito (31%) pacientes apresentaram complicações no pós-operatório e as mais frequentes foram infecção na incisão cirúrgica, dificuldades na deambulação, dispneia, infecção urinária e fraqueza generalizada. Pacientes do sexo masculino apresentaram menos complicações que os do sexo feminino (P=0,005). Pacientes com diagnóstico de doença pulmonar obstrutiva crônica permaneceram maior tempo hospitalizados (P=0,019). Complicações pós-operatórias ocorreram em 50% dos pacientes com creatinina aumentada, enquanto que apenas 27,1% dos pacientes com valor normal de creatinina apresentaram complicações (P=0,049). Ocorreram também complicações em 50% dos pacientes com diabetes mellitus, enquanto que apenas 23,8% dos pacientes sem diabetes mellitus tiveram complicações (P=0,032). Os fatores intraoperatórios não apresentaram diferenças significativas estatisticamente. CONCLUSÃO: Os fatores pré-operatórios estão associados com complicações pós-operatórias em pacientes submetidos à cirurgia de revascularização miocárdica.

Aplicabilidade das equações de referência para o teste de caminhada de seis minutos em adultos e idosos saudáveis de um município do estado de São Paulo / Applicability of reference equations for the six-minute walk test in health elderly adults in a municipality of Sao Paulo / Aplicabilidad de las ecuaciones de referencia para el test de marcha seis minutos en adultos y adultos mayores saludables de un municipio del estado de São Paulo

O teste de caminhada de seis minutos (TC6) tem sido considerado simples, seguro, de fácil administração, além de fornecer resultados representativos sobre atividades habituais do dia a dia. Os objetivos do estudo foram avaliar e comparar a distância percorrida no TC6 com as distâncias previstas por equações disponíveis na literatura científica em adultos e idosos saudáveis do município de São Carlos (SP), e verificar a aplicabilidade dessas equações nessa população. Foram avaliados 43 indivíduos (23 homens), dos 55 aos 78 anos, por meio da avaliação física, espirometria e do TC6. Observamos que a distância percorrida no TC6 foi significativamente (teste t-pareado: p<0,05) maior que os valores previstos pelas equações de Enright e Sherril, Masmoudi et al., Alameri, Al-Majed e Al-Howaikan e Dourado, Vidotto e Guerra, e os mesmos foram significativamente menores que os previstos por Troosters, Gosselink e Decramer, Gibbons et al., Enright et al., Camarri et al., Ben Saad et al. e Soares e Pereira. Não foram observadas diferenças significativas entre a distância percorrida no TC6 e os valores previstos pelas equações de Chetta et al. e Iwama et al. A maioria das equações de referências utilizadas no presente estudo subestima ou superestima os valores obtidos no TC6, exceto as propostas por Chetta et al. e Iwama et al. que se mostraram aceitáveis para a população estudada. Existe diferença entre as distâncias, mesmo quando o TC6 é realizado com uma metodologia semelhante e rigorosa padronização, assim salienta-se a necessidade de equações específicas para cada população...

The six-minute walk test (6MWT) has been considered simple, safe, easy administration, and provide representative results about normal activities of day-to-day. The objective of the study was to evaluate and compare the 6-min walk distance (6MWD) with predicted distance by reference equations available in the scientific literature in healthy elderly adults, and to verify the applicability of these reference equations in this population. Forty-three elderly adults apparently healthy (23 males) between 55 to 78 years old were assessed by means of general physical assessment, the spirometry and 6MWT. The 6MWT was performed twice, with 30-min interval between them. The 6MWD was significantly (paired t-test: p<0.05) higher than those predicted by the equations of Enright and Sherrill, Masmoudi et al., Alameri, Al-Majed and Al-Howaikan and Dourado, Vidotto and Guerra, and they were significantly lower than those provided by Troosters, Gosselink and Decramer, Gibbons et al., Enright et al., Camarri et al., Ben Saad et al. and Soares and Pereira. No significant differences were observed between the 6MWD and the predicted values by the equations of Chetta et al. and Iwama et al. Most reference equations used underestimates or overestimates the 6MWD, except of the Chetta et al., and Iwama et al. that showed acceptable to this population. There difference between the distances, even when the 6MWT is realized with similar methodology and rigorous standardization, thus emphasizes the need for specific equations for each population...

El test de marcha de seis minutos (TM6) es considerado simple, seguro y de fácil administración, además de entregar resultados representativos sobre actividades habituales del día a día. Los objetivos del estudio fueron evaluar y comparar la distancia recorrida en el TM6 con las distancias previstas por ecuaciones disponibles en la literatura científica en adultos y adultos mayores saludables del municipio de Sao Carlos/SP, y verificar la aplicabilidad de esas ecuaciones en esta población. Fueron evaluados 43 individuos (23 hombres), entre los 55 a los 78 años, por medio de evaluación física, espirometría y del TM6. Observamos que la distancia recorrida en el TM6 fue significativamente (test t-pareado: p<0,05) mayor que los valores previstos por las ecuaciones de Enright y Sherril, Masmoudi et al., Alameri, Al-Majed y Al-Howaikan y Dourado, Vidotto y Guerra, y los mismos fueron significativamente menores que los previstos por Troosters, Gosselink y Decramer, Gibbons et al., Enright et al., Camarri et al., Ben Saad et al. y Soares y Pereira. No fueron observadas diferencias significativas entre la distancia recorrida en el TM6 y los valores previstos por las ecuaciones de Chetta et al., y Iwama et al. La mayoría de las ecuaciones de referencias utilizadas en el presente estudio subestima o superestima los valores obtenidos en el TM6, excepto las propuestas por Chetta et al. y Iwama et al. que se observaron aceptables para la población estudiada. Existe diferencia entre las distancias, incluso cuando el TM6 es realizado con una similar metodología y estandarización rigurosa, además se hace hincapié en la necesidad de ecuaciones específicas para cada población...

Association of pre and intraoperative variables with postoperative complications in coronary artery bypass graft surgery.

OBJECTIVE: To associate the pre- and intraoperative variables with postoperative complications of patients undergoing coronary artery bypass graft surgery. METHODS: The pre- and intraoperative risk factors of individuals of both genders with diagnosis of coronary insufficiency undergoing coronary artery bypass graft have been studied. RESULTS: Fifty-eight individuals with median age 62 ± 10 year-old were included in the study, 67% of whom were male. Fourteen (24.1%) patients were smokers, 39 (67.2%) had previous myocardial infarction history, 11 (19%) had undergone coronary angioplasty, 74% had hypertension, 27% had diabetes mellitus, 64% had dyslipidemia and 15.5% had chronic obstructive pulmonary disease. Eighteen (31%) patients presented postoperative complications, most frequent being: infection in surgical incision, difficulties in deambulation, dyspnea, urinary infection and generalized weakness. Male patients had fewer complications than females (P=0.005). Patients with chronic obstructive pulmonary disease remained hospitalized for longer time periods (P=0.019). Postoperative complications occurred in 50% of the patients with creatinine increased, while only 27.1% of the patients with normal value of creatinine had complications (P=0.049). In addition, complications occurred in 50% of the patients with diabetes mellitus, while only 23.8% of patients without diabetes mellitus had complications (P=0.032). The intraoperative factors showed no statistically significant differences. CONCLUSION: The preoperative factors are associated with postoperative complications in patients undergoing coronary artery bypass graft surgery.

Manual hyperinflation combined with expiratory rib cage compression for reduction of length of ICU stay in critically ill patients on mechanical ventilation.

OBJECTIVE: Although manual hyperinflation (MH) is widely used for pulmonary secretion clearance, there is no evidence to support its routine use in clinical practice. Our objective was to evaluate the effect that MH combined with expiratory rib cage compression (ERCC) has on the length of ICU stay and duration of mechanical ventilation (MV). METHODS: This was a prospective randomized controlled clinical trial involving ICU patients on MV at a tertiary care teaching hospital between January of 2004 and January of 2005. Among the 49 patients who met the study criteria, 24 and 25 were randomly assigned to the respiratory physiotherapy (RP) and control groups, respectively. Of those same patients, 6 and 8, respectively, were later withdrawn from the study. During the 5-day observation period, the RP patients received MH combined with ERCC, whereas the control patients received standard nursing care. RESULTS: The two groups were similar in terms of the baseline characteristics. The intervention had a positive effect on the duration of MV, as well as on the ICU discharge rate and Murray score. There were significant differences between the control and RP groups regarding the weaning success rate on days 2 (0.0% vs. 37.5%), 3 (0.0% vs. 37.5%), 4 (5.3% vs. 37.5%), and 5 (15.9% vs. 37.5%), as well as regarding the ICU discharge rate on days 3 (0% vs. 25%), 4 (0% vs. 31%), and 5 (0% vs. 31%). In the RP group, there was a significant improvement in the Murray score on day 5. CONCLUSIONS: Our results show that the use of MH combined with ERCC for 5 days accelerated the weaning process and ICU discharge.

Hiperinsuflação manual combinada com compressão torácica expiratória para redução do período de internação em UTI em pacientes críticos sob ventilação mecânica / Manual hyperinflation combined with expiratory rib cage compression for reduction of length of ICU stay in critically ill patients on mechanical ventilation

OBJETIVO: Embora a hiperinsuflação manual (HM) seja largamente usada para a remoção de secreções pulmonares, não há evidências para sua recomendação como rotina na prática clínica. O objetivo do estudo foi avaliar o efeito da HM combinada com compressão torácica expiratória (CTE) na duração de internação em UTI e no tempo de ventilação mecânica (VM) em pacientes sob VM. MÉTODOS: Ensaio clínico prospectivo, randomizado e controlado com pacientes de UTI sob VM em um hospital acadêmico terciário entre janeiro de 2004 e janeiro de 2005. Dentre os 49 pacientes que preencheram os critérios do estudo, 24 e 25 foram randomicamente alocados nos grupos fisioterapia respiratória (FR) e controle, respectivamente, sendo que 6 e 8 foram retirados do estudo. Durante o período de observação de 5 dias, os pacientes do grupo FR receberam HM combinada com CTE, enquanto os controles receberam o tratamento padrão de enfermagem. RESULTADOS: Os dois grupos apresentaram características basais semelhantes. A intervenção teve efeito positivo na duração de VM, alta da UTI e escore de Murray. Houve diferenças significativas entre os grupos controle e FR em relação à taxa de sucesso no desmame nos dias 2 (0,0% vs. 37,5%), 3 (0,0% vs. 37,5%), 4 (5,3 vs. 37,5%) e 5 (15,9% vs. 37,5%), assim como à taxa de alta da UTI nos dias 3 (0% vs. 25%), 4 (0% vs. 31%) e 5 (0% vs. 31%). No grupo FR, houve uma melhora significante no escore de Murray no dia 5. CONCLUSÕES: Nossos resultados mostraram que o uso combinado de HM e CTE por 5 dias acelerou o processo de desmame e de alta da UTI.

OBJECTIVE: Although manual hyperinflation (MH) is widely used for pulmonary secretion clearance, there is no evidence to support its routine use in clinical practice. Our objective was to evaluate the effect that MH combined with expiratory rib cage compression (ERCC) has on the length of ICU stay and duration of mechanical ventilation (MV). METHODS: This was a prospective randomized controlled clinical trial involving ICU patients on MV at a tertiary care teaching hospital between January of 2004 and January of 2005. Among the 49 patients who met the study criteria, 24 and 25 were randomly assigned to the respiratory physiotherapy (RP) and control groups, respectively. Of those same patients, 6 and 8, respectively, were later withdrawn from the study. During the 5-day observation period, the RP patients received MH combined with ERCC, whereas the control patients received standard nursing care. RESULTS: The two groups were similar in terms of the baseline characteristics. The intervention had a positive effect on the duration of MV, as well as on the ICU discharge rate and Murray score. There were significant differences between the control and RP groups regarding the weaning success rate on days 2 (0.0% vs. 37.5%), 3 (0.0% vs. 37.5%), 4 (5.3% vs. 37.5%), and 5 (15.9% vs. 37.5%), as well as regarding the ICU discharge rate on days 3 (0% vs. 25%), 4 (0% vs. 31%), and 5 (0% vs. 31%). In the RP group, there was a significant improvement in the Murray score on day 5. CONCLUSIONS: Our results show that the use of MH combined with ERCC for 5 days accelerated the weaning process and ICU discharge.

Biomarkers for oxidative stress in acute lung injury induced in rabbits submitted to different strategies of mechanical ventilation.

Oxidative damage has been said to play an important role in pulmonary injury, which is associated with the development and progression of acute respiratory distress syndrome (ARDS). We aimed to identify biomarkers to determine the oxidative stress in an animal model of acute lung injury (ALI) using two different strategies of mechanical ventilation. Rabbits were ventilated using either conventional mechanical ventilation (CMV) or high-frequency oscillatory ventilation (HFOV). Lung injury was induced by tracheal saline infusion (30 ml/kg, 38°C). In addition, five healthy rabbits were studied for oxidative stress. Isolated lymphocytes from peripheral blood and lung tissue samples were analyzed by alkaline single cell gel electrophoresis (comet assay) to determine DNA damage. Total antioxidant performance (TAP) assay was applied to measure overall antioxidant performance in plasma and lung tissue. HFOV rabbits had similar results to healthy animals, showing significantly higher antioxidant performance and lower DNA damage compared with CMV in lung tissue and plasma. Total antioxidant performance showed a significant positive correlation (r = 0.58; P = 0.0006) in plasma and lung tissue. In addition, comet assay presented a significant positive correlation (r = 0.66; P = 0.007) between cells recovered from target tissue and peripheral blood. Moreover, antioxidant performance was significantly and negatively correlated with DNA damage (r = -0.50; P = 0.002) in lung tissue. This study indicates that both TAP and comet assay identify increased oxidative stress in CMV rabbits compared with HFOV. Antioxidant performance analyzed by TAP and oxidative DNA damage by comet assay, both in plasma, reflects oxidative stress in the target tissue, which warrants further studies in humans.

High-frequency oscillatory ventilation attenuates oxidative lung injury in a rabbit model of acute lung injury.

Mechanical ventilation (MV) can induce lung oxidative stress, which plays an important role in pulmonary injury. This study compared protective conventional mechanical ventilation (CMV) and high-frequency oscillatory ventilation (HFOV) for oxygenation, oxidative stress, inflammatory and histopathological lung injury in a rabbit model of acute lung injury (ALI). Rabbits (n = 30) were ventilated at FiO(2) 1.0. Lung injury was induced by tracheal saline infusion (30 mL/kg, 38°C). Animals were randomly assigned to: (a) sham control (CG: tidal volume [V(T)] 6 mL/kg, positive end expiratory pressure [PEEP] 5 cmH(2)O, respiratory rate [RR] 40 ipm); (b) ALI + CMV (CMVG: V(T) 6 mL/kg, PEEP 10 cmH(2)O, RR 40 ipm); or (c) ALI + HFOV (HFG: mean airway pressure [Paw] 14 cmH(2)O, RR 10 Hz) groups. Lung oxidative stress was assessed by total antioxidant performance assay, inflammatory response by the number of polymorphonuclear leukocytes/bronchoalveolar lavage fluid/lung and pulmonary histological damage was quantified by a score. Ventilatory and hemodynamic parameters were recorded every 30 min. Both ALI groups showed worse oxygenation after lung injury induction. After four hours of ventilation, HFG showed better oxygenation (partial pressure of oxygen [PaO(2)] - CG: 465.9 ± 30.5 = HFG: 399.1 ± 98.2 > CMVG: 232.7 ± 104 mmHg, P < 0.05) and inflammatory responses (CMVG: 4.27 ± 1.50 > HFG: 0.33 ± 0.20 = CG: 0.16 ± 0.15; polymorphonuclear cells/bronchoalveolar lavage fluid/lung, P < 0.05), less histopathological injury score (CMVG: 5 [1-16] > HFG: 1 [0-5] > CG: 0 [0-3]; P < 0.05), and lower lung oxidative stress than CMVG (CG: 59.4 ± 4.52 = HFG: 69.0 ± 4.99 > CMVG: 47.6 ± 2.58% protection/g protein, P < 0.05). This study showed that HFOV had an important protective role in ALI. It improved oxygenation, reduced inflammatory process and histopathological damage, and attenuated oxidative lung injury compared with protective CMV under these experimental conditions considering the study limitations.

Efeito de diferentes técnicas de ventilação mecânica sobre o estresse oxidativo pulmonar induzido por lesão pulmonar aguda experimental / Effect of different techniques of mechanical ventilation on pulmonary oxidative stress induced by experimental acute lung lesion

Ventilação mecânica (VM) pode induzir estresse oxidativo pulmonar, o qual desempenha papel importante na lesão pulmonar. Este estudo comparou a ventilação mecânica convencional proterora (VMC) e a ventilação oscilatória de alta frequência (VAF) quanto a oxigenação, estresse oxidativo pulmonar, inflamação e lesão pulmonar histopatológica em modelo de lesão pulmonar aguda (LPA) em coelhos. Coelhos (n = 30) foram ventilados com FiO2 1.0. A lesão pulmonar foi induzida por infusão traqueal de solução salina (30mL/kg, 38 ºC). Os animais foram aleatoriamente distribuidos para compor os seguintes grupos: a) Controle [GC: volume corrente (VT) 6mL/kg, pressão expiratória final positiva (PEEP) 5cmH2O, frequência respiratória (FR) 40 ipm], b) LPA + VMC [GVMC: VT 6ml / kg, PEEP 10cmH2O, FR 40 ipm] e c) LPA + VAF [GVAF: pressão média de vias aéreas (Paw) 14 cmH2O, FR 10Hz]. Estresse oxidativo pulmonar foi avaliado por meio da capacidade antioxidante total, a resposta inflamatória pelo número de leucócitos polimorfonucleares/lavado broncoalveolar/pulmão e o dano histológico pulmonar foi quantificado por um escore. Parâmetros ventilatórios e hemodinâmicos foram registrados a cada 30 minutos. Ambos os grupos com LPA apresentaram piora da oxigenação após a indução da lesão pulmonar...

Estresse oxidativo como evento determinante na síndrome do desconforto respiratório agudo / Oxidative stress as determinant event acute respiratory distress syndrome

A lesão pulmonar aguda e sua forma mais grave, a síndrome do desconforto respiratório agudo (SDRA), são complicações frequentes em pacientes internados em unidades de terapia intensiva, sendo responsáveis pela alta mortalidade e morbidade. Embora seja considerada uma doença multifatorial, a presença do estresse oxidativo é denominador comum e determinante no mecanismo de lesão. A maioria dos estudos experimentais confirma a importância do estresse oxidativo na patogênese da SDRA. Novas estragégias terapêuticas vêm sendo tentadas, com base nos estudos clínicos e experimentais sobre patogênese da síndrome. O artigo destaca o papel do estresse oxidativo na patogênese da síndrome, por meio de apresentação dos mais recentes estudos na área. O texto objetiva também a desmistificação do tema estresse oxidativo apresentando definições e conceitos básicos.

Acute lung injury (ALI) and its most severe form, the acute respiratory distress syhdrome (ARDS), are frequent complications in critically ill patients and are responsible for significant morbidity and mortality. Although ALI and ARDS appears to be multilfactorial, a common denominator to most of the proposed mechanisms is the cellular damage mediated by oxidative stress. Evidence of oxidative stress and injury are common to most experimental models of lung injury and are corroborated in studies of patients with ALI/ARDS, underscoring the physiologic importance of these processes. New therapies strategies have been proposed based on clinical and experimental research results. The article approaches the role of oxidative stress on ALI/ARDS and also presents the main concepts of free radicals and antioxidants.

Respiratory muscular strength decrease in children with myelomeningocele.

STUDY DESIGN: Case-control study. OBJECTIVE: To evaluate respiratory muscle force in children with myelomeningocele. SUMMARY OF BACKGROUND DATA: Myelomeningocele is a common spinal cord malformation with limitations linked to central nervous system lesions and abnormalities in respiratory movements. Despite this, little attention has been given to evaluating respiratory muscle force in these patients. METHODS: Children with myelomeningocele aged between 4 and 14 years (myelomeningocele group; MG, n = 20) were studied and compared with healthy children (control group; CG, n = 20) matched for age and gender. Respiratory muscular force was evaluated by maximum inspiratory (Pimax) and expiratory (Pemax) pressures. RESULTS: Groups were similar for age [CG = 8 (6-13) x MG = 8 (4-14), P > 0.05]; gender, and body mass index [CG = 17.4 (14.1-24.7) x MG = 19.2 (12.6-31.9), P > 0.05]. The lumbosacral region was predominantly affected (45%). Maximum respiratory pressures were significantly higher in CG than MG (Pimax = CG: -83 +/- 21.75 > MG: -54.1 +/- 23.66; P < 0.001 and Pemax = CG: +87.4 +/- 26.28 > MG: +64.6 +/- 26.97; P = 0.01). Patients with upper spinal lesion (UL) had lower maximum respiratory pressure values than those with lower spinal lesion (LL), [Pimax (UL = -38.33 +/- 11.20 cm H2O x LL = -60.85 +/- 24.62 cm H2O), P < 0.041 and Pemax (UL = +48 +/- 20.82 cm H2O x LL + 71.71 +/- 26.73 cm H2O), P = 0.067]). CONCLUSION: Children with myelomeningocele at the ages studied presented reduced respiratory muscle force with more compromise in upper spinal lesion.